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mti)f  CitpofBfttjgork 

College  of  ^bpgicians  anh  #)urgeong 


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THE    OPERATIONS    OF 
SURGERY 


THE 

OPERATIONS  OF 
SURGERY 

(JACOBSON) 


SIXTH  EDITION 

BY 

R.   P.   ROWLANDS,   M.S.Lond.,  F.R.C.S.Eng. 

Surgeon  to  Guy's  Hospital ;  Lecturer  on  Anatomy 
to  the  Medical  School 

AND 

PHILIP  TURNER,  B.Sc,  M.S.Lond.,  F.R.C.S.Eng. 

Surgeon  to  Guy's  Hospital ;   Teacher  of  Operative 
Surgery  to  the  Medical  School 


Timitb  707  illustrations  (40  in  Colour) 


VOLUME   I 

THE  UPPER  EXTREMITY;  THE  HEAD  AND  NECK; 

THE  THORAX;  THE  LOWER  EXTREMITY; 

THE  VERTEBRAL  COLUMN 


NEW    YORK 
THE    MACMILLAN    COMPANY 

1915 


■RD3.2. 

V.I 


Printed  in  Ureal  Britain 


PREFACE  TO  THE  SIXTH  EDITION 


This  book,  of  which  five  previous  editions  have  appeared,  was  the 
outcome  of  a  strong  belief  which  Mr.  Jacobson  held  for  many  years, 
that  a  work  on  operative  surgery  which  aimed  at  being  more  comprehen- 
sive in  scope  and  fuller  in  detail  than  those  already  published,  would  be 
of  service  to  many  who  had  recently  been  appointed  to  hospital  staffs, 
and  to  those  who  were  working  for  the  higher  examinations.  For  these 
this  book  is  specially  intended,  and,  as  the  authors  have  pointed  out 
here  and  there,  some  of  the  recommendations  made  apply  to  those  who 
have  not  a  well-appointed  hospital  staff  at  their  back. 

Time  and  space  set  a  limit  to  the  operations  which  can  be  described. 
Therefore  preference  is  given  to  those  we  have  found  most  useful. 

In  the  special  departments  of  surgery  such  as  those  of  the  nose,  ear 
and  throat,  gynaecology  and  orthopaedics,  only  the  important  and  well- 
established  operations  which  a  general  surgeon  can  safely  perform  are 
considered  here,  and  no  attempt  is  made  to  compete  with  treatises  on 
these  special  subjects. 

In  this  edition  we  have  endeavoured  to  save  space  and  avoid  needless 
repetition  by  devoting  special  chapters  to  "  the  examination,  preparation 
and  after-treatment  of  the  patient." 

The  whole  book  has  been  carefully  revised  and  a  great  deal  of  it  has 
been  entirely  rewritten  ;  this  applies  especially  to  the  sections  on 
Abdominal  Surgery,  and  the  chapters  on  the  Surgery  of  the  Blood- 
vessels, and  of  the  Brain,  Ear,  Nose  and  Throat. 

We  are  well  aware  that  the  book  will,  from  time  to  time,  require 
much  alteration.  This  is  unavoidable  in  a  subject  so  progressive  and 
changeful  as  modern  surgery  ;  it  is  especially  unavoidable  when  a  writer 
desires  to  do  full  justice  to  the  work  done  by  the  crowd  of  labourers 
engaged  in  the  same  field  at  the  present  time.  Many  of  the  methods 
suggested  in  these  pages  will,  later  on,  be  rejected,  but  it  is  only  by 
submitting  novelties  and  suggestions  to  the  one  true  test,  that  of  time, 
that  we  shall  know  how  many  are  really  worthy  to  survive.  If  this 
book  aids  in  bringing  about  the  application  of  this  test,  it  will  not  have 
failed,  altogether,  in  its  purpose. 

The  plan  of  the  book,  with  which  some  judges  found  fault,  remains 
unchanged.  Mr.  Jacobson  adopted  the  division  by  regions  deliberately, 
desiring  that  those  for  whom  the  book  is  intended  should  study  the 
anatomy  of  each  region  at  the  same  time  as  the  account  of  the  operations. 
In  this  edition  it  has  been  found  convenient  to  insert  the  section  on  the 
Leg  in  the  first  volume,  so  that  the  increasing  claims  of  abdominal 
surgery  could  be  adequately  met  in  the  second  volume. 

To  our  great  regret  Mr.  Jacobson  has  been  unable  to  continue  the 
laborious  and  brilliant  work  which  built  up  this  book  and  maintained 


vi  PREFACE 

its  great  reputation  for  so  many  years.  Mr.  Philip  Turner  has  made 
himself  entirely  responsible  for  the  sections  dealing  with  the  Surgery  of 
the  Head  and  Neck,  Chest  and  Upper  Extremity.  Mr.  G.  Bellingham 
Smith,  Senior  Obstetric  Physician  and  Gynsecologist  to  Guy's  Hospital, 
has  again  thoroughly  revised  and  largely  rewritten  the  chapters  dealing 
with  the  operations  on  the  Ovary  and  Uterus. 

Many  new  and  original  illustrations  have  been  added,  and  we  desire 
to  express  our  grateful  acknowledgments  to  Sir  Watson  Cheyne,  Sir  A. 
Pearce  Gould,  Sir  Victor  Horsley,  Sir  Arbuthnot  Lane,  Sir  W.  Macewen, 
Sir  Henry  Morris,  Sir  Berkeley  Moynihan,  Sir  St.  Clair  Thomson, 
Messrs.  Barker,  James  Berry,  Burghard,  Dobson,  Freyer,  Hey  Groves, 
Sampson  Handley,  Jonathan  Hutchinson,  McGavin,  Miles,  Paul,  Rawling, 
Scott,  Swain,  Tilley,  West,  and  to  Doctors  Binnie,  Connell,  Crile,  Garre, 
Halstead,  Kelly,  Kocher,  C.  H.  Mayo,  W.  J.  Mayo,  Willy  Meyer, 
Quincke,  Scudder,  Tuttle,  Young  and  others ;  also  to  The  Annals  of 
Surgery,  and  acknowledgments  are  also  made  to  some  who  have  passed 
away,  such  as  Bucknall,  Edebohls,  Heath,  Lockwood,  Greig  Smith,  and 
Wheelhouse.  It  remains  for  us  to  acknowledge  very  gratefully  the 
encouragement  given  by  the  reviewers  of  previous  editions,  and  a  host 
of  correspondents  from  all  parts  of  the  world.  We  only  wish  that  this 
edition  may  deserve  some  of  the  kind  things  written  of  its  predecessors, 
and  that  it  will  be  found  to  give  proof  of  the  two  main  objects  which  we 
have  tried  to  keep  before  us — to  do  justice  to  the  work  of  others  and  to 
save  our  readers  some  of  the  difficulties  and  anxieties  which  have  beset 
our  paths. 


CONTENTS 

PART  I 
OPERATIONS  ON  THE  UPPER  EXTREMITY 


CHAP. 


I    Prelimixary  Considerations. — Examination  and  preparation 

of  the  patient     .........  1 

II.  Infusion. — Transfusion. — Skin-grafting 34 

III.  Some  Generai,  Points  with  regard  to  Amputations,  the 

Ligature  of  Arteries,  and  the  Surgery  of  Blood-vessels 

and  Lymphatics         ........  46 

IV.  Operations  on  the  Hand. — Amputation  of  fingers. — Amputa- 

tion of  the  thumb.— Partial  excision  of  the  thumb. — Excision 
of  the  fingers. — Conservative  surgery  of  the  hand. — Reunion  of 
severed  digits. — Supernumerary  digits. — Webbed  fingers. — 
Contracted  palmar  fascia. — Congenital  and  other  contractions 
of  the  fingers. — Needles  in  the  hand. — Palmar  haemorrhage. — 
Compound  palmar  ganglion.— Tuberculous  teno-s}Tiovitis. — 
Palmar  aneurysm. — Operations  for  the  union  of  divided  tendons. 
— Tenorraphy. — Tenoplasty. — Tendon  transplantation  espe- 
cially in  relation  to  its  employment  in  infantile  paralysis     .  .  57 

V.  Operations  on  the  Wrist. — Excision  of  the  wrist-joint  — 
Operation  in  mal-united  Colles"s  fracture  and  separation  of  the 
lower  epiphysis  of  the  radius. — Amputation  through  the  -nTist- 
joint. — Ligature  of  the  radial  artery  at  the  back  of  the  wrist         .  Ill 

VI.  Operations  on  the  Forearm. — Ligature  of  the  radial  artery  in 
the  forearm. — Ligature  of  the  ulnar  artery  in  the  forearm. — 
Partial  excision  of  the  radius  or  ulna. — Operative  treatment  of 
Volkmann's  contraction. — ^Amputation  through  the  forearm       .  126 

VII.  Operations  in  the  neighbourhood  of  the  Elbow-joint. — 
Amputation  through  the  elbow-joint. — Excision  of  the  elbow- 
joint. — Erasion  of  the  elbow-joint. — Operation  for  fracture  of 
the  olecranon. — Operations  for  fracture  of  the  condyles  of  the 
humerus  and  for  separation  of  the  lower  epiphysis  of  the 
humerus. — Venesection. — lagature  of  the  brachial  artery  at 
the  bend  of  the  elbow  .......  142 

Vin.  Operations  on  the  Arm. — Ligature  of  the  brachial  arterj-. — 
Amputation  through  the  arm. — Excision  in  continuity  of  the 
shaft  of  the  humerus. — Bone-grafting. — Operations  on  the 
musculo-spiral  nerve    ,.".,....  171 

vii 


viii  CONTENTS 


CHAP. 


IX.  Operations  on  the  Axilla  and  the  Shottlder. — Ligature  of 
the  axillary  artery. — Amputation  at  the  shoulder-joint. — 
Excision  of  the  shoulder-joint. — Gunshot  injuries  of  the 
shoulder-joint      .........  187 

X.  Excision  of  the  Scapula 228 

XI.  Removal  of  the  Upper  Extremity,  Arm,  Scapula,  and 
GREATER  P.UIT  OF  THE  Clavicle. — Interscapulo-thoracic  am- 
putation    ..........  234 

XII.  Operations  on  the  Clavicle. — Renioval  of  the  clavicle    .  .  240 


PART  II 
THE  HEAD  AND  NECK 

XIII.  Operations  on  the  Scalp. — Fibro-cellular  growths,  moUusoum 

fil)rosum,  or  pachj'dermatocele  of  the  scalp. — Aneurysm  by 
anastomosis. — Operative  interference  in  growth  of  the  cranial 
bones  and  dura  mater  .  ...  .  .  .  .  244 

XIV.  Trephining. — Operative    interference    immediate    or    later    in 

fractures  of  the  skuU. — Trejihining  in  fractured  skull. — ^Trephin- 
ing  for  pus  between  the  skull  and  dura  mater, — Trephining  for 
middle  meningeal  haemorrhage. — Trephining  and  exploration 
of  cerebral  abscess  due  to  injury. — Trephining  for  epilepsy  and 
other  later  results  of  a  cranial  injuri% — ^Operative  interference 
in  the  case  of  foreign  bodies  in  the  brain  .  .  .  .  .  250 

XV.  Cerebral  Locausation  in  reference  to  Operations. — Opera- 
tions for  tumour  of  the  brain. — Practical  value  of  cerebral  locali- 
sation. — Questions  arising  before  operation  on  a  cerebral  growth. 
— Operative  procedures  on  the  brain,  chiefly  for  the  removal 
or  the  palliative  treatnient  of  growths. — Craniectomy  for 
microcephalus,  idiocy,  &c. — Trephining  in  general  paral3'sis 
of  the  insane,  and  in  other  forms  of  insanity. — Operative  treat- 
ment of  hydrocephalus. — Drainage  of  the  ventricles  .  .  289 

XVI.  Operations  on  the  Ear. — The  radical  mastoid  operation. — 

Abscess  in  the  brain. — Meningitis. — Ojjeration  for  otitis  media  330 

XVII.  Operations  on  the  Face. — Operations  on  the  fifth  nerve. — 
Removal  of  parotid  growths. — Operations  on  the  facial  nerve. — 
Stretching  the  facial  nerve. — Operative  treatment  of  intractable 
facial  paralj'sis  of  peripheral  origin. — Restoration  of  Steno's 
duct. — Operative  treatment  of  lupus. — Operative  treatment  of 
rodent  ulcer. — Removal  of  parotid  growths. — Practical  points 
in  the  removal  of  parotid  growths. — Operative  treatment  of 
na?vi. — Operative  methods  of  treatment  ....  363 

XVIII.  Excision  of  the  Eyeball 406 

XIX.  Operations  on  the  Frontal  Sinuses  ....  410 


CONTENTS  ix 

CHAP.  l'A(Ji: 

XX.  Operations  OF  THE  Jaws. — Excision  of  tlic  upijei-  jaw,  paitiiii 
and  coniijlcte. — Operations  on  the  antrum  of  Higliinorc. — 
Excision  of  the  lower  jaw,  partial  and  complete. — Operations 
for  fixity  of  the  lower  jaw   .  .  .  .  .  .  .  41!) 

XXr.  Plastic  Operations  for  Repair  of  the  Xosk    .  .  .  44^ 

XXII.  Operations  on  the  Nasal  Foss.e. — Removal  of  foreign 
bodies. — Turbinectomy.—  Operations  for  deflected  septum. — 
Removal  of  nasal  polypi. — Operation  for  naso-pharyngeal 
fibroma  and  sarcoma. — Removal  of  adenoids  and  enlarged 
tonsils       ..........  454 

XXIII.  Operations  on  the  Lips.- -Hare-lip  and  other  plastic  opera- 

tions on  the  lips  and  face    .  .  .  .  .  .  .  47i) 

XXIV.  Operations  on  the  Palate. — Operations  for  cleft  palate. — 

Removal  of  growths  from  the  palate    .....  504 

XXV.  Removal  of  the  Toncjue. — Operations  for  epithelioma  of  the 

tongue      ..........  59 

XXVI.  Operations  for  Growths  of  the  Tonsil,  FauceS;  i3as:3  o:-' 

the  ToNcaiE  and  Pharynx       ......  550 

XXVII.  Operations  on  the  Air-pass*ages  in  the  Xeck. — Thy- 
rotomy.  —  Laryngotomy  or  inter-crico-thyrotomy.  —  Trache- 
otomy.— Tracheotomy  with  special  reference  to  cases  of  mem- 
branous laryngitis. — Intubation  of  the  larynx  as  a  substitute 
for  tracheotomy  in  membranous  laryngitis  or  stenosis  of  the 
larynx. — Technique  of  intubation. — Other  indications  for 
tracheotomy. — Extra-laryngeal  operations  for  removal  of 
growths  of  the  larynx ;  excision  of  the  larynx,  partial  or 
complete  ..........  559 

XXVIII.  Removal  OF  Foreign  Bodies  from  the  Upper  Air-passages 

•  AND   FROM   THE    ClisOPHAGUS  ......  602 

XXIX.  Operations  on  the  Thyroid  Gland. — Extirpation  of  part 
of  the  gland. — Enucleation  of  encapsuled  tumours. — Ijgature 
of  the  thyroid  arteries  .  .  .  .  .  .  .  610 

XXX.  Operations  for  the  Removal  of  Large  Deep-seated 
Growths  in  the  Xeck,  Tuberculous  Glands, Lymphangeto- 
MATA,  Thyroglossal  AND  BRANCHIAL  Cysts. — Removal  of 
cervical  ribs       .........  638 

XXXL  Operations    on    the    (Esophagus. — ffisophagotomy. — O^so- 

phagostomy. — Esophagectomy. — Oesophageal  pouches  .  649 

XXXII.  Operations  on  the  Spinal  Accessory,  LTpper  Cervical 
Nerves,  and  Sympathetic. — Partial  neurectomy,  or  nerve- 
stretching. — Resection  of  the  cervical  sympathetic  for  exoph- 
thalmic goitre,  &c.      ......  .  .  661 

XXXIII.  Ligature  of  the  Arteries  of  the  Head  and  Neck. — 
Ligature  of  the  temporal  arterJ^ — Ligature  of  the  facial  artery. 
— Ligature  of  the  occipital  artery. — Ligature  of  the  lingual 
artery. — Ligature  of  the  common  carotid. — Ligature  of  the 
external  carotid. — Ligature  of  the  internal  carotid. — Ligature 
of  the  vertebral  artery. — Ligature  of  the  subclavian  in  its  second 
and  third  parts. — Ligature  of  the  first  part  of  the  subclavian. — 
Ligature  of  the  irmominate. — Surgical  intei-ference  in  aneurysms 
of  the  innominate  and  aorta         ......  670 


CONTEXTS 


PART  III 
OPERATIONS  ON  THE  THORAX 

CHAP.  PAGE 

XXXIV.  Removal  of  the  Breast        ......  727 

XXXV.  Paracentesis  and  Incision  of  the  Chest. — Empyema. — 
Resection  of  ribs. — ^Operative  interference  in  injuries  of  the 
chest 760 

XXXVI.  Operations  on  the  Lvng  and  the  ^Iediastinum        .         .  778 

XXXVII.  Tapping  or  Incising  the  Pericardium. — Suture  of  wounds 

of  the  heart. — Cardiolj^sis         ......  794 


PART  IV 
OPERATIONS  ON  THE  LOWER  EXTREMITY 

XXX\'III.  Amputation  at  the  Hip-joint. — Excision  of  the  hip-joint. — 
Operative  treatment  of  hip-disease. — Operative  treatment  of 
sacro-iHac  disease    ........  805 

XXXIX.  Congested  Dislocation  of  the  Hip  :    Coxa  Vara  .         .  826 

XL.  Ligature  of  Arteries  in  the  Buttock  and  Thigh  835 

XLI.  Amputation  through  the  Thigh. — Removal  of  exostosis. — 

Fractures  of  the  femur    .......  846 

XLII.  Amputation  through  the  Kkee- joint. — Erasion,  excision 
and  arthrodesis  of  the  joint  a\  iring  of  fractures  of  the  jiateUa. 
— Removal  cf  loose  bodies  and  detached  cartilages  from 
the  knee-joint       ....  .  862 

XLIII.  Ligature  of  Arteries  in  the  Popliteal  Space  and  the 

Leg 894 

XLIV.  Amputation  of  the  Leg. — Operation  for  Xecrosis. — Com- 

jjound  fracture. — Simiile    fracture.— Varicose  veins    .  .  905 

XLV.  Ligature  of  Dorsalis  Pedis. — Amputations  of  the  foot. — 
Excision  and  erasion  of  the  anlde-jomt.— Excision  of  the  os 
calcis. — Tarsectomy         .......  930 

XLVI.  Osteotomy  for  Ankylosis  of  the  Hip-joint,  Coxa  Vara, 

Genu  Valgum,  and  Genu  Varum  ....  953 

XL^'II.  Tenotomy  and  Tendon  Lengthening. — Treatment  of  severe 

talipes 961 

XLVIII.  Operations  ON  Xerves. — Suture,  grafting,  and  anastomcsis  .  978 

PART  V 
OPERATIOXS  OX  THE  VERTEBRAL  COLUMX 

XLIX.  Spina  Bifida. — Laminectojuy. — Tapping  the  spinal  theca. — 

Spinal  anx'sthesia. — Amci-association        ....  983 

IXDEX .  1009 


\>5 

PAKT    I 

()Im:ijati()ns  on  thi:  l  i>im:r  ex tkemij  v 

CHAPTER  I 

PRELIMINARY  CONSIDERATIONS.     EXAMINATION  AND 
PREPARATION  OF  THE  PATIENT 

Patients  requiring  surgical  operative  treatment  may  roughly  be  divided 
into  two  groups  :  I.  Those  in  whom  the  operation  is  urgently  required 
for  some  injury  or  disease  w^hich  seriously  imperils  life.  II.  Those  in 
whom  the  condition  is  less  urgent,  so  that  there  is  no  immediate  necessity 
for  the  operation. 

In  the  first  group,  cases  of  acute  intestinal  obstruction  for  instance, 
the  symptoms  may  be  so  grave  that  previous  examination  of  the  patient 
may  be  undesirable  ;  any  risk  must  be  taken  in  the  attempt  to  save  life. 

In  the  latter  group  undue  haste  is  not  only  unnecessary  but  should 
be  avoided  ;  a  careful  examination  and  preparation  of  the  patient  should 
always  be  made  before  the  operation.  The  preliminary  examination  will 
frequently  enable  the  surgeon  to  decide  upon  the  most  desirable  treat- 
ment, i.e.  as  to  w^hether,  in  elderly  patients,  a  palliative  or  a  radical 
operation  will  give  the  best  prospect  of  ultimate  success  ;  it  will  also 
aid  the  anaesthetist  in  the  selection  and  the  administration  of  the  anaes- 
thetic. The  preliminary  preparation,  too,  will  usually  play  a  very 
important  part  in  determining  the  success  of  the  operation. 

In  addition  to  an  examination  of  the  physical  condition  and  the 
functional  activity  of  the  chief  organs  it  is  also  necessary  to  take  into 
consideration  the  age,  sex,  occupation,  habits,  and  temperament  of  the 
patient,  and  to  make  inquiries  as  to  the  existence  of  any  general  consti- 
tutional or  hereditary  disorder. 

Age.  It  was  formerly  thought  that  operations  were  not  well  borne  in 
childhood  and  in  old  age.  Though  to  a  certain  extent  still  true,  modern 
methods  and  precautions  have  considerably  diminished  the  risk  of 
operations  at  the  two  extremes  of  life.  Young  children  are  said  to 
stand  haemorrhage  badly,  but  as  Sir  Frederick  Treves  has  pointed  out, 
if  the  relation  of  the  amount  of  blood  lost  to  the  total  amount  in  the 
body  is  considered,  young  children  are  probably  not  more  seriously 
affected  than  adults.  Post-operative  shock  is  often  excessive  in  infants 
and  young  children,  and  is  a  frequent  cause  of  death  after  abdominal  and 
other  operations  which  necessitate  the  manipulation  of  the  intestines 
or  other  important  \'iscera.  On  the  other  hand,  children  often  show" 
a  remarkable  power  of  recuperation  and  may  recover  from  an  apparently 
desperate  condition.  Both  these  points  are  illustrated  by  the  results 
obtained  by  the  modern  method  of  treating  an  intussusception  by 
laparotomy  {q.v.).  Difficulties  with  children  often  arise  from  the  restless 
character  of  the  patients,  which  may  make  it  almost  impossible  to  keep 
the  affected  part  at  rest ;  displacement  of  dressings  may  also  occur, 
which  is  likely  to  interfere  with  the  healing  of  the  wound.     When  the 

SURGERY  I  1  I 


2  OPERATIONS  ON  THF:  UPPER  EXTREMITY 

incision  is  in  the  region  of  the  groin  the  dressings  may,  in  spite  of  the 
most  careful  nursing,  get  soiled,  and  then  infection  of  the  wound  and 
serious  suppuration  may  ensue.  A  point  in  favour  of  operations  in 
children  is  that  they  are  not  adversely  affected  by  prolonged  rest  in  bed 
and  show  no  tendency  as  the  result  of  this  to  develop  such  complications 
as  chest  troubles  or  bed-sores. 

In  old  age  attention  should  be  directed  to  the  condition  of  the  patient's 
organs  and  tissues  rather  than  to  the  actual  number  of  years.  Some 
elderly  people  are  quite  good  subjects  for  operation.  Such,  generally 
speaking,  are  spare,  active  and  mry  ;  fat,  flabby,  plethoric  old  people  are, 
on  the  other  hand,  usually  bad  subjects. 

Like  children,  old  people  do  not  stand  shock  well ;  they  also  are 
seriously  affected  by  loss  of  blood  and  do  not  show  the  recuperative 
powers  of  younger  patients. 

It  must  be  remembered,  too,  that  in  old  people  confinement  to  bed  may 
lead  to  congestion  of  the  base  of  the  lungs  and  hypostatic  pneumonia — 
a  very  fatal  sequela  in  such  patients. 

Bed-sores  may  appear  as  the  result  of  long-continued  pressure  on  the 
ill-nourished  skin  over  the  bony  prominences,  and  will  not  infrequently 
contribute  to  a  fatal  result. 

ISTo  operation,  however,  for  an  acute  condition,  seriously  threatening 
life,  and  capable  of  cure  or  relief  by  surgical  interference,  is  contra- 
indicated  solely  on  account  of  old  age.  If  a  skilled  ana'sthetist  considers 
that  a  general  ansesthetic  is  not  desirable,  either  spinal  anaesthesia  or 
local  anaesthesia  may  be  employed. 

The  results  of  prostatectomy  show  what  can  be  done  by  operative 
treatment  in  old  men,  who  apart  from  their  urinary  trouble  are  often 
very  feeble  and  whose  organs  are  by  no  means  healthy. 

Sex.  By  some,  women  are  regarded  as  better  subjects  for  surgical 
operations  than  men.  This,  however,  is  the  effect  of  temperament 
rather  than  sex,  and  the  bearing  of  the  former  upon  operative  treatment 
will  be  discussed  below. 

When  operating  upon  women  it  is  always  necessary  to  bear  in  mind 
the  importance  of  any  unsightly  or  disfiguring  scar,  especially  upon  any 
exposed  part  of  the  body.  In  a  man  a  scar  upon  the  face  can  often  be 
completely  concealed  by  the  moustache  or  beard  ;  in  a  woman  such  con- 
cealment is  impossible. 

It  is  thus  necessary,  when  planning  any  such  operation,  to  take  care 
that  the  scar  is  in  as  inconspicuous  a  position  as  possible.  This  can 
frequently  be  accomplished  by  making  the  incision  in  the  line  of  some 
natural  fold  or  crease  in  the  skin.  Accurate  apposition  of  the  edges  of 
the  incision,  early  removal  of  stitches,  and  primary  union  of  the  wound 
are  all  of  the  greatest  importance  in  securing  a  neat  scar. 

Unless  urgently  called  for  by  some  acute  trouble,  operations  in  Ihe 
groin,  perineum,  or  abdomen  should  not  be  carried  out  during  menstrua- 
tion. With  regard  to  operations  in  other  regions  the  wish  of  the  patient 
should  be  considered.  Many  women  prefer  to  have  nothing  done  at 
this  time,  but  should  the  patient  make  no  objection  no  harm  is  likely 
to  result.  Operations  are  best  avoided  during  pregnancy,  especially 
during  the  later  months.  The  danger  here,  of  course,  is  that  an  abortion 
may  follow.  The  chance  of  such  an  accident  is  however  slight,  and 
not  infrequently  it  will  be  felt  that  the  risk  should  be  taken. 

Operations  for  acute  abdominal  troubles,  and  the  removal  of  ovarian 


EXAMINATION  OF  THE  PATIENT  .3 

cysts,  have  frequently  been  undertaken  in  pregnant  women  without 
anv  mishap.  What  has  })een  said  about  pregnancy  also  to  a  great  extent 
applies  to  operations  during  lactation.  This  throws  considerable  strain 
upon  the  system  and  renders  it  desirable  to  postpone  any  operation  which 
is  not  urgently  required. 

Temperament.  Before  recommending  any  serious  operation  it  is 
always  well  to  have  some  knowledge  of  the  patient's  temperament  and 
to  observe  his  mental  attitude  towards  the  disease  and  the  treatment. 
Such  information  may  help  one  considerably  in  the  choice  of  treatment, 
operative  or  otherwise  ;  it  will  also  frequently  have  a  great  influence 
upon  the  ultimate  result.  A  placid  and  cheerful  state  of  mind  is  an 
encouraging  sign  in  a  patient  who  has  to  face  a  serious  operation.  An 
apathetic  fatalistic  attitude,  in  which  the  patient  does  not  care,  or  scarcely 
wishes  to  recover,  is  on  the  other  hand  of  very  bad  omen.  Considerable 
care  must  be  exercised  before  recommending  operations,  unless  they  are 
very  ob\'iously  indicated,  in  neurotic  subjects. 

A  good  example  of  this  is  seen  in  the  symptoms  which  are  associated 
with  a  movable  kidney.  These  patients  are  very  often  neurotic,  and  in 
such,  even  though  the  kidney  by  the  operation  of  nephropexy  be  firmly 
fixed  in  its  normal  position,  the  symptoms  wdll  probably  continue. 
The  same  operation  for  similar  symptoms  in  a  patient  of  normal  sensi- 
bility and  placid  temperament  will  probably  result  in  their  complete 
disappearance.  Mental  worry  of  any  description  is  a  serious  disadvantage 
to  any  patient  who  requires  operative  treatment.  Restlessness  of  mind 
will  probably  lead  to  bodily  restlessness,  and  the  two  combined  mav 
have  a  very  ill  effect.  Worry  in  men  is  generally  due  to  business  matters, 
and  in  women  to  their  household  affairs  and  their  children.  On  this 
account,  as  well  as  for  convenience  in  nursing  and  treatment  generally, 
it  is  usually  advisable  not  to  operate  in  the  patient's  own  home  but  to 
have  them  removed  from  familiar  surroundings  to  a  hospital  or  nursing 
institution.  Under  these  circumstances  visitors  can  be  limited  or  if 
necessary  totally  forbidden,  and  the  worries,  which  though  often  trivial 
are  very  real,  can  thus  be  kept  from  the  patient  ;  it  is  practically  im- 
possible to  secure  this  freedom  from  mental  irritation  if  the  operation 
takes  place  in  the  patient's  own  home.  In  restless  and  neurotic  patients, 
too,  the  new  surroundings  and  unaccustomed  faces  are  often  of  the  very 
greatest  benefit. 

Habits.  The  success  of  an  operation  may  be  seriously  affected  by  the 
patient's  habits.  Unfortunately  these  are  often  unrecognised  before  the 
operation,  for  the  patient  is  naturally  averse  to  give  information,  and  if 
the  suspicions  of  the  surgeon  are  aroused  the  suggestion  will  probablv 
be  denied.  That  the  vicious  habit  is  indulged  in  is  thus  usually  revealed 
by  disturbances,  either  mental  or  physical,  after  the  operation.  The 
most  frequent  and  important  of  these  habits  to  be  considered  is  alcoholism. 
An  alcoholic  is  certainly  a  bad  subject  for  at  any  rate  major  operations. 
This  is  true  not  only  in  the  case  of  drunkards  but  also  in  that  more 
numerous  class  of  individuals  who,  though  they  would  deny  ever  being 
intoxicated,  are  yet  continually  taking  small  doses  and  are  unable  to 
do  without  the  drug.  The  dangers  attending  operations  upon  alcoholics 
are  three  in  number ;  (a)  there  is  the  possibility  of  an  attack  of  de- 
lirium tremens,  or  of  some  less  serious  mental  disturbance ;  (b)  the 
normal  healing  of  the  wound  is  likely  to  be  interfered  with;  (c)  there 
may  be  serious  general  complications. 


4  OPERATIONS  OX  THE  UPPER  EXTREMITY 

Delirium  tremens  may  appear  for  the  first  time  in  an  alcoholic  subject 
after  an  operation.  It  may  occur  in  a  chronic  alcoholic  patient  as  well  as 
in  an  occasional  or  habitual  drunkard.  The  actual  cause  is  probably 
alteration  in  diet  and  mode  of  life,  and  enforced  abstinence,  rather  than 
the  actual  operation.  When  operating  on  an  alcoholic  subject  it  is 
thus  best  not  to  deprive  him  completely  of  the  drug,  but  to  allow  small 
regular  doses  of  stimulant.  Post-operative  delirium  tremens  is  always  a 
serious  and  not  infrequently  a  fatal  complication. 

The  continued  absorption  of  alcohol  has  undoubtedly  a  deleterious 
effect  upon  the  tissues.  The  powers  of  repair  are  seriously  affected,  so 
that  the  healing  of  the  wound,  both  superficially  and  in  its  deeper  parts, 
may  be  impeded.  The  resistance  of  the  tissues  to  bacterial  infection 
is  also  diminished,  and  hence  suppuration,  cellulitis,  and  erysipelas 
occur  much  more  readily  and  are  overcome  with  greater  difficulty  than 
in  a  healthy  patient. 

Alcoholics  are  also  liable,  for  much  the  same  reasons,  to  a  number  of 
grave  \"isceral  troubles,  such  as  pneumonia,  dilatation  of  the  heart, 
chronic  nephritis,  while  gastric  disturbances  of  more  or  less  severity 
are  also  exceedingly  common.  These  may  appear  after,  or  if  already 
present  are  likely  to  be  accentuated  by,  an  operation.  These  troubles 
are  often  accompanied  by  delirium  tremens.  All  these  complications  are 
especially  likely  to  appear  in  hard  drinkers  after  severe  operations  for 
serious  acute  injuries  and  diseases.  It  will  thus  be  seen  that  a  considerable 
mortality  is  to  be  expected  after  such  operations  on  these  patients. 
Alcoholics,  too,  will  probably  give  much  trouble  to  the  anaesthetist. 
They  may  be  expected  to  take  large  quantities  of  ether  or  chloroform, 
the  stage  of  excitation  is  much  prolonged,  and  it  is  difficult,  and  indeed 
in  some  cases  almost  impossible,  to  secure  complete  muscular  relaxation. 

What  has  been  said  of  alcohol  is  to  a  great  extent  true  of  the  subjects 
of  other  drug  habits,  such  as  morphia  and  cocaine.  The  sudden  depriva- 
tion of  the  drug  is  likely  to  upset  both  the  mental  and  physical  functions 
of  the  body.  On  this  account  the  patient  should  in  all  these  cases  be 
still  allowed  reduced  cpiantities  of  the  drug  to  which  he  is  accustomed. 
Excessive  smoking  mav  lead  to  troubles  in  anaesthetising  of  a  similar 
though  less  severe  character  to  those  seen  in  alcoholics.  Such  a  patient 
may  often  with  advantage  be  allowed  to  smoke  occasionally  a  few  days 
after  the  operation,  provided  of  course  that  the  disease  or  injury  was  not 
in  the  region  of  the  mouth,  respiratory  passages,  or  other  situation  where 
the  practice  would  be  harmful. 

We  must  now  consider  certain  general  constitutional  conditions  which 
have  an  important  bearing  upon  operative  treatment. 

Obesity.  This  is  of  the  greatest  importance,  for  such  patients  are 
bad  subjects  for  nearly  all  operations.  This  is  due  to  a  varietv  of  causes. 
The  excessive  deposit  of  fat  may  be  the  result  of  continued  excess  in 
eating  and  drinking,  which  of  itself  is  a  serious  matter.  The  excess  of 
fat  in  the  subcutaneous  tissues  may  be  associated  with  a  fatty  deposit  in 
the  mesentery  and  the  omentum,  while  fatty  liver  and  fatty  infiltration 
or  degeneration  of  the  heart  are  also  likely  to  be  present.  Such  patients 
may  be  unable  to  breathe  satisfactorily  unless  well  propped  up  in  bed, 
a  position  which  their  weight  may  render  it  difficult  to  maintain.  The 
administration  of  the  anaesthetic  will,  on  account  of  the  fatty  ^^scera, 
be  both  difficult  and  dangerous.  Their  unwieldiness  may  make  subse- 
quent nursing  and  after-treatment  very   difficult.     The  skin  itself  is 


EXAMINATION  OF  THE  PATIENT  5 

often  unhealthy,  eczema  may  be  actually  present,  or  readily  appear 
in  natural  folds  or  clefts  such  as  the  ^roin,  the  axilla,  the  umbilicus,  or 
in  women,  beneath  the  breasts.  Satisfactory  cleansing  of  the  skin  is 
under  these  circumstances  difficult  or  impossible,  and  the  wound  on  this 
account  is  very  liable  to  become  infected.  The  thick  layer  of  adipose 
tissue  may  impede  the  satisfactory  exposure  of  deep  parts,  and  also 
interferes  with  the  exact  closure  of  the  wound ;  its  blood-supply  is  poor 
and  hence  sloughing  and  cellulitis  are  likely  to  occur,  especially  if  the 
margins  of  the  skin  incision  have  been  much  undermined.  These 
facts  help  to  explain  the  bad  prognosis  in  cases  of  strangulated  umbilical 
hernia,  which  nearly  always  occurs  in  excessively  obese  patients.  The 
mortality  after  operations  in  these  cases  is  very  high,  and  is  a  great 
contrast  to  the  results  after  operations  for  strangulated  femoral  and 
inguinal  hernias,  which  are  not  usually  associated  with  obesity. 

The  prognosis  in  malignant  disease,  e.g.  of  the  breast,  is  worse  in 
obese  than  in  spare  patients.  The  growth  extends  widely  in  the  fat,  and 
its  limits  cannot  be  recognised  ;  the  presence  of  the  fat,  too,  obscures 
and  renders  difficult  the  recognition  and  complete  removal  of  outlying 
nodules  and  of  enlarged  glands. 

Hsemophilia  is  a  contra-indication  to  any  but  an  absolutely  essential 
and  necessary  operation.  It  is  a  rare  condition,  and  as  nothing 
abnormal  is  usually  noticed  until  the  hgemorrhage  occurs,  the  surgeon 
often  does  not  suspect  it  until  after  the  operation.  Most  serious  and 
even  fatal  haemorrhage  may  occur  after  the  most  trivial  procedures,  such 
as  extraction  of  a  tooth  or  incising  an  abscess.  It  must  be  remembered 
that  though  the  tendency  to  excessive  bleeding  is  usually  noticed  at  a 
very  early  age,  the  child  may  reach  the  age  of  eight  years  or  more  before 
any  abnormal  liability  to  bleed  is  noticed.  Should  the  patient  live  so  long, 
the  tendency  to  bleed  diminishes  towards  middle  age. 

Status  lymphaticus  is  a  condition  about  which  little  is  known, 
but  which  is  of  the  greatest  importance  both  to  the  surgeon  and  the 
anaesthetist.  It  is  characterised  by  enlargement  of  the  thymus,  and  a 
general  increase  of  the  lymphatic  tissues  of  the  body,  which  may  be 
indicated  by  slight  enlargement  of  the  lymphatic  glands,  enlargement  of 
the  tonsils,  the  presence  of  adenoids  and  a  palpable  spleen.  These 
patients  are  generally  pale  flabby  children,  frecjuently  rickety,  who  in 
spite  of  an  unhealthy  appearance  are  usually  thought  to  be  quite  well. 
The  subjects  of  this  disease  are  liable  to  die  suddenly  from  some  apparently 
very  trivial  cause  ;  death  may  take  place  either  during  or  shortly  after 
the  administration  of  an  anaesthetic,  or  from  shock  after  an  opera- 
tion, often  for  some  comparatively  slight  trouble  such  as  adenoids. 
Postmortem  nothing  to  account  for  the  sudden  death  is  usually  found, 
except  the  excess  of  lymphoid  tissue.  The  exact  way  in  which  death 
is  caused  is  thus  still  a  matter  of  doubt.  The  symptoms  are  so  vague 
that  status  lymphaticus  can  scarcely  be  diagnosed  though  it  may 
sometimes  be  suspected.  Needless  to  say,  under  these  circumstances 
the  administration  of  an  anaesthetic  or  any  surgical  operation  must  be 
undertaken  with  great  caution. 

Other  general  constitutional  conditions  such  as  tuberculosis,  syphilis, 
rheumatism,  and  gout  are  not  in  themselves  of  great  importance  in 
relation  to  operative  treatment.  Their  chief  importance  is  that  they  may 
be  the  cause  of  serious  visceral  troubles,  which  will  be  discussed  in  detail 
later  on.      Of  course  no  operation  should  be  performed  during  an  acute 


6  OPERATIONS  OX  THE  UPPER  EXTREMITY 

attack  of  gout  or  rheumatism,  or  during  the  primary  or  secondary  stages 
of  syphihs,  unless  it  were  most  urgently  called  for.  Apart  from  this,  and 
in  the  absence  of  visceral  complications,  there  is  no  reason  why  such 
patients  should  not  do  well.  Tuberculous  patients  who  require  surgical 
treatment  stand  even  extensive  operations  remarkably  well.  Active 
phthisis  is.  however,  a  strong  contra-indication  to  the  operative  treatment 
of  co-existing  surgical  tuberculous  disease,  unless  for  the  relief  of  some 
urgent  symptom. 

It  is  now  necessary  to  consider  the  influence  which  lesions  of  the 
various  viscera  exercise  upon  the  prognosis  and  the  results  of  surgical 
operations.  Very  commonly  when  an  operation  is  recommended  the 
patient  or  his  friends  will  ask  "  What  is  the  risk  ?  "  or  '*  Is  the  operation 
dangerous  ?  "  These  are  frequently  difficult  questions  to  answer.  Xo 
operation  is  entirely  free  from  risk,  even  in  a  young  and  robust  individual 
with,  as  far  as  one  can  tell,  perfectly  healthy  organs.  Indeed,  when  a 
death  does  occur  during  ansesthesia,  it  is  surprising  how  often  the  operation 
is  of  a  comparatively  trivial  nature,  such  as  removal  of  adenoids  or 
circumcision,  in  an  apparently  healthy  patient.  Death  is  then  often  due 
to  some  unsuspected  or  undiagnosable  trouble  such  as  the  status  lymphati- 
cus.  The  danger  is  naturally  increased  when  the  patient  has  some 
definite  organic  disease,  for  though  he  may  survive  the  actual  anaesthetic 
and  operation,  yet  death  may  still  occur  after  a  longer  or  shorter  interval 
from  the  additional  strain  thrown  upon  the  diseased  organ,  or  the  vital 
powers  may  be  so  depressed  that  the  patient  dies  from  post- operative 
shock.  It  is  thus  of  the  greatest  importance  that  some  examination  of 
the  chief  organs  should  be  carried  out  before  all  except  the  most  urgent 
operations.  In  the  latter  this  examination  may  be  reduced  to  a  minimum, 
or  even  omitted  altogether,  for  the  disease  or  injury,  a  depressed  fracture 
of  the  skull  or  a  strangulated  hernia  for  instance,  may  be  such  that  unless 
quickly  relieved  death  will  surely  and  quickly  occur.  Under  these 
circumstances  any  examination  which  will  delay  the  operation  must  be 
avoided ;  any  risk,  however  serious,  has  to  be  taken. 

In  young  and  healthy  patients  an  elaborate  investigation  of  all  organs 
is  not  usually  called  for.  The  patient's  general  appearance  is  noted  and 
he  is  questioned  with  reference  to  pre\aous  illnesses  and  his  general  health. 
It  should,  however,  be  an  invariable  rule  before  any  operation,  even  of 
the  most  trifling  description,  if  a  general  anaesthetic  is  required,  that 
the  condition  of  the  heart  and  circulation  should  be  ascertained  by  actual 
examination,  and  that  the  urine  should  be  carefully  tested,  especially 
for  the  presence  of  sugar  and  albumen.  Xeglect  of  these  precautions  may 
result  in  a  lamentable  disaster. 

The  influence  oi  \'iscerai  lesions  upon  the  prognosis  of  operative 
treatment  may  be  considered  under  the  following  two  heads,  (a)  As 
regards  the  immediate  danger  of  the  operation.  Here  it  is  necessary  to 
estimate  the  effect  of  the  anaesthetic  and  the  shock  of  the  operation  upon 
•  the  diseased  organ.  We  have  already  seen  that  even  when  serious  visceral 
disease  is  known  to  exist,  operation  may  be  strongly  indicated  as  the  only 
possible  means  of  saving  the  patient's  life.  The  dangers  of  the  anaesthetic 
may  then  be  usually  overcome  with  the  help  of  a  skilled  anaesthetist,  by 
the  use  of  modern  apparatus  and  methods,  or  by  the  employment  of 
local  or  of  spinal  anaesthesia.  These  patients,  however,  may  be  unable 
to  rally  after  the  operation,  the  diseased  organ  may  fail,  or  some  compli- 
cation may  develop  which  will  lead  to  a  fatal  termination. 


Examination  of  the  patient  7 

(b)  The  (jfect  of  the  Irsio)!,  upon,  the  ultimate  result  of  the  operation.  Even 
where  no  iniinediato  (liiiij^'cr  is  anticipated  frotn  the  antesthetic  or  the  oper- 
ation, the  probabh'ciTect  of  the  visceral  trou})h',  upon  the  ultimate  result 
must  be  carefully  considered.  For  instance,  if  an  elderly  patient  is  known 
to  suffer  from  chronic  Bright's  disease,  or  from  a  serious  valvular  lesion 
of  the  heart,  one  would  not  recommend  an  operation  for  the'radical  cure 
of  an  uncomplicated  hernia,  for,  apart  from  the  immediate  risks,  the 
visceral  disease  is  likely  to  prove  fatal  in  the  course  of  a  few  months  or 
years.  On  the  other  hand,  should  such  a  patient  have  a  strangulated 
hernia,  one  would  unhesitatingly  advise  him  to  take  the  risk  of  the 
operation.  In  this  case,  while  the  immediate  danger  would  not  be 
excessive,  the  alternative  to  operation  would  be  certain  death  from  ob- 
struction. The  existence  of  visceral  trouble  will  in  many  serious  diseases 
lead  the  surgeon  to  advise  palliative  treatment  in  preference  to  a  radical 
operation.  These  points  have  especially  to  be  considered  before  advising 
extensive  operations  for  the  removal  of  malignant  growths  in  elderly 
patients.  The  present  writer  some  time  ago  removed  an  extensive  growth 
from  the  floor  of  the  mouth  of  a  patient  who  had  a  trace  of  albumen  in  his 
urine.  Though  at  the  time  of  the  operation  this  man  appeared  to  be 
strong  and  in  good  health,  yet  he  died  only  four  months  later  of  cardiac 
dilatation  and  failure  secondary  to  the  chronic  renal  disease. 

Heart  and  Circulatory  System.  Preliminary  examination  of  the  heart 
and  the  circulatory  system  should  be  systematically  carried  out,  chiefly 
on  account  of  the  danger  of  the  anaesthetic  and  post-operative  shock  to  a 
patient  suffering  from  valvular  disease  or  myocardial  degeneration.  ^ 

In  addition  to  an  examination  of  the  cardiac  sounds,  it  is  of  the 
greatest  importance  to  ascertain  whether  there  is  any  hypertrophy  or 
dilatation  of  the  heart,  and  in  the  event  of  this  to  look  for  any  signs  of 
circulatory  failure  such  as  oedema,  enlargement  of  the  liver,  or  an  unduly 
rapid  or  irregular  pulse.  Advanced  valvular  disease  is  an  absolute 
contra-indication  to  any  but  the  most  indispensable  operations.  Fibroid 
or  fatty  degeneratian  of  the  myocardium  is  probably  of  at  least  as  great 
importance  as  valvular  disease  and  is  far  more  difficult  to  detect.  Before 
deciding  upon  an  operation  upon  patients  with  these  serious  lesions,  the 
risk  of  the  operation  and  the  ultimate  benefit  to  be  expected  must  be 
carefully  considered.  Such  patients  require  careful  anaesthetisation,  but 
then  usually  take  the  anaesthetic  well ;  indeed,  the  pulse  of  a  patient 
with  valvular  disease  frequently  becomes  slower  and  more  regular  when 
he  is  under  the  influence  of  an  anaesthetic.  During  the  administration 
the  greatest  care  must  be  taken  to  avoid  any  obstruction  to  respiration, 
for  a  diseased  heart  is  liable  to  fail  with  the  extra  stress  thrown  upon 
it  by  even  a  slight  degree  of  asphyxia.  The  successful  termination  of  the 
anaesthetic  and  the  operation  by  no  means  ends  the  danger  for  such  a 
patient,  for  after  he  has  been  returned  to  bed  the  pulse  may  gradually 
get  weaker,  and  death  may  still  occur  after  a  longer  or  shorter  interval  from 
cardiac  failure.  The  existence  of  cardiac  disease  has,  as  a  rule,  no  adverse 
influence  upon  the  wound,  which  may  be  expected  to  heal  in  a  normal 
manner.  In  advanced  cases  of  valvular  disease,  however,  oedema  may 
appear  around  the  wound,  and  there  then  is  an  increased  liability  to 
infection.    Quite  apart  from  any  gross  lesion  of  the  heart,  the  circulation 

1  Dr.  Joseph  C.  Bloodgood  (Annals  of  Surgery.  1912,  vol.  Iv,  p.  641)  in  a  paper  on 
"The  Estimation  of  the  Vital  Resistance  of  the  Patient  with  Reference  to  the  Possibility  of 
Recovery  after  Operations,"  insists  also  on  the  importance  of  measuring  the  blood  pressure. 


§  OPERATIONS  ON  THE  UPPER  EXTREMITY 

may  be  seriously  depressed  as  the  result  of  some  chronic  disease  such  as 
tuberculosis  of  a  bone  or  joint  with  many  sinuses,  or  from  some  serious 
acute  trouble  such  as  intestinal  obstruction  or  peritonitis.  In  the 
latter,  indeed,  if  for  any  reason  delay  has  occurred,  the  pulse  may  be 
so  rapid  and  small  that  it  can  scarcely  be  felt  or  counted  ;  if  in  addition 
the  extremities  are  cold,  death  may  shortly  be  expected,  and  any  operation 
is  contra-indicated.  When  the  circulation  is  less  severely  affected,  the 
operation  may  be  carried  out  under  spinal  or  local  anaesthesia,  if  a 
general  anaesthetic  is  considered  undesirable.  Such  patients  often  take 
a  general  anaesthetic  surprisingly  well,  but  only  too  frequently  after 
the  operation  the  pulse  again  fails,  the  heart  does  not  respond  to  stimula- 
tion or  infusion,  and  the  patient  dies.  In  addition  to  the  condition  of 
the  heart,  attention  should  also  be  directed  to  the  character  of  the 
arteries.  Extensive  atheroma  means  that  the  tissues  are  degenerate, 
and  that  their  nutrition  is  imperfectly  carried  out.  A  thickened  arterial 
wall  or  a  high  tension  pulse  may  direct  the  attention  of  the  surgeon  to 
arterio-sclerosis  or  to  chronic  renal  disease. 

If  there  is  any  disease  of  the  heart  or  of  the  circulatory  system,  and 
the  operation,  though  desirable,  is  not  urgently  necessary,  the  operation 
may  often  vnth  advantage  be  postponed  for  some  days  or  weeks,  during 
which  time  the  cardiac  lesion  is  treated. 

While  the  operation  is  in  progress  the  surgeon  should  always  observe 
the  amount  of  bleeding  and  the  colour  of  the  blood.  In  this  way  important 
indications  of  depression  of  the  circulation  will  often  be  brought  to  his 
notice.  In  severe  cases  of  cardiac  failure  an  extensive  incision  may  be 
made  ■v^ith  practically  no  haemorrhage,  and  the  few  drops  of  blood  which 
escape  will  be  distinctly  bluish  in  colour.  These  are  indications  for 
immediate  attention  to  the  condition  of  the  patient. 

Respiratory  System.  A  patient  with  any  recent  acute  lung  or 
pleural  disease  is  naturally  a  bad  subject  for  an  anaesthetic  or  an  operation. 
Occasionally,  however,  operation  may  be  the  only  possible  method  of 
treatment  of  some  complication,  an  empyema  for  instance.  Under  such 
circumstances  the  operation,  or  rather  the  anaesthetic,  may  be  accompanied 
by  considerable  risk.  Speaking  of  these  cases.  Sir  Frederick  Hewitt  ^ 
says  :  "  The  most  hazardous  cases  are  those  in  which  respiratory  em- 
barrassment from  recent  pleurisy  or  pleuro-pneumonia  co-exists  with 
quick  and  hampered  cardiac  action.  When  the  patient  is  slightly  dusky, 
his  temperature  elevated,  his  breathing  rapid  and  his  pulse  accelerated 
and  sharp  under  the  finger,  the  use  of  an  anaesthetic  is  attended  by 
considerable  risk.  This  risk  is  greater  in  patients  with  previously  fatty 
and  dilated  hearts  than  in  others."  Means  for  minimising  this  risk 
will  be  considered  when  the  operation  for  empyema  is  described,  but  in 
very  serious  cases  a  local  anaesthetic  may  be  employed.  Patients  with 
slight  chronic  bronchitis,  phthisis  or  emphysema  may  be  expected  to 
take  an  anaesthetic  and  to  stand  an  operation  well,  provided  that  the 
heart  is  not  secondarily  affected.  Obese  patients  with  bronchitis  are 
very  bad  subjects.  They  may  be  unable  to  breathe  in  the  recumbent 
position  ;  the  pulmonary  trouble  may  be  increased  by  the  anaesthetic  and 
lead  to  failure  of  the  heart,  which  is  probably  already  weakened  by  fatty 
infiltration  and  degeneration.  A  bronchitic  patient  presents  other 
difficulties  to  the  surgeon.  The  continual  coughing  will  make  the  patient 
restless  and,  especially  after  abdominal  operations,  will  throw  great  strain 

1  Ancesthetics,  1901,  p.  127. 


EXAMINATION  OF  THE  PATIENT  9 

upon  the  stitches.  Bandages  around  the  chest  or  the  abdomen  if  tight 
produce  much  dyspnoea  and  discomfort,  while  if  loose  they  are  very 
liable  to  slip  and  the  dressings  to  become  displaced.  An  ansesthetic, 
especially  ether,  may  sometimes  apparently  be  the  cause  of  an  acute 
attack  of  bronchitis  or  pneumonia.  The  latter  may  be  a  broncho- 
pneumonia when  it  is  probably  due  to  imperfect  expectoration  of  catarrhal 
secretion,  or  a  lobar  pneumonia  when  the  inhalation  may  be  the  pre- 
disposing cause.  In  rare  cases  an  anaesthetic  may  render  active  a  latent 
tuberculous  disease.  In  elderly  patients  prolonged  rest  in  bed  may  lead 
to  congestion  of  the  bases  of  the  lungs,  a  condition  which  is  likely  to 
develop  into  hypostatic  pneumonia.  This  is  a  very  fatal  post-operative 
complication  in  such  patients,  and  is  best  avoided  by  getting  them  up  as 
soon  as  possible. 

The  condition  of  the  upper  respiratory  passages  should  always  be  noted, 
for  any  obstruction  to  the  free  flow  of  air  is  pretty  certain,  owing  to 
venous  engorgement,  to  be  increased  during  anaesthesia.  When  the  field  of 
operation  is  the  buccal  or  pharyngeal  cavity,  the  removal  of  a  malignant 
growth  of  the  tongue,  floor  of  the  mouth,  or  the  pharynx,  for  example, 
blood  may  be  drawn  into  the  larynx  and  seriously  obstruct  breathing. 
Even  when  it  causes  no  actual  obstruction,  portions  of  clot  may  be  inhaled 
and  thus  be  the  starting-point  of  a  septic  broncho-pneumonia — a  serious 
danger  after  these  operations.  In  such  cases  intratracheal  insufilation 
of  ether  ^  is  the  most  satisfactory  method  of  maintaining  anaesthesia,  and 
is  most  efficient  in  preventing  the  entrance  of  blood  into  the  respiratory 
passages.  Plugging  the  pharynx  with  sterilised  gauze  after  a  preliminary 
laryngotomy,  or  Crile's  method  of  inducing  anaesthesia  by  means  of  nasal 
tubes  with  subsequent  packing  of  the  pharynx  may  also  be  employed. 

Tumours  of  the  neck,  especially  an  enlarged  thyroid,  may  be  a 
considerable  source  of  danger  during  anaesthesia.  This  to  a  great  extent 
is  mechanical,  and  is  the  result  of  asphyxia  brought  about  by  the  pressure 
of  the  tumour,  which  is  increased  in  size  by  vascular  engorgement,  upon 
the  trachea.  These  dangers  and  the  means  by  which  they  may  be  over- 
come will  be  fully  considered  when  the  operative  treatment  of  goitre 
is  discussed. 

Urinary  System.  An  examination  of  the  urine  should  be  made  as 
a  routine  measure  before  every  surgical  operation.  Should  albumen 
be  present  every  endeavour  should  be  made  to  ascertain  its  origin  and  its 
significance.  If  necessary  the  centrifugalised  deposit  should  be  examined 
microscopically  for  the  presence  of  casts,  for  if  the  albumen  is  the  result 
of  any  form  of  nephritis  it  must  have  a  most  important  bearing  upon 
the  prognosis  and  the  treatment.  Patients  suffering  from  Bright's 
disease  are  certainly  bad  subjects  for  operation.  They  may  be  unable 
to  rally  from  the  shock  of  a  severe  operation,  owing  probably  to  the 
imperfect  excretion  of  toxic  products.  In  other  cases  definite  symptoms 
of  uraemia  may  supervene  or  even  suppression  of  urine,  either  of  which 
is  practically  certain  to  terminate  fatally.  These  serious  complications 
are  especially  likely  to  occur  when  the  operation  is  for  some  injury  or 
disease  of  the  pelvic  or  renal  organs.  It  must  also  be  remembered  that 
patients  with  chronic  nephritis  are  very  liable  to  a  number  of  serious 
complications.  Of  these  cardiac  dilation  and  hypertrophy  which  may 
terminate  in  heart  failure  is  the  most  important.  Other  complications, 
such   as   bronchitis,   pleurisy,    pneumonia,   pericarditis,  and   peritonitis, 

1  See  p.  781. 


10  OPERATIONS  ON  THE  UPPER  EXTREMITY 

are  of  a  chronic  inflammatory  nature.  Any  of  these  may  readily  appear 
as  the  result  of  the  extra  strain  of  an  operation  upon  the  system.  If 
already  present  they  will  certainly  be  made  worse,  and  in  either  case 
the  patient  is  very  likely  to  succumb.  Lastly,  as  the  result  of  changes 
in  the  vascular  system  and  the  deficient  excretion  of  toxic  products, 
various  cutaneous  lesions,  such  as  eczema,  boils,  carbuncles,  and  even 
erysipelas,  may  already  be  present  or  are  likely  to  develop.  These,  in 
addition  to  a  greatly  increased  liability  to  wound  infection,  may  seriously 
and  adversely  affect  the  progress  of  the  patient.  The  mere  presence  of 
albumen  is,  of  course,  in  itself  not  a  contra-indication  to  operation  ;  in 
women  it  may  be  the  result  of  a  vaginal  discharge,  while  in  men  it  may  be 
derived  from  some  lesion  in  the  urethra  or  the  bladder.  An  explanation  of 
the  albuminuria  should,  however,  in  all  cases  be  sought  for.  Even  when 
chronic  nephritis  is  known  to  exist,  operations  are  not  necessarily  contra- 
indicated  ;  such  patients  may  do  well  even  after  severe  operations.  What 
is  needed  is  a  careful  consideration  and  estimation  of  the  risks  to  be 
run  and  the  benefits  to  be  expected.  The  latter  will  often  be  found  to 
altogether  outweigh  the  former.  If  possible  in  such  a  case  a  period  of 
rest  and  treatment  of  the  nephritis  and  its  complications  should  precede 
the  surgical  treatment. 

Should  the  operation  be  required  for  some  disease  of  the  kidneys 
or  other  portion  of  the  genito-urinary  tract,  it  is  most  necessary  to 
ascertain  the  source  of  any  albuminuria,  haematuria,  or  pyuria,  and  to 
investigate  the  excretory  functions  of  the  kidneys.  Fortunately  the 
modern  methods  of  radiography,  cystoscopy,  and  catheterisation  of  the 
ureters,  with  examination  of  the  urine  secreted  by  each  kidney,  are  of  the 
greatest  service  in  enabling  one  to  estimate  the  functional  condition 
of  these  organs. 

We  may  here  consider  the  question  of  operations  upon  patients  who 
are  suffering  from  diabetes.  Such  patients  are  very  bad  subjects  for 
operative  treatment,  and  this  disease  should  contra-indicate  any  except 
absolutely  necessary  operations.  The  dangers  may  be  considered  in  the 
three  following  groups. 

(a)  There  is  a  distinct  danger  that  the  patient  may  die  of  diabetic  coma. 
This  condition  usually  develops  as  the  result  of  mental  or  physical  shock 
in  the  subjects  of  this  disease.  An  anaesthetic  or  an  operation  is  thus 
very  likely  to  be  the  exciting  cause.  The  liability  to  coma  is  much 
diminished  if  the  disease  is  being  treated  and  the  amount  of  sugar  lost  is 
under  control.  Especially  dangerous  are  those  cases  in  which  the  disease 
is  unrecognised  and  untreated,  when  death  may  unexpectedly  follow  a 
comparatively  trivial  operation.  For  instance,  the  writer  knows  of  the 
case  of  a  young  man  aged  20  who  was  operated  upon  for  a  varicocele. 
Next  day  the  patient  became  comatose,  and  the  urine,  then  tested  for  the 
first  time,  was  found  to  contain  large  quantities  of  sugar. 

(6)  The  tissues  of  a  diabetic  patient  are  unduly  liable  to  infection  by 
pyogenic  organisms.  The  wound  is  thus  liable  to  slough,  suppurate,  or  to 
become  the  starting-point  of  a  spreading  cellulitis  which  is  very  difficult 
to  treat.  Gangrene,  usually  moist  in  character,  may  occur  in  diabetics, 
either  spontaneously  or  after  operation.  In  either  case  arterial  degen- 
eration and  peripheral  neuritis,  which  commonly  co-exist,  are  probably 
predisposing  causes.  The  gangrene  usually  occurs  in  elderly  patients, 
is  commonly  moist  in  character,  spreads  rapidly,  and  almost  always 
ends  fatally. 


EXAMINATION  OF  THE  PATIENT  11 

(c)  Certain  complications  are  likely  to  occur  in  diabetic  patients  which 
will  assuredly  have  a  serious  bearing  upon  the  prognosis.  In  addition 
to  the  septic  troubles  mentioned  alDove,  the  skin  may  be  the  seat  of 
various  lesions  such  as  eczema,  boils,  or  even  carbuncles.  Lastly  it  must 
be  remembered  that  a  diabetic  is  very  liable  to  develop  tuberculous 
disease  of  the  lungs.  It  is  always  desirable  in  diabetic  patients  to  post- 
pone, if  possible,  any  operation  until  treatment  by  dieting  and  by  drugs 
has  produced  a  considerable  decrease  in  the  excretion  of  sugar.  The 
dangers  of  the  operation  will  in  this  way  be  greatly  diminished.  Should 
the  condition  be  regarded  as  glycosuria  rather  than  as  diabetes,  that 
is  when  there  is  but  a  small  amount  of  sugar  and  no  polyuria,  the  actual 
operation  risk  is  not  serious.  It  must,  however,  be  remembered  that  a 
persistent  glycosuria  is  a  grave  condition  and  that  such  cases  may  eventu- 
ally develop  into  true  diabetes. 

Alimentary  System.  Diseases  of  the  digestive  tract  will  naturally 
have  a  considerable  effect  upon  the  general  health  and  condition  of  the 
patient.  The  subjects  of  chronic  dyspepsia,  and  those  suffering  from 
chronic  constipation,  are  not  likely  to  be  in  a  satisfactory  state  for  a 
severe  operation,  and  it  must  be  remembered  that  these  troubles  are 
certain  to  be  increased  by  the  subsequent  rest  in  bed.  Operations  should 
be  avoided,  if  possible,  in  patients  with  serious  organic  disease  of  the 
liver  such  as  cirrhosis,  lardaceous  or  fatty  disease.  Colitis,  dysentery, 
and  other  chronic  intestinal  disorders  are  also  contra-indications  to  general 
operations,  though  in  these  and  other  similar  conditions  surgical  treat- 
ment may  be  required,  and  successfully  carried  out,  for  the  intestinal 
disease  itself.  The  condition  of  the  mouth  and  teeth  should  always  be 
observed,  and  if  septic  or  carious  teeth  are  present  they  should,  if  time 
permits,  be  attended  to  before  the  operation.  This  is  especially  desirable 
if  the  operation  is  for  some  disease  in  the  mouth  or  pharynx.  Apart  from 
its  effect  upon  digestion  and  the  general  health,  oral  sepsis  means  that 
the  patient  has  a  septic  focus  from  which  organisms  may  be  carried  by  the 
blood-stream  to  the  wound,  or  indeed  to  any  part  of  the  body. 

Nervous  System.  The  influence  of  functional  disease  of  the  nervous 
system  has  been  indicated  A\'hile  the  question  of  temperament  was  under 
discussion.  An  hysterical  p;itient  i-s  very  liable  to  nervous  attacks 
either  before  or  after  the  operation  ;  in  the  latter  case  these  are  likely 
seriously  to  interfere  with  the  after-treatment.  Necessary  operative 
measures  may  be  carried  out  in  the  insane  with  a  good  prospect  of  success. 
provided  that  there  is  no  marked  bodily  disease  and  that  there  are  no 
unclean  or  mischievous  habits  which  would  seriously  imperil  a  satisfactory 
result.  When,  however,  the  patient  is  \'ioleut  or  maniacal,  an  operation 
has  but  a  faint  prospect  of  success.  "When  there  is  a  definite  organic 
nervous  trouble,  such  as  locomotor  ataxy  for  instance,  none  but  essential 
operations  should  be  carried  out.  These  diseases  may,  however,  run  a 
very  chronic  course,  and  the  patients  often  do  well  in  spite  of  the  disease 
of  the  nervous  system.  When  grave  symptoms  are  caused  by  some 
lesion  of  the  nervous  system  which  is  amenable  to  surgical  treatment,  an 
operation  may  be  successful  even  when  the  condition  of  the  patient 
appears  to  be  most  desperate.  He  may  be  absokitely  comatose  as  the 
result  of  increased  intra-cranial  pressure  after  a  depressed  fracture, 
haemorrhage  from  the  middle  meningeal  artery,  or  from  a  cerebral  abscess, 
and  vet  recover  after  these  conditions  have  been  relieved. 


12         OPERATIONS  ON  THE  UPPER  EXTREMITY 


PREPARATION  OF  THE  PATIENT  FOR  THE  OPERATION 

General  Preparation.  It  is  now  necessary  to  consider  in  some 
detail  the  preliminary  treatment  and  the  general  preparation.  It  is 
advisable  in  all  cases  that  the  patient  should  be  mider  observation  in  the 
hospital  ward,  imrsing  home,  or  wherever  the  treatment  is  to  be  carried 
out.  for  at  least  twenty-four  hours  beforehand.  Of  course  in  grave  surgical 
emergencies,  time  is  of  such  importance  that  the  operation  must  be 
performed  as  soon  as  possible,  at  the  expense  of  or  even  to  the  total 
exclusion  of  all  these  precautions.  In  many  cases  a  longer  period  than 
twenty-four  hours  is  desirable,  and.  as  has  already  been  indicated,  when 
there  is  any  adverse  local  or  constitutional  trouble  ample  time  should  if 
possible  be  allowed  for  its  satisfactory  treatment. 

Immediately  upon  admission  to  the  institution  the  patient  should  have 
a  hot  bath  and  thoroughly  wash  the  whole  body.  Should  the  local 
or  constitutional  condition  render  this  undesirable,  he  is  at  once  put  to 
bed  and  then  thoroughly  washed  by  a  nurse.  This  will  be  repeated  daily 
through  the  whole  period  of  preliminary  observation.  During  this  time 
the  condition  of  the  teeth  and  mouth  should  also  always  receive  attention, 
especially  if  the  operation  is  for  some  disease  of  the  upper  respiratory 
passages.  When  tartar  is  present,  or  when  there  are  septic  or  carious 
teeth  or  roots,  it  is  desirable  that  these  should  receive  attention  before  the 
operation.  When  these  troubles  are  not  present,  the  use  of  the  tooth- 
brush, and  the  occasional  use  of  some  antiseptic  mouth-wash  such  as 
chinosol  1  in  1000,  are  all  that  are  required.  Any  other  focus  of  infection 
such  as  tonsilUtis,  nasal  catarrh,  boils  or  other  cutaneous  lesions,  especially 
if  in  or  near  the  field  of  operation,  should  also  receive  careful  attention. 
The  bowels  should  be  emptied  by  a  purgative  administered  on  the 
preceding  day,  followed  by  a  saline  aperient  or  soap  and  water  enema 
six  hours  before  the  operation.  Should  the  operation  be  for  some 
disease  of  the  rectum  or  other  part  of  the  intestinal  tract,  it  is  most 
desirable  that  the  bowel  shall  be  empty.  In  the  former  case,  an  opera- 
tion for  piles  for  example,  a  copious  enema  should  be  administered  about 
eight  hours  before  the  operation.  On  the  other  hand  the  purging 
must  not  be  overdone,  for  it  is  naturally  a  bad  thing  for  the  operation  to 
take  place  while  the  patient  has  an  attack  of  diarrhoea  from  this  cause. 
Excessive  purgation,  too.  is  likely  to  have  a  serious  effect  in  elderly 
patients,  or  in  those  suffering  from  an  exhausting  disease. 

It  is  desirable  that  for  some  days  beforehand  only  light  and  easily 
digestible  food  should  be  taken.  The  stomach  should  always  be  empty 
during  the  administration  of  an  ansesthetic.  and  hence  the  time  of  the  meal 
immediately  preceding  vdW  depend  upon  the  hour  at  which  the  operation 
will  take  place  ;  it  is  generally  agreed  that  the  best  time  is  the  morning 
at  an  early  hour.  In  this  case  a  healthy  adult  will  have  had  nothing  after 
his  evening  meal  the  preceding  day,  with  perhaps  the  exception  of  a  cup 
of  weak  tea  two  or  three  hours  before. 

If,  however,  the  patient's  general  condition  is  weak,  or  in  old  people, 
such  long  starvation  is  undesirable.  These  may  be  allowed  small  oc- 
casional feeds  of  clear  soup  or  chicken  broth  throughout  the  night.  In 
some  cases  where  there  is  much  exhaustion  a  little  alcohol  in  the  form 
of  weak  brandy  or  whisky  and  water  may  also  be  allowed.  If  the  opera- 
tion is  to  take  place  at  any  other  hour  of  the  day  the  last  meal  should,  as 


prp:paratiox  of  the  patient  13 

a  general  rule,  be  given  about  five  hours  before  the  commencement  of  the 
anaesthesia. 

The  bladder  should  always  be  emptied  before  the  patient  is  brought 
into  the  operating  room.  Should  there  be  any  question  as  to  this  having 
been  satisfactorily  accomplished,  a  catheter  should  be  passed,  especially 
before  abdominal  or  pelvic  operations.  The  patient  should  be  suitably 
clothed  in  a  clean  night-gown  or  pyjama  suit  ;  the  former  is  usually  to  be 
preferred,  and  should  be  made  to  completely  unbutton  at  the  back  so  that 
it  may  be  readily  adjusted  or  removed  as  required  during  the  operation. 
In  weak  and  exhausted  patients,  and  especially  in  elderly  people  and 
children,  additional  warmth  may  be  secured  by  loosely  bandaging  the 
limbs  and  any  part  of  the  body  which  need  not  be  exposed,  over  a  thin 
covering  of  cotton-wool  or  gamgee  tissue.  Any  false  teeth  must  be 
removed  before  the  commencement  of  the  ansesthetic. 

Asepsis.  It  is  now  necessary  to  consider  a  most  important  series 
of  preparations  and  precautions,  the  object  of  which  is  to  prevent  infection 
of  the  wound.  In  other  words  we  have  to  describe  the  means  for  securing 
Asepsis.  A  short  sketch  is  all  that  can  here  be  given  ;  for  fuller  details 
the  reader  is  referred  to  some  such  book  as  Lockwood's  Aseptic  Surgery 
(1909),  from  which  many  of  the  facts  described  below  are  taken. 

The  importance  of  asepsis  is  now  universally  admitted.  If  any 
wound  suppurates,  even  to  the  slightest  extent,  it  means  that  infection 
has  somehow  occurred  ;  in  the  great  majority  of  cases  this  is  brought 
about  by  some  failure  in  the  aseptic  precautions  of  the  surgeon  or  his 
assistants.  The  universal  presence  of  pathogenic  organisms  which  are  the 
cause  of  inflammation,  suppuration,  and  serious  comphcations  such  as 
pyaemia  and  septicaemia,  has  been  amply  proved.  Any  object,  be  it 
a  ligature,  an  instrument,  the  hand  of  the  surgeon  or  the  skin  of  the 
patient,  must  be  regarded  as  septic  and  liable  to  infect  a  wound,  unless 
it  has  been  specially  prepared  to  ensure  the  destruction  of  all  organisms 
which  may  be  present.  Infection  of  a  wound  may  be  brought  about  in 
any  of  the  following  ways. 

(1)  Air  Infection.  Though  the  air  may  contain  large  numbers  of 
micro-organisms.^  both  pathogenic  and  non-pathogenic,  this  source  of 
infection  is  not  of  great  importance  provided  that  certain  precautions  are 
taken.  When  the  air  is  dry  and  contains  much  dust,  many  organisms 
will  be  present ;  if  the  air  is  perfectly  still  the  dust  and  bacteria  gravitate, 
with  the  result  that  the  air  does  not  infect  culture-plates.  Also  when  the 
air  is  saturated  ^^^th  moisture  it  is  practically  sterile. 

Organisms  are  with  difficulty  detached  from  a  moist  surface  ;  dust 
must  therefore  be  both  carefully  and  thoroughly  removed  from  the  ope- 
rating room.  Expired  air,  in  ordinary  quiet  breathing,  is  stated  to  be 
practically  free  from  organisms.  When,  however,  as  happens  in  coughing, 
sneezing,  or  talking,  small  particles  of  saliva  or  nasal  mucus  are  projected, 
various  pathogenic  organisms  are  certain  to  be  present.  Streptococci, 
for  instance,  are  always  found  in  saliva.  Particles  of  dust  from  the  hair 
are  naturally  septic  and  can  readily  infect  a  wound.  It  is  thus  very 
necessary  that  the  surgeon  and  his  assistants  should  take  precautions  to 

^  Mr.  Lockwood  quotes  experiments  in  which  sterilised  culture-plates  were  exposed 
for  a  few  minutes  in  hospital  wards  and  operating  theatres.  Among  the  organisms 
found  were  the  Bacillus  coU,  Staphylococcus  pyogenes  aureus  and  albus,  as  well  as  many 
non-pathogenic  moulds  and  sarcinse.  Streptococcus  pj'ogenes  was  found  in  the  air  of 
the  erysipelas  ward,  while  the  tubercle  bacillus  was  very  commonly  present  in  the  air 
of  wards  occupied  by  phthisical  patients. 


14  OPERATIONS  ON  THE  UPPER  EXTREMITY 

prevent  this  accident,  which  is  exceedingly  hkely  to  happen  on  bending 
over  a  wound,  especially  if  two  heads  should  come  into  contact.  It  may 
here  be  mentioned  that  flies  and  other  insects  may  be  the  means  of  con- 
veying septic  organisms  and  so  infecting  a  wound. 

(2)  Skin  Infection.  Infection  of  the  wound  by  organisms  which  are 
found  either  upon  the  surface  or  in  the  deeper  layers  of  the  skin  is 
undoubtedly  a  very  common  cause  of  suppuration  after  operations.  I'he 
wound  may  be  infected  from  the  skin  of  the  patient  or  from  the  hands  of 
the  surgeon  or  of  any  of  his  assistants. 

The  surface  of  the  human  skin  swarms  vnth  various  cocci,  bacteria, 
and  other  organisms  both  pathogenic  and  non-pathogenic,  even  in  a 
cleanly  individual ;  this  is  especially  the  case  when  there  is  any  hair 
present  to  collect  and  retain  particles  of  dust.  When  the  skin  is  obviously 
dirty,  or  when  any  disease  such  as  eczema  is  present,  their  variety  and 
number  are  greatly  increased.  Organisms  are  certain,  too,  to  be  present 
in  large  numbers  in  any  natural  folds,  wrinkles,  or  depressions,  such  as 
the  axillse,  the  groin,  or  the  umbilicus.  Such  localities  always  require 
careful  attention,  and  even  then,  owing  to  the  numerous  sweat  and 
sebaceous  glands  and  a  liability  to  dermatitis,  are  very  difficult  to  render 
surgically  clean.  With  regard  to  the  hands  of  the  surgeon,  the  grooves 
beneath  the  nails,  and  any  loose  tags  of  skin,  are  certain  to  contain  and 
shelter  many  infective  organisms.  Needless  to  say,  rough,  cracked,  or 
chapped  hands,  or  the  presence  of  any  sej^tic  lesion,  mean  many  organisms 
which  it  will  be  difficult  or  impossible  to  destroy  even  by  the  most  careful 
cleansing  process.  It  is  necessary  to  bear  in  mind  that  numerous  cocci 
and  bacteria  always  exist  in  the  deeper  layers  of  the  skin.  This  is 
largely  owing  to  the  presence  of  the  sebaceous  and  the  sweat  glands. 
If  the  surface  of  the  skin  is  carefully  cleansed,  and  perspiration  subse- 
quently occurs,  these  septic  organisms  are  brought  to  the  surface  in  large 
numbers  by  the  secretion  ;  their  presence  may  also  be  proved  if,  after  the 
skin  has  been  prepared,  material  is  squeezed  from  the  sebaceous  glands. 

The  fatty  nature  of  the  secretion  also  to  a  great  extent  protects  the 
organisms  and  thus  hinders  their  destruction  by  watery  antiseptic  solutions 
which  do  not  dissolve  fatty  substances. 

(3)  Infection  hy  Instruments.  Unless  careful  precautions  are  taken, 
a  clean  wound  may  be  easily  infected  by  the  use  of  instruments  which 
have  previously  been  ■  employed  for  a  septic  case.  Blood,  pus,  or  other 
septic  material  may  readily  lodge  in  the  serrations  or  joints  of  such 
instruments  as  forceps  or  scissors.  Instruments  are  now  made  as  far 
as  possible  entirely  of  metal,  with  only  necessary  grooves  and  ridges,  in 
order  to  facilitate  cleaning.  After  use,  all  blood  or  discharge  must  be 
removed  by  careful  washing  and  brushing  ;  many  such  instruments  as 
forceps  and  scissors  are  constructed  with  detachable  joints  which  allow  the 
two  halves  of  the  instrument  to  be  separated  during  the  cleansing  process. 
If  not  properly  cleaned,  even  boiling  may  fail  to  effect  perfect  sterilisation, 
for  the  albumen  of  the  blood  \n\\  be  coagulated  and  will  thus  form  an 
envelope  which  is  likely  to  protect  organisms  and  especially  spores  from 
the  action  of  antiseptic  lotions,  or  even  for  some  time  from  the  action  of 
boiling  water. 

(4)  Infection  hy  Towels,  Swabs,  and  Dressings.  Unless  all  these  articles 
are  freshly  and  effectively  sterihsed  before  the  operation  they  may 
easily  infect  the  wound.  Towels,  for  instance,  though  fresh  from  the 
laundry  and    apparently  quite  clean,  are  in  reahty  extremely  septic, 


PREPARATION  OK  THE  PATIENT  l.> 

partly  owing  to  contamination  by  dust,  but  also  by  the  water  in  whicii 
they  were  washed,  probably  in  company  with  many  other  soiled  and 
dirty  articles.  Dry  gauzes  and  wools,  even  though  impregnated  with 
antiseptics,  will  also  collect  dust  and  thus  harbour  many  organisms. 
Unless  recently  sterilised,  gauzes  should  only  be  applied  to  the  wound 
after  immersion  in  an  antiseptic  lotion.  Marine  sponges  are  now  practi- 
cally obsolete,  for,  owing  to  their  porous  structure,  when  they  have  once 
been  used  their  subsequent  sterilisation  is  a  matter  of  considerable 
difficulty  and  uncertainty.  Their  place  is  taken  by  swabs  of  absorbent 
material  such  as  gamgee  tissue  enclosed  in  layers  of  gauze. 

(5)  Infection  hy  Sutures  and  Ligatures.  All  materials  used  for  ligatures 
and  sutures  are  certain  to  be  contaminated  until  they  have  been  carefully 
sterilised.  This  is  especially  the  case  with  catgut,  which  is  prepared  from 
the  intestines  of  sheep  after  the  mucous  membrane  has  been  more  or  less 
thoroughly  removed  by  scraping.  Raw  catgut,  from  its  origin  and  mode 
of  preparation,  is  thus  certain  to  contain  numerous  pathogenic  organisms, 
and  unless  effectively  sterilised  is  extremely  likely  to  infect  the  wound. 
It  is  said  that  even  anthrax  has  been  transmitted  to  a  wound  by  im- 
perfectly sterilised  catgut. 

This  material  has,  however,  many  advantages  in  favour  of  its  use  for 
buried  sutures  :  it  is  strong,  pliable,  easy  to  manipulate,  and  is  eventually 
absorbed  and  is  hence  very  ganerally  employed.  Fortunately,  though 
it  cannot  be  sterilised  by  boiling  in  water,  there  are  other  very  effective 
methods  of  sterilisation  which  render  it  quite  safe  and  reliable. 

(6)  hifeetion  hy  Water.  There  is  less  danger  of  infection  from  water 
than  might  have  been  supposed,  for  though  ordinary  tap  water  may  con- 
tain many  bacteria,  cocci  and  other  organisms  are  chiefly  saprophytes, 
and  hence  do  not  grow  in  living  tissues.  Sej^tic  organisms  such  as  the 
Bacillus  coli  and  various  forms  of  streptococci  and  staphylococci  may,  how- 
ever be  found,  but  in  good  tap  water,  such  as  is  supplied  in  London,  these 
organisms,  if  present,  occur  only  in  very  small  numbers.  The  water  may, 
however,  be  contaminated  by  dirty  taps  or  by  contact  with  improperly 
prepared  vessels.  In  the  operating  theatres  of  Guy's  Hospital  the  water, 
both  hot  and  cold,  which  is  used  for  preparing  lotions  and  saline  solutions 
for  irrigation  and  other  purposes,  is  filtered  through  Berkefeld  filters. 

This  water  is  regularly  examined  bacteriologically,  and  organisms 
of  any  description  are  only  found  on  rare  occasions.  Cleansing  or  renewing 
the  internal  mechanism  of  the  filter  then  results  in  their  disappearance. 
If  tap  water  is  boiled  for  a  few  minutes,  or  if  antiseptics  in  the  pr.oportion 
required  for  making  the  ordinary  lotions  are  added,  all  organisms  are 
quickly  destroyed.  Boiled  tap  water  may  thus  be  quite  safely  used  for 
the  preparation  of  lotions,  or  of  saline  solutions  for  infusion  or  irrigation. 
Indeed,  for  the  former  purpose  boiled  tap  water  is  preferable  to  distilled 
water,  which  usually  contains  many  organisms  and  may  on  this  account 
be  decidedly  toxic. 

(7)  Auto-inoculation.  Infection  of  the  wound  by  organisms  conveyed 
by  the  patient's  own  blood-stream  may  certainly  occur.  It  is,  however, 
unlikely,  and  though  its  frequency  cannot  be  ascertained,  it  is  probably 
a  very  rare  cause  of  suppuration  compared  with  local  infection  of  the 
wound.  This  is  shown  by  the  rarity  of  suppuration  after  an  injury 
which  does  not  wound  the  skin — a  simple  fracture  for  instance.  When 
it  does  occur  there  is  nearly  always  some  obvious  local  septic  focus  such 
as  pyorrhoea  alveolaris,  a  septic  throat,  or  some  septic  ulcer  or  sinus, 


16  OPERATIONS  ON  THE  UPPER  EXTREMITY 

On  this  account  it  is  highly  desirable  that  any  such  trouble  should  be 
recognised  and  efficiently  treated  before  the  operation. 

It  will  now  be  necessary  to  consider  the  precautions  which  must  be 
taken  to  guard  against  infection.  Sterilisation  may  be  effected  either 
by  the  action  of  heat  or  by  the  use  of  chemical  antiseptics.  The  former 
is  the  more  effective  method  but  cannot  always  be  employed.  The 
skin  and  other  living  tissues,  for  instance,  can  only  be  cleansed  by  the 
mechanical  processes  of  washing  and  irrigation,  and  by  the  use  of  anti- 
septics. It  must  be  remembered  that  strong  antiseptic  lotions  may  have 
a  very  serious  effect  upon  living  tissues,  the  vitality  of  which  is  probably 
already  lowered  by  injury  or  disease.  The  skin  may  be  irritated,  or  even 
a  severe  dermatitis  may  be  produced  ;  delicate  tissues  may  slough  or  have 
their  vitality  so  depressed  that  their  power  of  resistance  to  infecting 
organisms  is  greatly  diminished. 

A.  Preparation  oJ  the  Skin  of  the  Patient.  Two  methods  must  be 
described.  (1)  By  antiseptic  comipresses.  This  method  is  now  but  seldom 
employed.  After  careful  shaving  for  some  distance  around  the  proposed 
incision,  the  surgeon,  having  first  carefully  cleaned  his  own  hands,  then 
thoroughly  scrubs  the  skin  with  a  sterilised  nail-brush  and  hot  soap  and 
water  to  which  a  little  dilute  liquor  potassse  has  been  added.  The 
process  is  then  repeated  with  an  antiseptic  lotion  such  as  lysol  1  per  cent, 
or  carbolic  lotion  1  in  40.  A  compress,  consisting  of  several  layers  of  lint, 
which  after  sterilisation  by  boiling  is  soaked  in  the  same  antiseptic 
solution,  is  then  applied.  This  is  covered  with  a»  layer  of  gutta-percha 
tissue  and  is  then  bandaged  in  position.  The  compress  remains  in 
position  for  twelve  or  twenty-four  hours,  or  even  longer  before  the  opera- 
tion. In  the  latter  case  it  is  usually  changed  and  a  fresh  compress 
similarly  prepared  applied  every  twelve  hours.  Unfortunately  this 
treatment  not  infrequently  defeats  its  own  object.  The  mechanical 
effect  of  the  brush  combined  with  the  irritant  action  of  the  antiseptic  may 
produce  severe  irritation  of  the  skin  or  even  an  acute  dermatitis.  When 
this  occurs,  infecting  organisms  are  certain  to  be  present  and  the  operation 
must  be  postponed  until  the  skin  has  recovered.  It  is  now  recognised 
that  all  irritation  of  the  skin  is  harmful  and  that  thorough  washing 
with  soap  and  hot  water  is  the  most  effective  and  least  irritating  means 
of  cleansing  the  skin.  This  will  not  destroy  the  organisms  in  the  deeper 
layers,  though  the  mechanical  effect  of  the  washing  will,  to  a  considerable 
extent,  remove  the  secretion  of  the  glands.  Alcoholic  solutions  of 
antisepti-cs,  such  as  biniodide  of  mercury  1  in  1000,  have  however  a 
powerful  action  in  destroying  these  cutaneous  organisms,  probably  because 
the  alcohol  dissolves  fatty  substances  and  thus  secures  greater  penetration 
of  the  solution. 

(2)  The  Iodine  Method.  Within  the  past  few  years  it  has  also  been 
recognised  that  an  alcoholic  solution  of  iodine  has  remarkable  powers  of 
destroying  the  cutaneous  organisms.  The  strength  of  the  solution  should 
be  between  2  per  cent,  and  5  per  cent.  The  tincture  of  iodine  (B.P.) 
contains  2|  per  cent,  iodine  and  answers  admirably.  A  solution  of 
iodine  in  methylated  spirit  should  not  be  used,  since  the  iodine  readily 
evaporates  from  this  and  causes  intense  irritation  of  the  eyes  of  those 
present  in  the  room.  A  most  important  point  to  remember  when  iodine 
is  used,  is  that  for  its  efficient  action  the  skin  must  be  dry.  This  has 
led  some  surgeons  to  dispense  with  preliminary  shaving  of  the  skin. 
Hair  is,  however,  of  such  importance  in  collecting  dust  that  shaving  is 


PREPARATION  OF  THE  PATIENT  17 

certainly  desirable.  It  may  be  carried  out  by  means  of  a  sharp  dry 
razor  without  wetting  the  skin,  or  if  the  razor  is  used  after  washing  and 
lathering,  the  skin  should  be  thoroughly  dried  with  a  sterilised  swab  and 
then  treated  with  alcohol  or  ether  before  the  application  of  the  iodine 
solution.  The  sterility  of  the  skin  may  be  tested  by  examining  bacterio- 
logically  a  thin  snip  through  its  entire  thickness  from  the  margin  of  the 
operation  incision.  In  one  series  of  thirty-five  consecutive  cases,  in  which 
tincture  of  iodine  was  the  only  antiseptic  used,  only  three  on  cultivation 
showed  the  presence  of  any  organisms,  and  in  each  of  these  the  Staphy- 
lococcus albus  was  found,  ^ 

The  exact  details  of  this  mode  of  skin  preparation  naturally  vary 
somewhat  in  different  hospitals  and  with  different  surgeons.  It  is, 
however,  generally  agreed  that  it  should,  whenever  possible,  be  carried 
out  before  the  patient  is  removed  to  the  operating  room.  By  this  means 
much  mess  and  unnecessary  loss  of  time  may  be  avoided.  The  entire 
preparation,  however,  may  in  an  urgent  case  be  carried  out  with  ad- 
vantage in  the  operating  room. 

If  the  former  method  is  decided  upon,  the  surgeon,  after  carefully 
washing  and  preparing  his  own  hands,  shaves  the  skin  of  the  patient 
for  an  area  considerably  beyond  the  limits  of  the  proposed  incision  : 
should  this  be  in  the  groin  or  the  abdomen  the  pubes  should  always  be 
completely  shaved  ;  it  is  not  sufficient  to  remove  the  hair  from  the 
side  of  the  incision  only.  The  shaved  area  is  then  thoroughly  washed 
with  soap  and  hot  water  for  at  least  five  minutes,  A  boiled  nail-brush 
should  be  used,  but  not  too  \agorously,  and  the  dirty  soap  and  water  must 
be  frequently  washed  away.  Soft  soap  may  be  used,  but  ether  soap  or 
a  solution  of  soap  in  spirit  is  preferable.^  The  skin  is  dried  as  thoroughly 
as  possible  with  a  sterilised  swab  and  then  washed  over  with  ether. 
When  this  has  evaporated,  tincture  of  iodine  is  freely  applied  to  the 
whole  prepared  area.  Special  care  is  directed  to  the  umbilicus  or  to 
any  skin  fold  such  as  the  axilla  or  the  groin.  The  prepared  area  is  then 
covered  with  a  sterilised  pad  or  towel,  which  is  secured  in  position  by  a 
bandage.  The  patient  is  now  ready  to  be  transferred  to  the  anaesthetising 
room.  Before  the  commencement  of  the  operation  the  pad  is  removed 
and  a  final  application  of  tincture  is  made.^ 

When  in  urgent  cases  the  entire  preparation  is  carried  out  in  the 
operating  theatre,  this  procedure  must  be  modified.  In  a  cleanly 
patient  the  skin  may  be  shaved  with  a  sharp  dry  razor,  and  then,  after 
washing  with  ether,  the  iodine  solution  is  applied.  If  the  skin  is  devoid 
of  hair  the  shaving  may  be  omitted  ;  if  it  is  obviously  dirty  it  must  be 
first  scrubbed  with  ether  soap  and  hot  water,  then  thoroughly  dried  with 
a  sterilised  pad,  and  finally,  after  treatment  with  ether  or  alcohol,  is 
painted  over  with  the  iodine  solution.  When  septic  ulcers,  sinuses, 
fistulae,  or  granulating  surfaces  are  present,  it  is  impossible  to  sterilise  them 
or  the  adjacent  skin.  The  use  of  a  nail-brush  under  these  circumstances 
is  liable  to  be  actually  harmful,  as  by  this  means  infective  material  may 

1  Hec  Lancet,  1911,  vol,  1,  p,   73.3, 

2  A  solution  of  two  parts  of  soft  soap  in  one  of  methylated  spirit  may  be  used.  Ether 
soap  (B.P.C.)  has  the  following  composition:  oleic  acid,  .^vij  ;  potassium  hydroxide, 
saturated  solution,  a  sufficient  quantity  ;  alcohol,  giij  ;  oil  of  lavender,  iq  xx  ;  methy- 
lated ether  to  5xx. 

^  A  1  per  cent,  solution  of  picric  acid  in  rectified  or  methylated  spirit  has  also  been 
strongly  recommended  for  sterilising  the  skin.  It  is  applied  in  the  same  way  as  the 
tincture  of  iodine.  This  solution  is  much  cheaper  and  is  said  to  penetrate  much  more 
readily  to  the  deeper  layers  of  the  epidermis  than  the  iodine  solution. 

SURGERY  I  2 


IS  OPERATIONS  ON  THE  UPPER  EXTREMITY 

be  rubbed  into  and  thus  infect  the  sldn.  Septic  sinuses  and  fistulse  may 
be  plugged  with  gauze,  but  should  if  possible  be  covered  by  steriHsed 
towels  or  pads  during  the  operation.  Masses  of  granulation  tissue  or 
fungating  growth  may  sometimes  with  advantage  be  sterilised  by  the 
use  of  the  actual  cautery. 

B.  Preparation  of  the  Operating  Room.  In  every  properly  equipped 
hospital  or  nursing  institution  one  or  more  rooms  are  specially  constructed 
and  set  apart  for  the  performance  of  operations.  A  modern  operating 
theatre  need  not  be  described  here  in  detail.  It  should,  however,  be  a 
large,  well- ventilated  room  which  can  be  quickly  heated.  The  floor 
should  be  of  some  material  such  as  mosaic  or  concrete — not  of  wood — 
which  is  free  from  cracks  and  joints  and  can  readily  be  cleaned.  The 
walls  and  ceiling  should  be  tiled,  or  made  of  some  smooth  material  which 
will  not  collect  dust  and  can  easily  be  washed.  All  corners  and  angles 
should  be  rounded,  and  there  should  be  no  ledges,  cracks,  or  crevices 
in  which  dust  can  collect.  Needless  to  say  there  must  be  no  unnecessary 
furniture,  only  the  operating  table,  smaller  tables  for  in.struments, 
dressings,  and  aneesthetic  apparatus,  and  if  desired,  stools  for  the  operator 
and  the  anaesthetist.  These  should  all  be  constructed  as  simply  as 
possiVjle  of  metal  and  glass  and  should  be  kept  scrupulously  clean. 

It  will  sometimes  be  impossible  to  move  the  patient,  and  the  surgeon 
will  then  have  to  operate  in  a  room  .in  a  private  house.  In  this  event 
all  unnecessary  articles  of  furniture,  as  well  as  all  pictures,  curtains, 
carpets,  and  rugs,  should  be  removed  from  the  room  most  suitable  for 
this  purpose.  It  is  desirable  that  these  preparations  should  be  carried  out 
on  the  preceding  day.  so  as  to  allow  time  for  thorough  dusting  of  the 
room  and  scrubbing  the  floor.  Immovable  articles  of  furniture  should 
be  covered  over  with  sheets  which  have  been  sprinkled  with  carbolic 
lotion.  Most  modern  operating  rooms  are  provided  with  a  small  adjoining 
room  in  which  the  patient  is  anaesthetised,  and  another  in  which  the 
surgeon  and  his  assistants  prepare  for  the  operation.  No  one  thus  enters 
the  operating  room  until  he  is  fully  prepared  and  is  wearing  a  sterilised 
overall,  cap,  and  mask. 

C.  Preparation  oi  the  Surgeon  and  his  Assistants.  The  hands  of 
the  surgeon  and  his  assistants  are  undoubtedly  a  very  likely  source  of 
wound  infection.  Their  preparation  thus  demands  the  greatest  care.  At 
the  present  day  thin  rubber  gloves,  which  can  be  sterilised  by  boiling, 
are  almost  invariably  worn.  This,  however,  does  not  render  careful 
preparation  of  the  hands  any  the  less  necessary.  During  the  operation 
the  glove  may  be  pricked  or  torn  ;  septic  fluid  will  then  exude  through  the 
puncture  and  infect  the  wound  unless  the  hands  have  been  thoroughly 
sterihsed.  Exactly  the  same  precautions  must  be  taken  by  all  assistants, 
otherwise  instruments,  sutures,  or  dressings  may  be  infected  by  contact 
with  their  septic  hands.  If  the  surgeon  has  any  suppurating  or  infective 
lesion  on  the  hand  or  fingers  he  ought  not  to  operate,  for  it  is  impossible 
to  sterilise  such  an  area  which  is  thus  a  source  of  great  danger.  The  nails 
should  be  cut  as  short  as  possible  to  facilitate  cleansing  of  the  underlying 
groove.  The  skin  of  the  hands  must  be  kept  smooth,  for  any  roughness, 
from  the  repeated  use  of  lotions  or  other  cause,  means  innumerable  minute 
cracks  and  depressions  in  which  organisms  may  collect,  and  which  render 
sterilisation  a  matter  of  great  difficulty  or  even  impossibiUty.  The  hands 
should  be  cleaned  by  thoroughly  scrubbing  them  with  a  boiled  nail-brush 
and  hot  soap  and  water  for  at  least  five  minutes.     The  water  must  be  as 


PREPARATION  OF  TIIK  PATIENT  19 

hot  as  possible  and  should  flow  as  a  continuous  stream  or  spray.  If 
a  basin  is  used  for  washing,  the  water  should  be  changed  several  times 
during  the  cleansing  process.  The  hands  may  then  be  rinsed  in  weak 
lysol  and  finally  are  immersed  in  an  alcoholic  solution  of  biniodide 
of  mercury  (1  in  1000).  The  gloves,  which  have  been  rendered  sterile 
by  boiling  for  five  minutes,  are  now  put  on.  The  surgeon  then  takes  an 
overall,  a  cap  and  a  mask,  all  of  which  have  been  previously  sterilised. 
The  case  containing  these  is  opened  by  a  nurse,  and  care  is  taken  that 
neither  the  overall  nor  the  surgeon's  hands  touch  the  edge  of  this  receptacle. 
The  overall  should  be  of  sufficient  length  to  reach  to  the  ankles,  and  it 
should  be  provided  with  sleeves  which  are  not  too  loose  and  can  be 
buttoned  at  the  wrist.  The  cuff  of  the  glove  should  be  turned  up  over  the 
sleeve  of  the  overall  so  that  no  part  of  the  forearm  or  wrist  is  left  exposed. 
Short-sleeved  overalls  should  not  be  worn,  as  they  leave  a  considerable 
area  of  forearm  uncovered  which  is  probably  imperfectly  sterilised 
and  is  certain  to  come  into  contact  with  towels  or  instruments.  The  cap, 
which  ought  to  completely  cover  the  hair  and  fit  fairly  tightly  to  the  head, 
may  be  placed  on  the  head  by  an  assistant.  The  mask,  which  consists  of 
several  layers  of  gauze,  should  cover  both  the  nose  and  the  mouth,  and  if 
the  surgeon  wears  a  moustache  or  beard  these  also.  It  is  desirable  that 
clean  rubber  overshoes  should  be  worn  over  boots  while  in  the  operating 
theatre.  Otherwise  mud  and  dirt  from  the  streets,  which  is  swarming 
with  organisms  and  can  easily  be  disseminated  as  dust,  will  certainly  be 
brought  into  the  theatre. 

D.  Sterilisation  of  Instruments.  Instruments  should  be  sterilised  by 
boiling  them  in  a  metal  steriliser  for  at  least  five  minutes,  care  being  taken 
that  the  instruments  are  completely  immersed.  A  teaspoonful  of 
ordinary  washing  soda  may  with  advantage  be  added  to  each  pint  of 
water.  This  shghtly  raises  the  boiling-point  and  also  prevents  the 
instruments  rusting.  Most  sterilisers  are  provided  with  a  perforated  tray 
which  may  be  removed  and  the  instruments  tipped  into  a  sterilised 
dish  containing  carbolic  lotion  (1  in  20),  lysol  2  per  cent.,  or  boiled  water, 
according  to  the  wish  of  the  operator. 

If  there  is  no  perforated  tray,  the  instruments  should  be  removed  one 
by  one  with  a  pair  of  boiled  forceps.  Before  the  operation  the  instru- 
ments may  be  arranged  upon  a  sterilised  towel  spread  out  upon  and 
completely  covering  a  small  glass  table  set  apart  for  this  purpose. 
Cutting  instruments  are  liable  to  be  blunted  by  this  treatment.  If 
boiled  they  should  be  wrapped  in  gauze  to  prevent  contact  with  other 
instruments,  or  they  may  be  effectively  sterilised  by  leaving  them  in 
carbolic  lotion  (1  in  20)  for  fifteen  to  thirty  minutes,  or  in  absolute 
alcohol  for  about  the  same  time.  Though  instruments  should  not  be 
needlessly  prepared,  all  that  are  required  or  are  likely  to  be  required 
should  be  sterilised  before  the  commencement  of  the  operation  :  if  any 
instrument  is  unexpectedly  required  the  process  of  sterilisation  is  apt  to 
be  hurried  and  hence  imperfect.  After  the  operation  the  instruments 
must  be  carefully  washed  and  scrubbed  to  remove  all  traces  of  blood  and 
discharge.     They  are  then  boiled  and  dried  before  being  put  away. 

E.  Sterilisation  of  Sutures  and  Ligatures.  Many  materials  have  been 
employed  for  sutures  and  ligatures.  Those  in  common  use  at  the 
present  day  are  silkworm  gut  and  horsehair  for  the  skin,  and  celluloid 
thread,  silk,  and  catgut  for  uniting  deeper  structures.  Michel's  metal 
clips  are  also  frequently  used  for  bringing  the  divided  edges  of  the 


20  OPERATIONS  ON  THE  UPPER  EXTREMITY 

skin  into  apposition.  Silver  wire,  though  occasionally  used  for  suturing 
bone,  is  but  seldom  used  for  approximating  soft  parts.  AU  the  above 
with  the  exception  of  catgut  can  be  sterilised  by  boihng  ;  silk,  however, 
requires  special  precautions.  Short  lengths  should  be  unwound  from  the 
wooden  reels  on  which  it  is  supphed  and  rewomid  on  small  glass  reels 
or  rods,  taking  care  that  the  threads  are  nowhere  more  than  two  or 
three  deep.  These  are  boiled  for  twenty  to  thirty  minutes  immediately 
before  the  operation  and  are  then  transferred  to  a  sterilised  vessel 
containing  1  in  20  carboUc  or  other  antiseptic  lotion. 

The  sterihsation  of  catgut  is  a  matter  of  much  greater  difficulty. 
This  material  is  made  from  the  intestines  of  sheep,  and  though  the  mucous 
membrane  is  supposed  to  have  been  scraped  away  this  is  by  no  means 
perfectly  carried  out.  Raw  catgut  is  thus  certain  to  contain  many 
organisms,  and  unless  effectively  sterilised  is  very  likely  to  infect  woimds 
in  which  it  is  used.  It  is  destroyed  by  boiling  in  water,  and  hence  other 
more  complicated  and  lengthy  means  have  to  be  employed.  Catgut  has 
the  crreat  advantage  that  it  is  eventually  absorbed ;  it  is  also  strong, 
phant-  and  easy  to  manipulate.  Thus,  in  spite  of  difficulties  in  sterilisa- 
tion, it  is  a  favourite  material  for  deep  or  buried  sutures.  Most  instru- 
ment makers  supply  catgut  already  sterilised  in  sealed  tubes.  If  supphed 
bv  a  good  firm  these  are  thoroughly  rehable.  The  tubes  should  be 
hermetically  closed  ;  any  information  as  to  the  size  of  the  contained 
threads  or  the  mode  of  preparation  should  be  etched  upon  the  glass ; 
there  should  be  no  paper  labels  either  within  or  outside.  Before  break- 
ing open  the  tubes  their  outer  surface  should  be  sterilised  by  prolonged 
immersion  in  an  antiseptic  lotion.  Many  methods  have  been  suggested 
for  the  sterilisation  of  catgut.  Most  of  these  are  comphcated.  and  the 
result  is  often  uncertain.  The  following  are  simple  and  effective.  In 
all  cases  the  raw  material  should  first  be  thoroughly  washed  in  water,  and 
then  soaked  in  ether  for  twelve  hours  to  remove  all  grease.  Mayo  Robson 
recommends  that  catgut  should  be  sterilised  by  placing  the  washed 
strands  in  a  strong  metal  vessel  proArided  with  a  screw  top  containing 
xylol.  This  is  immersed  in  boiling  water  for  half  an  hour,  at  the  expira- 
tion of  which  the  catgut  is  transferred  to  a  5  per  cent,  solution  of 
carboUc  acid  in  alcohol. 

Moynihan  recommeniJsthat  the  catgut,which  has  been  previously  cleaned  and  wound 
on  glass  reek,  should  be  boiled  for  twenty  minutes  in  a  saturated  solution  of  ammonium 

sulphate,  the  boiling-point  of 
which  is  128"  C.  It  is  subse- 
quently washed  in  boiled  water 
to  remove  excess  of  the  salt, 
and  is  then  placed  in  a  solu- 
tion of  iodoform  1  part,  ether 
6  parts,  in  absolute  alcohol  14 
parts.  By  either  of  these  means 
catgut  may  be  raised  to  a  tem- 
perature of  KiO-  C.  or  above 
without  being  destroyed. 
Another  simple  and  effective 
mode  of  preparing  catgut  is  by 
prolonged  immersion  in  a  solu- 
tion of    iodine  :    either  of  the 

,,       ,       .  -it  * t       *  _„  following    mav   be    emploved. 

Fig.  1.     A  convenient  form  of  sntore  forceps.  ,i  .  t  j-        ,    *  *     *•   ~ 

'^  (1)  Iodine  1  ounce,  potassium 

iodide  I  ounce,  water  5  pints.    (2)  Tincture  of  iodine  1  part,  alc-ohol  (45  per  cent.) 
15  parts.     In  either  case  it  should  not  be  used  until  it  has  soaked  for  eight  days. 


PREPARATION  OF  THE  PATIENT  21 

Sterilised  sutures  of  all  descriptions,  and  especially  silk  and  catgut, 
should  be  handled  as  little  as  possible.  The  assistant  who  has  charge 
of  them  must  exercise  the  greatest  care  to  ensure  that  they  do  not  touch 
the  outside  of  the  vessel  in  which  they  are  contained,  and  that  the  ends 
do  not  come  into  contact  with  any  septic  object  as  he  hands  them  to  the 
operator.  Special  forceps  with  smooth  blades  that  vdW  not  fray  the 
material  (Fig.  1)  should  be  used  for  their  manipulation,  especially  for 
keeping  the  tlir^ad  taut  duriiitr  the  iiisprtiou  of  a  continuous  suture. 

F.  Preparation  oJ  Towels  and  Overalls.  A  number  of  sterilised 
towels  will  be  required  for  every  operation.  They  are  arranged  around 
the  prepared  area  in  such  a  way  that,  though  this  is  adequately 
exposed,  the  patient  and  all  blankets.  &c.,  over  him  are  completely 
covered.  Should  the  operation  be  in  the  region  of  the  thorax,  head, 
or  neck,  the  towels  must  be  arranged  so  as  to  shut  off  the  anaesthetist 
and  his  apparatus  from  the  field  of  operation.  This  may  be  accomplished 
by  fastening  a  towel  round  the  patient's  neck  and  then  raising  it  over 
a  hoop,  or,  in  some  cases,  by  securing  a  large  sterilised  pad  across  the 
patient's  face.^  All  towels  should  be  securely  fastened  in  place  by  means 
of  sterilised  clip  forceps.  Towels  and  overalls  should  be  sterilised  by 
steam  under  high  pressure.  Unless  this  precaution  is  adopted  it  is  found 
that  the  folds  of  the  towels  interfere  with  the  due  penetration  and  action 
of  the  steam.  They  are  taken  from  the  steriliser  in  air-tight  cases,  from 
which  thev  are  removed  in  the  operating  room  by  an  assistant  who  has 
alreadv  prepared  himself  in  the  manner  described  above.  If  circum- 
stances render  it  impossible  to  obtain  towels  sterilised  in  this  way.  they 
mav  be  effectivelv  prepared  by  boiling  in  water  for  half  an  hour. 

G.  Preparation  of  Dressings,  Swabs,  &c.  Dressings  may  be  di\'ided 
into  two  classes  :  [a)  those  which  contain  no  antiseptics  but  are  sterilised 
by  heat ;  (b)  those  which  are  impregnated  with  antiseptics.  The  former 
include  gauze  and  pads  which  are  made  of  gamgee  tissue  cut  into  squares 
of  convenient  sizes  and  enclosed  between  layers  of  gauze.  These,  together 
with  absorbent  wool  and  bandages,  may  be  sterilised  in  the  same  manner 
as  the  towels.  \'iz..  by  steam  under  pressure.  The  latter  group  includes 
iodoform,  sal-alembroth.  and  cyanide  gauzes.  Though  impregnated  with 
antiseptics,  these  materials  are  liable  to  collect  dust,  and  so  may  contain 
many  infecting  organisms.  They  are  accordingly  kept  in  some  such 
antiseptic  lotion  as  formalin  (1  in  500).  which  soon  renders  them  sterile. 
Immediatelv  before  use  they  are  wTung  out  in  sterilised  water  to  remove 
the  formalin.  Sal-alembroth  and  salicylic  wools  are  also  occasionally 
used,  but  onlv  as  an  outer  covering  for  the  sterilised  dressings  in  actual 
contact  with  the  wound.  Pads  and  swabs,  which  are  used  for  spongmg, 
are  sterilised  in  the  same  way  as  the  towels  and  dressings.  Before  the 
commencement  of  the  operation  the  sterilised  instruments,  sutures,  and 
swabs  mav  be  arranged  by  an  assistant,  whose  hands  have  been  pre- 
pared and  gloved,  upon  one  or  more  small  tables,  the  glass  tops  of 
which  are  completelv  covered  by  sterilised  towels. 

THE  OPERATION 

Before  commencing  the  operation  the  surgeon  should  have  carefully 
thought  out  his  mode  of  procedure.     Each  assi-stant  should  have  his 
particular  duties  assigned,  and  care  must  be  taken  that  all  instruments, 
^   See  also  the  method  described  for  operations  on  the  Thyroid  Gland,  p.  620. 


22         OPERATIONS  ON  THE  UPPER  EXTREMITY 

dressings,  and  other  accessories  which  are  likely  to  be  required  are  quite 
ready.  In  this  way  only  can  rapidity  and  neatness  be  assured.  Generally 
speaking,  the  more  quickly  the  operation  is  completed  the  better  for  the 
patient,  though  of  course  care  and  thoroughness  must  not  be  sacrificed 
for  speed.  Careful  planning  and  organisation  are  essential  for  success  in 
modern  surgery. 

The  Administration  of  the  Anaesthetic.  Details  about  the  various 
kinds  of  anaesthetics  and  their  administration  will  not  be  given  here,  though 
it  is  desirable  that  the  operator  should  have  a  thorough  knowledge  of  this 
most  important  subject.  Full  information  may  be  obtained  from  one  of 
the  special  text-books  on  angesthetics.  Needless  to  say,  the  surgeon  should 
always  have  the  fullest  confidence  in  his  anaesthetist,  and,  at  any  rate 
in  difficult  cases,  should  secure  the  services  of  a  skilled  administrator  of 
anaesthetics.  Under  these  circumstances  the  operator,  after  a  preliminary 
consultation,  leaves  the  anaesthetic  and  its  administration  entirely  in  the 
hands  of  the  anaesthetist,  who  will  call  his  attention  to  any  unusual  or 
serious  symptoms  which  may  arise  during  the  course  of  the  operation. 
The  patient  should  not  be  anaesthetised  while  he  is  in  bed.  If  this  be 
done,  dangerous  symptoms  may  arise  while  he  is  being  transferred  to  the 
operating  room.  The  ideal  arrangement  is,  that  he  should  be  anaesthetised 
on  the  operating  table  in  a  small  room,  specially  set  apart  for  this  purpose, 
adjoining  and  opening  into  the  operating  theatre.  When  the  patient  is 
unconscious,  the  table  flan  then  be  wheeled  in  without  distracting  the 
attention  of  the  anaesthetist.  When  this  arrangement  cannot  be  carried 
out,  the  patient  should  be  anaesthetised  either  upon  the  table  in  the 
operating  room  or,  in  the  case  of  a  nervous  or  sensitive  patient,  upon 
a  trolley  which  can  easily  be  wheeled  in  and  the  patient  then  transferred 
to  the  table.  Bandages  and  pads  are  then  removed  by  a  nurse,  the  towels 
are  arranged  in  the  manner  already  described,  and  the  skin  receives  its 
final  application  of  tincture  of  iodine. 

The  Technique  of  the  Operation.  No  particular  operation  will  be 
described  here,  but  it  wall  be  as  well  in  this  place  to  give  a  few  general 
rules  and  instructions  which  apply  to  all  operations.  Necessary  special 
instructions  will  be  given  in  the  description  of  each  individual  operation. 

It  will  first  be  necessary  to  discuss  the  position  of  the  patient  during 
the  operation.  In  the  great  majority  of  cases  he  lies  flat  upon  his  back. 
Sometimes,  however,  for  the  satisfactory  exposure  of  the  diseased  parts 
some  other  position  is  required.     The  following  are  frequently  employed  : 

(a)  The  Prone  Position.  The  patient  is  here  turned  over  so  that  the 
face  looks  downwards.  One  arm  may  be  placed  under  the  chest  while  the 
other  rests  along  the  opposite  side  of  the  body,  which  may  be  supported 
by  a  small  pillow.  This  position  may  be  adopted  for  operations  on  the 
vertebral  column,  or  in  certain  cases  of  empyema  where  it  is  thought 
undesirable  to  allow  the  patient  to  rest  upon  the  sound  side  of  his  chest. 

(b)  The  Lateral  Position  is  frequently  employed.  Here  the  patient  is 
turned  upon  his  side,  left  or  right  as  the  circumstances  of  the  case  demand. 
The  arm  of  the  side  upon  which  he  rests  is  placed  under  the  chest,  while 
the  legs  are  flexed  both  at  the  knee-  and  the  hip-joints.  This  position 
may  be  used  for  some  operations  on  the  perineum  or  anus,  for  empyema 
and  for  kidney  operations.  In  the  latter  case  an  air-pillow  is  also  placed 
beneath  the  loin  to  render  prominent  the  region  of  the  incision. 

(c)  The  Trendelenherg  Position.  Here  the  patient  rests  upon  his  back, 
but  the  pelvis  is  raised  above  the  level  of  the  head  to  a  height  of  from 


POSITION  OF  THE  PATIENT  'j;i 

a  few  iiK'lies  to  as  nmch  as  two  feet.  All  modern  operating  tables  are 
provided  with  a  mechanism  by  which  the  body  is  easily  made  to  assume 
this  position.  The  intestines  and  other  abdominal  viscera  will  then  tend 
to  gravitate  from  the  pelvis  towards  the  diaphragm,  thus  greatly  facili- 
tating operations  in  which  a  clear  view  of  the  depths  of  the  pelvis  is 
desirable.  In  an  exaggerated  Trendelenberg  position  the  patient  will  be 
almost  vertical.  If  this  is  maintained  for  any  length  of  time,  grave 
disturbances  of  the  circulation  may  occur,  and  the  continued  pressure  of 
the  viscera  upon  the  diaphragn  may  seriously  embarrass  the  action  of  the 
heart  when  that  organ  is  not  perfectly  healthy. 

(d)  In  other  operations,  upon  the  gall-bladder  for  instance,  it  may  be 
desirable  to  displace  the  intestines  from  the  upper  part  of  the  abdomen 
and  cause  them  to  gravitate  towards  the  pelvis.  This  may  be  effected  by 
tilting  the  operating  table  so  that  the  head  and  the  upper  part  of  the 
trmik  are  at  a  higher  level  than  the  pelvis. 

(e)  The  Lithotomy  Position  is  essential  for  most  operations  upon  the 
rectum  or  the  perineum.  This  may  be  conveniently  arranged  either  by 
means  of  a  Clover's  crutch,  or  by  resting  the  patient's  hams  upon  two 
adjustable  vertical  supports  attached  to  the  lower  end  of  the  operating 
table. 

(/)  For  special  operations  the  affected  part  may  be  steadied  or  raised  by 
means  of  sand-bags  or  pillows  placed  beneath  the  towels,  as  has  been  seen 
in  the  case  of  the  kidney.  Also  in  operations  upon  the  gall-bladder  a 
small  cushion  beneath  the  lower  part  of  the  thorax  throws  the  liver 
forward  and  thus  renders  both  the  ducts  and  the  gall-bladder  itself  much 
more  prominent  and  easily  accessible.  For  operations  upon  the  hand 
or  fingers  the  arm  mav  often  with  advantage  be  abducted  and  allowed 
to  rest  upon  a  small  table  at  the  side  of  the  operating  table.  As  a 
general  rule  the  patient  should  be  anaesthetised  in  the  dorsal  position  and 
then  be  placed  in  the  special  position  required  for  the  operation. 

The  skin  incision  should  be  carefully  planned  so  as  to  give  a  good  view 
of  the  deeper  parts  and  at  the  same  time  to  avoid  important  structures. 
If  the  incision  has  to  be  made  in  the  neighbourhood  of  large  vessels  or 
nerves,  it  should  always  be  made  parallel  to  and  not  across  them.  Whenever 
possible,  the  incision,  especially  if  upon  the  face,  neck,  or  other  exposed 
part  of  the  body,  should  follow  the  line  of  natural  folds  or  creases  of  the 
skin.  In  this  way  subsequent  disfigurement  is  minimised  and  the  resulting 
scar,  if  the  wound  heals  by  primary  miion,  will  be  a  scarcely  noticeable 
white  line.  An  excellent  example  of  this  is  the  remarkably  small 
deformity  after  excision  of  the  upper  jaw  where  the  incision  follows  the 
natural  folds  at  the  side  of  the  nose  and  beneath  the  lower  eyelid.  To 
ensure  healing  by  primary  union,  the  sldn  should  be  clean  cut  with  a  sharp 
knife,  avoiding  all  lacerations  and  irregularities.  Care  should  be  taken 
that  the  incision  is  not  too  short ;  a  long  skin  incision  does  not,  for  instance, 
weaken  the  abdominal  wall,  and  the  more  thorough  exposure  of  deep  parts 
frequently  enables  the  operation  to  be  completed  with  less  injury  to  these 
more  importa  nt  structures.  Similar  rules  are  to  be  followed  in  the  di^^sion 
of  deeper  structures.  AVhen  the  deep  fascia  is  reached  it  should,  before 
it  is  di\dded,  be  fully  exposed  by  separating  the  superficial  fascia  and  the 
skin  on  each  side  ■R'ith  a  few  touches  of  the  knife.  All  aponeurotic  and 
fascial  layers  should  be  divided  by  clean-cut  incisions.  Muscles  ought 
if  possible  to  be  drawn  to  one  side  ;  if  this  is  impracticable,  their  fibres 
should  be  separated  by  some  blunt  instrument,  after  the  sheath  has  been 


24         OPERATIONS  ON  THE  UPPER  EXTREMITY 

opened,  rather  than  be  divided  by  the  knife.  There  is.  however,  in  the 
great  majority  of  cases  no  reason  why  a  muscle  should  not  be  cut  across, 
provided  that  the  cut  ends  are  identified  and  subsequently  carefully 
united  by  sutures.  These  points  are  illustrated  by  two  of  the  common 
methods  of  opening  the  abdomen.  Separation  of  muscular  fibres  is  often 
used  in  the  "  muscle-splitting"  method  of  opening  the  abdomen  in  the 
operation  of  appendicectomy.  Another  method  which  also  inflicts  but 
little  damage  is  to  incise  the  anterior  layer  of  the  rectus  sheath,  retract 
the  rectus  muscle,  and  then  incise  the  posterior  layer  of  the  sheath.  The 
greatest  care  must  be  taken  to  avoid  unnecessary  injury  to  large  vessels. 
Smaller  vessels  should  be  secured  between  two  pairs  of  Spencer  Wells 
forceps  and  then  divided. 

It  is  of  even  greater  importance  to  avoid  injury  to  nerves.  Di^^sion 
of  a  large  nerve-trunk  is  a  serious  matter,  for  it  will  certainly  lead  to  para- 
lysis and  muscular  atrophy,  which  in  spite  of  suture  may  be  permanent. 
Division  of  smaller  muscular  nerves  should  also  be  avoided,  for  such  an 
injury  will  result  not  only  in  partial  or  complete  paralysis  of  that  muscle, 
but  also  atrophy,  which  together  may  cause  considerable  disfigurement 
and  disability. 

At  the  conclusion  of  the  operation  all  hemorrhage  must  he  stopped. 
Each  bleeding-point  in  the  course  of  the  operation  is  secured  by  Spencer- 
Wells  forceps,  care  being  taken  as  far  as  possible  to  clip  the  bleeding 
vessel  alone  without  taking  up  masses  of  surrounding  tissue.  Small 
superficial  vessels  will  be  probably  quickly  occluded.  Small  or  medium- 
sized  arteries  may  be  sealed  by  torsion,  care  being  taken  to  give  the 
vessels  six  or  seven  half-t^^^sts  and  not  to  twist  the  forceps  completely 
off. 

Other  vessels  will  require  to  be  ligatured  with  fine  catgut.  General 
oozing  may  be  checked  by  irrigating  with  sterilised  saline  solution  at  a 
temperature  of  130°  F.  Deep  structures  should  be  closed  in  layers, 
the  divided  edges  being  accurately  brought  together.  For  instance, 
in  abdominal  operations  separate  layers  of  sutures  are  used  for  the 
peritoneum  and  for  each  muscle  or  aponeurosis  that  has  been  divided. 
Continuous  sutures  of  silk  or  catgut  are  employed,  or  celluloid  thread 
if  a  stronger  material  is  recjuired.  The  cut  edges  of  the  skin  are  united 
by  continuous  or  interrupted  sutures  of  horsehair  or  silkworm-gut,  or 
Michel's  m':?tal  clips  may  be  employed.  Care  must  be  taken  that  the 
edges  of  the  skin  are  not  turned  in.  Should  this  occur,  epithelial  surfaces 
are  held  in  contact  instead  of  the  raw  edges,  with  the  result  that  when  the 
stitches  are  removed  some  gaping  will  take  place,  lea^^ng  a  small  area 
which  has  to  heal  by  granulation.  Special  care  to  secure  accurate 
apposition  must  be  taken  when  the  incision  is  on  the  face  or  neck. 

The  question  of  drainage  frequently  demands  careful  consideration. 
If  the  operation  is  essentially  septic,  for  instance  opening  an  appendicular 
abscess,  drainage  is  certainly  necessary.  When,  however,  the  operation 
is  aseptic,  but  a  large  ca\"ity  in  which  blood  and  serous  exudation  can 
collect  is  necessarily  left,  drainage  is  still  often  desirable,  otherwise  the 
cavity  will  probably  fill  up  with  blood-clot  and  coagulated  exudation, 
which  form  an  admirable  medium  for  the  growth  and  multiplication  of 
organisms.  A  few  cocci  of  a  not  very  virulent  type  which  would  soon  be 
destroyed  by  healthy  li\dng  tissues  may  easily  infect  and  cause  suppura- 
tion in  such  an  inert  mass. 

When  such  a  space  exists,  as  in  the  axilla  after  the  removal  of  the 


AFTER-TREATMENT  25 

breast  and  axillary  contents  for  carcinoma,  or  the  scrotum  after  a  radical 
cure  for  hydrocele,  it  is  best  to  insert  a  small  drainage-tube  to  allow  such 
exudation  to  escape.  Though  such  a  wound  may  appear  perfectly  dry 
and  free  from  blood  at  the  termination  of  the  operation,  it  is  almost  certain 
that  some  oozing  will  occur  as  the  effect  of  the  anaesthetic  is  passing  off. 
A  rubber  drainage-tube  may  pass  to  the  deeper  parts  of  the  wound 
between  the  stitches,  or  the  original  wound  may  be  completely  closed  and 
the  tube  inserted  through  a  small  stab  wound  in  close  proximity  to  it. 
This  method  allows  drainage  to  take  place  and  the  wound  to  heal  com- 
pletely— -a  point  of  great  importance  where  the  abdominal  wall  has  been 
di\'ided,  as  in  an  operation  for  acute  appendicitis.  For  draining  a  large 
suppurating  cavity,  several  lateral  holes  should  be  cut  in  the  tube  or  a 
layer  of  gauze  may  be  wrapped  round  it.  Efficient  drainage  may  also  be 
secured  by  cutting  the  tube  open  and  inserting  a  wick  of  ribbon  gauze. 
For  smaller  cavities  one  or  more  strips  of  gauze  may  be  employed,  while 
small  superficial  wounds  may  be  drained  by  inserting  a  few  strands  of 
silkworm-gut  between  the  stitches.  If  a  drain  is  employed  in  an  aseptic 
wound  to  allow  the  escape  of  blood  and  serum,  it  may  be  removed  at  the 
end  of  forty-eight  hours  and  then  will  in  all  probability  not  have  to  be 
replaced. 

After-treatment  of  the  Wound.  This  will  depend  upon  the  aseptic 
or  septic  character  of  the  operation  and  whether  drainage  has  been 
necessary.  An  aseptic  wound  which  has  been  completely  and  carefully 
closed  will  heal  by  primary  union  ;  under  these  circumstances  the 
temperature  and  the  pulse  will  remain  normal,  and  when  the  patient 
has  recovered  from  the  effects  of  the  anaesthetic  there  will  be  no 
constitutional  disturbance.  An  aseptic  wound  should  be  painless  or 
nearly  so.  since  inflammation  is  the  most  common  cause  of  pain  in  a  wound. 
Unless  the  dressings  or  bandages  require  re-adjustment,  such  a  wound 
need  not  be  dressed  until  the  stitches  are  removed,  which  is  usually  done 
between  the  eighth  and  the  tenth  days.  All  dressings  must  be  carried 
out  with  strict  aseptic  precautions.  The  dresser  must  carefully  prepare 
his  hands,  and  all  instruments,  dressings,  and  towels  are  sterilised  as 
carefullv  and  thoroughly  as  at  the  original  operation.  An  aseptic  w^ound 
is,  when  the  dressing  is  removed,  dry  and  free  from  all  redness,  swelling, 
and  induration. 

A  septic  wound  ^\"ill  require  more  frequent  dressing,  usually  every  day, 
or  if  fomentations  are  used,  these  ought  to  be  changed  every  four  hours. 
If  a  drainage-tube  has  been  used,  the  time  of  its  removal  will  to  a  great 
extent  depend  upon  the  situation  and  cause  of  the  suppuration.  If  super- 
ficial it  may  be  removed  at  the  end  of  forty-eight  hours,  and  after  cleansing 
and  boiling  be  replaced.  If  the  septic  focus  is  deep,  as  in  acute  appendix 
or  gall-bladder  cases  for  instance,  it  may  be  left  in  situ  for  three  or  four 
days  or  even  longer.  In  either  case  at  subsecjuent  dressings  it  should  be 
gradually  shortened,  and.  as  the  wound  closes,  a  smaller  tube  should  be 
substituted.  When  the  suppuration  diminishes  the  tube  is  omitted  and  a 
gauze  drain  used  in  its  place. 

Treatment  of  a  Wound  which  has  become  Septic.  Occasionally,  in 
spite  of  all  precautions,  the  wound  may  become  infected  and  suppurates. 
Usually  this  points  to  some  failure  in  the  preliminary  preparations  ;  some- 
times, however,  it  is  due  to  the  dressings  becoming  soiled  or  displaced,  or 
they  may  be  disturbed  either  consciously  or  unconsciously  by  the  patient. 
When  infection  does  occur,  it  is  of  great  importance  that  the  septic  nature 


26  OPERATIONS  ON  THE  UPPER  EXTREMITY 

of  the  wound  shall  be  recognised  and  treated  as  soon  as  possible.     Other- 
wise the  septic  process  may  extend  deeply  in  and  around  the  wound,  and 
even  invade  the  vessels  and  lymphatics.    The  most  important  information 
as  to  the  occurrence  of  sepsis  is  afforded  by  the  temperature  chart,  which 
should  be  carefully  watched  after  every  operation.     A  slight  rise  of 
temperature  (99°  or  1C0°)  is  not  infrequently  noticed  immediately  after 
operations  which  run  a  perfectly  aseptic  course,  and  hence  need  cause  no 
anxiety.     A  more  considerable  rise  (up  to  102'^)  on  the  second  or  third 
evening  is.  however,  of  more  serious    import   and   should    lead    to    an 
immediate  and  careful  examination  of  the  wound.     When  suppuration 
occurs,  pain  is  usually  experienced  in  the  region  of  the  wound.     Its 
intensity  varies  greatly.    It  may  be  very  severe  and  throbbing  in  character, 
but  on  the  other  hand  it  may  be  entirely  absent  or  the  patient  may  com- 
plain of  discomfort  only.     In  the  latter  case,  organisms  of  comparatively 
slight  \'irulence.  such  as  the  Staphylococcus  albus,  have  probably  infected 
a  collection  of  effused  blood.     In  these  cases,  too,  there  may  be  little  or 
no  pyrexia.     If  sepsis  is  suspected  the  wound  must  at  once  be  inspected. 
The  dressing  must  be  carried  out  with  the  same  precautions  and  care  as 
in  the  case  of  a  clean  wound.     The  reason  for  this  is  that  infection  may  be 
due  to  comparatively  harmless  organisms  ;    the  tissues  are.  however,  in 
the  most  favourable  condition  for  the  growth  of  any  organism,  and  hence 
the  greatest  care  must  be  taken  not  to  introduce  any  of  a  more  virulent 
type.     A  septic  wound  will  appear  swollen,  red,  and  cedematous  ;  pus  may 
also  be  exuding  from  the  incision  or  stitch  holes.     Sufficient  sutures  must 
be  removed  to  release  all  tension  and  to  open  the  wound  sufficiently  to 
ensure  a  free  exit  for  all  pus  and  discharge.     If  necessary  one  or  more  ad- 
ditional incisions  must  be  made  to  provide  free  drainage.     The  wound 
may  then  be  gently  swabbed  out  with  sterilised  saline  solution  or  dilute 
antiseptics  such  as   carbolic    lotion    (1    in    60)    or    hydrogen    peroxide 
10  per  cent.     Strong  antiseptic  lotions  should  not  be  used.    These  cannot 
destroy  all  the  organisms  present,  and  are  likely  to  damage  the  tissues  and 
thus  hinder  their  normal  reaction  against  the  invading  bacteria  and 
their  toxins.     The  wound  must  now  be  drained  ;   its  situation  and  depth 
will  enable  the  surgeon  to  decide  as   to  whether  rubber  drainage-tubes 
or  gauze  should  be  employed.     A  dressing  of  antiseptic  gauze  (cyanide, 
iodoform  or  sal-alembroth)  should  then  be  applied.     If  the  inflammation 
is  acute,  hot  fomentations  may  be  used  with  advantage.     Several  layers 
of  lint  wrung  out  of  hot  boracic  lotion  or  perchloride  of  mercury  (1  in  4000) 
may  be  used  for  this  purpose.     To  obtain  the  maximum  amount  of  benefit, 
the  fomentation  must  be  applied  as  hot  as  possible  and  be  changed  fre- 
cjuently.     Pain  is  relieved  by  the  heat,  pus  and  toxic  materials  are  readily 
discharged,  and  the  antiseptic  hinders  the  growth  of  the  infecting  organ- 
isms.    Should  the  wound  be  in  the  arm  or  leg.  immersion  of  the  limb  in  a 
metal  bath  containing  hot  boracic  or  other  lotion  may  often  be  carried  out 
with  advantage.     The  lotion  in  the  bath  must  be  kept  hot  and  clean ;  this 
may  be  ensured  by  allo^^^ng  a  continuous  stream  of  hot  lotion  to  flow 
slowly  through  the  bath. 

Constitutional  symptoms  may  be  severe,  and  hence  general  treatment 
is  of  great  importance.  The  strength  of  the  patient  must,  in  severe 
cases,  be  maintained  by  frequent  administration  of  small  quantities 
of  suitable  nourishment,  and  alcohol,  preferably  in  the  form  of  small 
doses  of  brandy,  may  also  be  of  service.  Free  and  regular  action  of  the 
bowels  must  also  be  secured.    When  the  wound  is  opened  up.  a  specimen 


AFTER-TREATMENT  27 

of  the  pus  should  be  collected  on  a  sterile  swab  for  e:xaminatioii  and 
identification  of  the  infecting  organism.  Should  signs  of  septicemia 
appear  or  should  the  condition  of  the  wound  not  quickly  improve  under 
the  above  treatment,  a  suitable  serum  (antistreptococcic  or  antistaphylo- 
coccic)  may  then  be  injected  if  the  cause  of  the  infection  is  known.  Or, 
if  thought  desirable,  a  vaccine  may  be  prepared  by  the  bacteriologist 
from  the  actual  organism. 

General  After-treatment.  At  the  termination  of  the  operation  the 
patient  is  likely  to  be  cold  as  the  result  of  the  necessary  exposure,  and 
after  a  prolonged  or  severe  operation  to  be  to  some  extent  in  a  state  of 
shock  or  collapse.  He  should  therefore  be  quickly  removed  to  bed 
and  kept  warm  with  the  help  of  hot-water  bottles  and  blankets.  He  is 
usually  placed  at  first  flat  upon  his  back  ;  some  one  must  be  at  hand 
to  turn  the  head  to  one  side  and  draw  the  jaw  forwards  in  the  event  of 
vomiting  occurring,  otherwise  vomited  material  may  be  drawn  down 
into  the  larynx  or  the  lungs.  There  is,  however,  no  reason  after  most 
operations  why  the  patient  should  not  be  propped  up  on  one  side,  which 
is  more  comfortable  and  renders  the  inhalation  of  regurgitated  material 
less  likely.  Later,  after  recovery  from  the  effects  of  the  anaesthetic, 
he  ay,  according  to  the  nature  and  the  situation  of  the  operation,  be 
kept  in  the  dorsal  position,  be  propped  on  his  side  (lateral  position),  or 
turned  upon  his  face  (prone  position).  Elderly  patients,  and  those 
suffering  from  general  peritonitis,  may  often  with  great  advantage  be 
propped  up  in  the  semi-recumbent  (Fowler's)  position.  This,  in  the 
latter,  aids  the  drainage  of  pus  to  the  lower  part  of  the  abdomen,  and  in 
the  former  throws  less  strain  upon  the  action  of  the  heart  and  lungs. 

Shock.  Shock  is  a  condition  of  the  greatest  importance  to  the  surgeon 
for  it  frequently  occurs,  and  is  a  common  cause  of  death  after  severe 
operations.  Much  excellent  work  has  been  done  in  recent  years  with 
reference  to  its  nature,  cause,  prevention,  and  treatment,  but  a  great 
deal  still  remains  to  be  done.  Shock  may  be  defined  as  a  condition 
produced  by  injury  in  which  the  action  of  the  vital  organs  is  seriously 
depressed.  A  brief  outline  of  the  mechanism  of  its  production  is  all  that 
can  be  given  here.^  When  shock  occurs  there  is  always  a  great  fall  in 
blood-pressure.  This  has  been  shown  by  Crile  to  be  due  to  dilatation  of  the 
splanchnic  veins.  This  leads  to  the  withdrawal  of  so  much  blood  from 
the  systemic  circulation  that  the  blood  pressure  is  greatly  reduced. 
Crile  has  further  shown  that  the  fall  in  blood  pressure  is  not  due  to  cardiac 
failure,  but  to  exhaustion  of  the  vaso-motor  centre.  At  first  the  fall  in 
pressure  may  be  rectified  to  a  certain  extent  by  the  increased  activity 
of  the  vaso-motor  mechanism  and  increased  action  of  the  heart.  Eventu- 
ally, however,  as  the  result  of  repeated  violent  afferent  stimuli,  the 
vaso-motor  centre  becomes  exhausted,  \nth  the  result  that  there  is  a 
still  greater  fall  in  blood  pressure  and  the  blood  collects  in  the  large  venous 
trunks  generally.     The  heart  is  now,  o\\dng  to  the  small  amount  of  blood 

1  For  further  information  on  this  subject  reference  may  be  made  to  the  following 
papers  and  lectures:  G.  W.  Crile,  "An  Experimental  Research  into  Surgical  Shock  and 
Collapse  {Trans.  Coll.  Phys.  Philadel.,  1901,  vol.  xxiii,  pp.  .59-82);  P.  L.  Mummery  and 
W.L.  Symes,  "The  Specific  Gravity  of  the  Blood  in  Shock"  (Trans.  Physiol.  Soc,  1907, 
p.  15);  P.  L.  Mummery,  "  Hunterian  Lectures  on  the  Treatment  of  Shock  and  Collapse" 
(Lancet,  190.5,  vol.  i,  pp.  696,  776,  and  846);  H.  Cushing,  "On  the  Avoidance  of  Shock 
in  Major  Amputations  bv  Cocainisation  of  the  Large  Nerve  Trunks  preHminary  to  their 
Division"  {Trans.  Med.' Soc.  Wisconsin,  1902,  p.  361  ;  H.  Tyrrel  Gray^nd  L.  Parsons 
{Brit.  Med.  Journ.,  1912,  vol.  i.  pp.  938,  1004,  1065,  1120). 


28        OPERATIONS  ON  THE  UPPER  EXTREMITY 

brought  to  it,  unable  to  efficiently  carry  on  the  circulation,  even  though 
for  a  time  it  attempts  to  do  so  by  more  forcible  and  rapid  action.  Sooner 
or  later  the  heart  will  become  exhausted  and  death  then  occurs,  or 
insufficient  blood  may  be  supplied  to  the  vital  centres  in  the  medulla 
with  the  same  result.  The  essential  thing  in  shock  is  thus  a  great  fall  in 
blood  pressure  brought  about  by  failure  of  the  vaso- motor  mechanism 
caused  by  exhaustion  of  the  vaso- motor  centre  owing  to  repeated  violent 
afferent  stimuli.  Shock  may  follow  any  severe  injury  or  operation,  but 
is  especially  likely  to  occur  if  the  thoracic  or  abdominal  viscera,  the  testicle 
or  urethra  is  involved.  With  regard  to  abdominal  operations,  shock  is 
most  likely  to  be  severe  when  the  viscera  in  the  neighbourhood  of  the 
solar  plexus,  especially  the  duodenum  and  stomach,  are  interfered  with. 

Collapse  is  a  condition  closely  allied  to  shock,  from  which  it  cannot 
always  be  distinguished ;  indeed,  the  two  may  occur  together  or  shock 
may  follow  collapse.  Collapse  is  also  associated  with  a  low  blood  pressure, 
but  Crile  regards  this  as  due  to  inhibition  of  the  vaso-motor  centre,  which 
is  the  essential  distinction  from  shock.  It  may  be  brought  about  by 
sudden  loss  of  a  large  quantity  of  blood  or  by  mental  impressions,  or 
violent  afferent  impulses  may  produce  a  sudden  inhibition  of  the  centres. 

Symptoms  of  Shock.  The  onset  is  usually  sudden,  though  by  no  means 
always  so.  The  pulse  is  rapid,  weak,  of  very  small  volume,  and  may  be 
irregular.  The  respirations  are  shallow  and  occasionally  show  the 
Cheyne-Stokes  rhythm.  The  surface  of  the  skin  is  cold  and  pallid,  and 
the  temperature  is  subnormal.  There  is  great  muscular  relaxation  and 
weakness,  and  though  consciousness  is  not  lost  the  mental  faculties  are 
dull.  The  pupils  are  moderately  dilated  and  their  reaction  to  light  is 
sluggish. 

Prevention  of  Shock.  Prophylactic  measures  are  especially  called 
for  in  all  cases  where,  from  the  nature  of  the  operation  or  the  con- 
dition of  the  patient,  shock  is  likely  to  occur.  Most  important  is  a 
thorough  preliminary  examination,  especially  of  the  kidneys,  and 
careful  preparation  extending  if  necessary  over  several  days,  during 
which  the  patient  is  got  into  as  good  condition  as  possible,  and 
attention  is  directed  to  the  treatment  of  any  visceral  disease.  Care 
must  be  taken  that  the  patient  is  kept  warm  during  the  operation,  which 
is  completed  as  rapidly  as  possible,  and  that  he  is  then  quickly  returned  to 
bed,  where  hot  bottles  and  blankets  are  used  to  guard  against  chill. 

It  has  been  pointed  out  that  shock  is  produced  by  the  effect  of  violent 
afferent  stimuli  on  the  vaso-motor  centre.  Any  means  of  preventing  or 
diminishing  these  stimuli  will  thus  be  of  service.  For  this  reason  an 
injection  of  morphia  (I.M.H.  gr.  I)  may  with  advantage  be  given  about 
twenty  minutes  before  the  commencement  of  the  anaesthesia.  Crile  insists 
on  the  importance  of  the  injection  of  cocaine  into  the  large  nerve -trunks 
which  supply  the  region  of  the  operation.  The  effect  of  this  is  to  block 
the  transmission  of  sensory  impulses  and  thus  to  lessen  the  likelihood  of 
shock.  Spinal  anaesthesia  also  will  have  the  effect  of  blocking  afferent 
impulses,  and  may  therefore  be  chosen  in  cases  which  are  in  other  respects 
suitable  in  which  severe  shock  is  anticipated.  The  importance  of  this  is 
emphasised  by  Tyrrel  Gray  and  Parsons  {q.v.). 

The  question  often  arises  as  to  the  desirability  of  operating  upon  a 
patient  who  is  already  in  a  state  of  shock  or  collapse,  the  result  of  some 
severe  injury  or  acute  disease.  No  invariable  rule  can  be  given  ;  each 
individual  case  must  be  considered  upon  its  merits.      If  when  a  patient 


AFTER  TUKATMENT  29 

is  first  seen,  after  a  severe  railway  crush  of  the  leg  or  with  acute  general 
peritonitis  for  example,  it  is  thought  that  the  pulse  and  general  condition 
may  possibly  improve,  it  will  be  well  to  allow  an  interval  of  some  hours 
to  elapse  while  he  is  kept  warm,  infused,  and  treated  with  stimulating 
nutrient  enemata.  Should  it  on  the  other  hand  be  considered  that 
improvement  is  unlikely  to  ensue,  immediate  operation  gives  the  only 
chance,  though  possibly  a  faint  one,  of  success. 

Treatment  of  Shock.  A  patient  suffering  from  shock  should  always 
be  kept  warm  by  the  use  of  hot  bottles  and  blankets  ;  the  foot  of  the  bed 
should  be  raised  so  that  the  head  is  lower  than  the  feet.  Stimulants  and 
other  drugs  administered  by  the  mouth  are  of  little  use,  for  their  absorption 
by  the  stomach  is  unlikely.  Hot  and  stimulating  nutrient  enemata  may, 
however,  be  employed  with  advantage.  They  should  be  administered 
through  a  tube  introduced  as  far  into  the  bowel  as  possible.  Strychnine 
and  other  stimulants,  whether  given  by  the  mouth  or  hypodermically, 
are  useless  in  shock  though  they  may  be  of  service  in  collapse.  In  the 
former  condition  they  only  stimulate  the  heart  when  that  organ  is  already 
making  increased  efforts  to  maintain  the  circulation  with  the  diminished 
quantity  of  blood  at  its  disposal.  Thus,  though  stimulants  may  tem- 
porarily improve  the  pulse,  they  soon  increase  the  tendency  to  cardiac 
failure. 

Crile  points  out  that  in  shock  there  is  a  deficiency  in  the  output  of 
the  heart  owing  to  the  stagnation  of  the  blood  in  the  large  veins  brought 
about  by  the  failure  of  the  vaso-motor  mechanism.  He  suggests, 
therefore,  that  the  treatment  should  be  directed  to  supplying  the  heart 
with  additional  fluid  to  compensate  for  the  diminished  intake,  and  to 
restore  that  peripheral  resistance  which  has  been  lost  as  the  result  of  the 
vaso-motor  failure.  The  first  of  these  is  effected  by  infusion,  the  second 
by  mechanical  means  and  by  the  use  of  adrenalin. 

Infusion  is  best  carried  out  by  allowing  sterilised  physiological  saline 
solution  to  flow  through  a  cannula  which  has  been  inserted  into  a  vein, 
usually  the  median  basilic.  It  may  also  be  given  subcutaneously,  when 
the  needle  is  usually  inserted  beneath  the  deep  fascia  into  the  loose  tissues 
of  the  axilla,  or  by  means  of  repeated  or  continuous  rectal  injections. 
The  first  method  is,  however,  best.  With  a  view  to  causing  contraction 
of  the  small  arteries  and  thus  increasing  the  peripheral  resistance,  he 
suggests  the  addition  of  adrenalin  to  the  saline  solution.  As  this  is  rapidly 
oxidised  by  the  tissues  he  advises  its  continuous  administration  by 
adding  sufficient  adrenalin  hydrochloride  to  the  saline  to  make  a  solution 
of  1  in  50,000  or  1  in  100,000  (5]  adrenalin  to  1  pint  of  saline). 

The  circulation  may  be  improved  mechanically  by  gentle  abdominal 
massage  and  by  firmly  bandaging  the  abdomen  and  limbs  over  a  layer  of 
cotton- wool.  Care  must  be  taken  that  respiration  is  not  impeded  and 
that  the  bandages  do  not  in  any  other  way  inconvenience  the  patient. 
Inhalations  of  oxygen  may  often  be  given  with  advantage,  and  Lockhart 
Mummery  advises  gentle  artificial  respiration  which  does  good  by  drawing 
blood  into  the  large  veins  which  open  into  the  heart  and  by  increasing  the 
oxygenation  of  the  blood.  Injections  of  atropine  may  also  be  good.  If  a 
patient  remains  in  a  condition  of  shock  for  some  considerable  time,  plenty 
of  fluid  should  be  given  by  the  mouth,  and  in  these  circumstances  it  may 
be  necessary  to  give  nutrient  enemata.  Should  severe  symptoms  of  shock 
appear  during  the  operation,  it  should  be  completed  as  rapidly  as  possible 
or  if  thought  desirable  abandoned. 


30    OPERATIONS  ON  THE  UPPER  EXTREMITY 

Feeding.  The  question  of  feeding  after  an  operation,  though  naturally 
of  great  importance,  will  depend  upon  the  age  and  actual  condition  of  the 
patient,  the  duration  of  the  ansesthesii,  and  the  nature  of  the  operation. 
A  few  general  rules  and  instructions  may,  however,  be  given.  After  an 
operation  of  any  magnitude  the  patient  usually  requires  but  little  food. 
The  thing  is  to  give  plenty  of  fluid,  either  by  the  mouth,  by  infusion,  or  by 
saline  enemata.  After  a  comparatively  slight  operation  a  little  light  food, 
such  as  a  cup  of  weak  tea  and  a  little  bread  and  butter,  may  be  allowed  at 
the  end  of  six  or  eight  hours,  provided  that  there  is  no  vomiting  and  that 
the  patient  feels  inclined  to  take  it.  After  abdominal  or  other  severe 
operations,  small  quantities  of  hot  water  may  be  given  at  frequent 
intervals  during  the  first  twenty-four  hours.  At  the  end  of  that  time,  fluid 
nourishment  may  be  allowed  at  regular  intervals  in  gradually  increasing 
quantities.  Milk  is  often  given,  but  is  by  no  means  essential.  Some 
patients  are  unable  to  assimilate  it,  and  it  may  cause  flatulence  and  thus 
lead  to  much  discomfort.  There  are  a  numlser  of  fluid  foods,  some  of 
which  are  partially  digested,  prepared  by  well-known  firms,  which  may 
be  used  with  advantage ;  while  chicken  or  mutton  broth,  or  even  light 
solid  food,  may  be  allowed  in  suitable  cases.  After  the  bowels  have  acted 
1  he  nature  and  variety  of  food  are  gradually  increased,  until  the  patient 
is  on  ordinary  diet,  care  being  taken  that  all  nourishment  is  light  and 
easily  digestible.  The  feeding  of  old  people  and  of  young  children  demands 
close  attention.  The  former  are  liable  to  suffer  from  exhaustion,  and 
hence  small  fluid  feeds  should  be  started  as  soon  as  possible.  The  latter 
are  liable  to  be  upset  by  any  change  of  diet,  Lad  hence  should  be  given 
the  food  to  which  they  have  been  accustomed  as  soon  as  they  have  re- 
covered from  the  anaesthetic.  Should  vomiting  persist,  or  should  feeds 
cause  nausea,  nutrient  enemata  may  be  desirable  in  these  patients. 

In  most  cases  it  is  advisable  that  the  bowels  should  act  on  the  second 
or  third  day.  It  is  sometimes  desirable  that  the  action  should  occur  even 
earlier,  while  occasionally — after  operations  on  the  rectum  for  instance — • 
it  may  be  necessary  to  keep  the  bowels  confined  for  a  longer  period. 
Drastic  or  irritating  purgatives  ought  to  be  avoided,  especially  when 
exhaustion  is  present.  As  a  general  rule  an  ounce  of  castor  oil  is  a 
satisfactory  aperient  for  an  adult.  This  may  be  followed  by  a  soap  and 
water  enema,  or  an  oil  enema  composed  of  castor  oil  §iij  and  olive  oil  §iij 
may  be  tried.  Another  useful  method  of  getting  the  bowels  to  act  is  to  give 
small  doses  of  a  saline  purge,  such  as  Mag.  Sulph.  ~,i],  at  intervals  of  an 
hour  until  an  action  occurs.  Small  doses  of  calomel  repeated  hourly  are 
sometimes  employed,  but  it  must  be  remembered  that  this  drug,  if  not 
quickly  successful,  may  set  up  a  serious  and  troublesome  colitis. 

Vomiting.  This  is  a  very  common  and  troublesome  post- anaesthetic 
complication.  It  may  occur  after  any  general  anaesthetic,  even  after 
nitrous  oxide,  but  is  especially  prone  to  occur  after  ether  or  chloroform. 
It  is  more  common  after  the  former,  but  the  more  serious  cases  of  per- 
sistent vomiting  usually  occur  when  the  latter  has  been  employed.  In 
either  case  it  is  far  less  likely  to  be  troublesome  if  the  patient  has  been 
carefully  prepared  and  the  stomach  is  empty  at  the  time  of  the  adminis- 
tration. Vomiting  after  the  use  of  ether  appears  to  be  due  to  the  presence 
of  the  drug  in  the  stomach,  since  the  vomited  material  consists  of  thick 
mucus  with  a  strong  ethereal  odour.  This  ether  is  to  a  great  extent  swal- 
lowed with  saliva,  but  there  is  also  considerable  evidence  to  show  that 
this  drug  is  also  excreted  by  the  gastric  mucous  membrane.     Vomiting  is 


AFTER-TREATMENT  31 

also  often  caused  after  operations  on  the  nose,  moutli,  and  throat  by  the 
presence  of  swallowed  blood  in  the  patient's  stomach. 

Jolting,  or  other  disturbance  after  the  operation,  is  also  very  liable 
to  start  vomiting  ;  the  patient  should  thus  be  transferred  from  the  oper- 
ating table  to  his  bed  as  quietly  and  gently  as  possible.  If  the  vomiting 
does  not  cease  after  a  few  hours  some  treatment  becomes  necessary.  A 
simple  and  effective  method  is  to  give  half  a  pint  of  hot  water.  This 
will  probably  cause  immediate  vomiting,  but  the  washing  out  of  the 
stomach  thus  brought  about  is  likely  to  remove  the  cause  of  the  trouble. 
Bicarbonate  of  soda  grs.  xv  may  with  advantage  be  dissolved  in  the  water. 
In  more  troublesome  cases  it  may  be  necessary  to  pass  a  soft  tube  and 
thoroughly  wash  out  the  stomach. 

Hot  strong  cottee  is  sometimes  effective  in  stopping  vomiting,  while 
in  other  cases  a  little  champagne  is  quickly  successful.  Small  doses  of 
tinctureof  iodine,  n\j  or  ll\ij  in  ,-^ij  of  hot  water,  given  hourly  for  four  or  five 
hours  is  often  very  effective  in  obstinate  cases.  Hewitt  recommends  an 
enema  of  Pot.  Brom.  grs.  xx  dissolved  in  water  §ij  for  persistent  vomiting 
in  neurotic  patients. 

Retention  of  Urine.  This  is  by  no  means  an  uncommon  sequela. 
It  may  occur  both  in  men  and  women  after  abdominal  operations,  but  is 
particularly  common  after  operations  on  the  perineum,  rectum,  especially 
hsemorrhoids,  and  the  pelvic  organs  ;  it  is  also  a  frequent  complication 
after  operations  for  hernia  and  varicocele.  This  post- operative  retention  is 
usually  regarded  as  reflex  in  origin.  In  some  cases  it  appears  to  be  due 
to  unwillingness  on  the  part  of  the  patient  to  make  the  effort  owing  to 
the  pain  or  discomfort  of  the  necessary  strain.  In  other  cases  the  presence 
of  dressings  and  bandages  mechanically  render  micturition  a  matter  of 
difficulty,  especially  if  the  bladder  has  been  allowed  to  become  over- 
distended.  Lastly,  when  the  retention  persists  for  some  days,  the  neurotic 
element  is  probably  an  important  factor  in  its  causation. 

The  urine  should  be  drawn  off  by  a  carefully  sterilised  soft  rubber 
catheter.  Should  this  be  necessary  on  more  than  one  occasion,  change 
of  position  may  be  successful  in  terminating  the  trouble.  A  male  patient 
can  be  rolled  over  on  to  his  side,  while  a  female  should  be  propped  up  in 
the  sitting  posture. 

Pulmonary  Complications.  These  are  usually  a  sequela  of  the  anaes- 
thetic rather  than  of  the  operation  ;  they  occur  more  frequently  after 
ether.  Bronchitis  is  the  commonest  trouble  ;  it  is  most  likely  to  occur 
in  patients  who  are  predisposed  to  this  disease.  In  rare  cases  a  typical 
attack  of  lobar  pneumonia  may  occur— the  so-called  "  ether  pneumonia." 
In  other  cases  inhalation  of  particles  of  vomit,  blood-clot,  or  septic  material 
from  the  mouth  or  upper  air-passages  may  set  up  a  broncho-pneumonia 
There  is  no  doubt,  however,  that  many  cases  regarded  as  pneumonia  or 
pleurisy  are  really  the  result  of  infarction  {vide  infra).  In  elderly  patients, 
the  bases  of  the  lungs,  where  the  circulation  is  likely  to  be  impaired  owing 
to  the  recumbent  position  and  the  action  of  gravity,  may  become  con- 
gested and  eventually  consolidated — a  process  known  as  "  hypostatic 
pneumonia."  This  complication,  which  is  often  fatal,  is  best  avoided  by 
getting  these  patients  up  as  soon  as  possible  and  by  keeping  them  well 
propped  up  during  the  necessary  stay  in  bed.  Sometimes  when  vomiting 
has  been  excessive  the  patient  may  complain  of  a  severe  pain  in  the  lower 
part  of  the  chest.  This  is  muscular  in  origin,  and  due  to  the  excessive 
strain,  but  its  situation  and  occurrence  when  a  deep  breath  is  taken  may 


32  OPERATIONS  ON  THE  UPPER  EXTREMITY 

suggest  the  existence  of  pleurisy.  In  rare  cases  where  there  is  some  latent 
tuberculous  trouble  at  the  apices  the  administration  of  an  anaesthetic  may 
be  followed  by  obvious  signs  and  symptoms  of  phthisis  which  may  not 
have  been  previously  suspected.    ■ 

Thrombosis  and  Embolism.  These  are  both  conditions  of  great 
gravity  which  occasionally  occur  after  operations  :  the  latter,  which  is 
always  preceded  by  the  former,  may  lead  to  sudden  death  without  any 
premonitory  symptoms.  Thrombosis  is  most  likely  after  operations 
upon  the  abdominal  or  pelvic  organs.  The  coagulation  may  take  place 
at  the  site  of  the  operation,  but  often  occurs  in  the  left  femoral  vein 
though  the  field  of  operation  may  be  some  distance  away — an  appendi- 
cectomy  for  instance.  The  cause  of  the  thrombosis  is  often  uncertain. 
Some  cases  are  undoubtedly  due  to  sepsis,  but  in  the  majority  not  only 
does  the  clotting  take  place  at  some  distance,  but  the  wound  heals  by 
primary  union  and  shows  no  evidence  of  infection.  Any  of  the  following 
conditions  may  play  an  important  part  in  its  causation. 

(a)  Thrombosis  is  likely  to  occur  after  prolonged  operations  upon 
anaemic  patients  or  those  suffering  from  some  wasting  disease.  (6)  When 
excessive  haemorrhage  has  occurred  either  before  or  during  the  operation, 
(c)  Traumatism  either  by  contusion  of  the  wall  of  the  vein  by  rough 
manipulation  or  traction,  or  by  the  application  of  a  ligature  to  a  small 
vein  close  to  its  junction  with  a  large  venous  trunk,  {d)  Tight  bandaging, 
especially  a  spica  bandage  which  may  press  upon  the  femoral  or  the 
internal  saphenous  veins  in  the  groin,  (e)  Prolonged  rest  upon  the 
back  after  an  operation,  especially  if  the  legs  are  flexed  and  kept  at  rest 
by  a  large  knee  pillow.  (/)  A  prolonged  milk  diet  is  stated  to  cause 
an  increase  of  calcium  salts  in  the  plasma  and  thus  to  increase  the 
coagulability  of  the  blood. 

The  interval  between  the  operation  and  the  onset  of  the  thrombosis 
varies  from  a  few  days  to  a  few  weeks.  In  a  series  of  66  cases  collected  by 
R.  G.  Anderson  ^  the  average  interval  was  13-3  days.  The  onset  is 
generally  sudden,  though  as  a  rule  for  some  days  before  the  occurrence  of 
any  local  symptoms  there  is  slight  pyrexia  and  some  malaise.  The  patient 
then  complains  of  more  or  less  severe  pain  in  the  leg.  On  examination 
the  limb  is  found  to  be  swollen  and  tender,  especially  along  the  course 
of  the  affected  venous  trunks,  which  may  be  palpable  as  hard  cords. 
Later  the  oedema  increases  and  the  limb  will  then  pit  on  pressure.  The 
great  danger  of  thrombosis  is  that  the  clot  may  become  detached  ;  it 
will  then  be  eventually  carried  by  the  blood  stream  to  the  pulmonary 
artery,  when  it  must  produce  pulmonary  embolism  ^  or  infarction  of  the 
lung.  Displacement  of  the  clot  is  likely  to  be  brought  about  by  some 
sudden  movement  or  exertion.  The  patient  must  therefore,  when 
thrombosis  is  known  to  have  occurred,  be  kept  at  rest  until  the  clot  is 
firmly  adherent  to  the  wall  of  the  vein.  This  will  take  from  two  to 
three  weeks  in  aseptic  cases  ;  but  when  the  thrombosis  is  of  septic  origin 
a  longer  period  is  required,  since  there  is  considerable  danger  of  embolism 
occurring  during  the  process  of  softening  of  the  clot. 

The  affected  limb,  which  should  be  kept  slightly  raised  on  a  pillow, 
may  be  loosely  bandaged  over  cotton- wool. 

Sandbags  may  be  used  to  steady  the  leg,  but  splints  and  tight  bandages 

1  Guy's  Hosp.  Gazette,  New  Series,  vol.  xix,  p.  9G. 

2  Reference  may  be  made  to  a  paper  by  Louis  Blanchard  Wilson  on  "Fatal  Post- 
operation  Embolism  "  {Aim.  of  Surg.,  1912,  vol.  Ivi,  p.  809). 


AFTER-TRKATMEXT  S'S 

should  be  avoided.  The  patient  must  be  told  of  the  necessity  of  re- 
fraining from  all  movement.  Purgatives  should  not  be  given,  but  regular 
action  of  the  bowels  nuist  be  ensured  by  means  of  enemata.  After  a 
few  weeks  the  swelling  usually  disappears  and  the  circulation  is  completely 
restored.  In  the  event  of  the  swelling  persisting,  massage  will  be  of 
service,  but  this  method  of  treatment  must  of  course  only  be  employed 
in  the  later  stages  and  even  then  with  caution. 

Embolism  usually  occurs  after  some  movement  or  exertion,  often  of 
a  very  trifling  nature  such  as  sitting  up  or  turning  over  in  bed.  The 
preceding  thrombosis  may  have  taken  place  in  some  deep  vessel  without 
any  signs  or  symptoms  and  thus  may  have  been  entirely  unrecognised. 
The  sudden  unexpected  death  which  may  then  take  place  in  a  convalescent 
patient  who  is  apparently  out  of  danger  after  the  operation  is  one  of  the 
most  terrible  accidents  in  surgery.  Should  the  clot  be  of  such  size  as  to 
block  either  the  whole  pulmonary  artery  or  one  of  its  main  branches, 
usually  the  left,  death  will  almost  certainly  occur.  Should,  however,  the 
clot  be  small  enough  to  be  carried  into  one  of  the  smaller  terminal  branches, 
the  patient  may  recover.  In  this  event  physical  examination  of  the  chest 
a  few  days  later  will  probably  reveal  an  area  of  solid  lung  and  a  patch  of 
pleurisy. 

When  embolism  occurs  the  patient  is  suddenly  seized  \^ath  a  most 
acute  pain  in  his  chest  and  at  once  becomes  collapsed.  There  is 
very  severe  and  distressing  dyspnoea  ;  the  pulse  is  feeble,  flutter- 
ing, and  very  rapid  (120-160).  The  face  is  cyanosed,  and  subse- 
quently the  whole  surface  of  the  body  may  have  a  greyish  tinge.  Oc- 
casionally there  may  be  one  or  several  convulsions.  As  the  result  of  the 
obstruction  to  the  pulmonary  circulation  the  whole  of  the  systemic 
venous  svstem  becomes  excessivelv  engorged.  Venesection  mav 
therefore  be  carried  out  with  advantage,  and  often  affords  great  relief. 
The  patient  should  be  propped  up  in  a  sitting  position  and  oxygen  freely 
administered.  This  will  cause  an  improvement  in  the  colour  and  also 
relieves  the  dyspnoea.  An  injection  of  strychnine  should  also  be  given 
to  stimulate  the  heart's  action.  In  very  acute  cases  artificial  respiration 
should  be  tried  when  the  breathing  has  stopped. 


SURGERY  I 


CHAPTER  II 

INFUSION.     TRANSFUSION.     SKIN-GRAFTING 

These  may  be  considered  together  here,  since  infusion  is  frequently 
employed  after  operations  in  the  treatment  of  the  general  condition 
of  the  patient,  and  skin-grafting  in  the  subsequent  treatment  of  a 
granulating  wound. 

I.  INFUSION 

While  this  method  had  been  occasionally  made  use  of  by  several 
different  workers  for  many  years — e.g.  the  Littles  in  the  cholera  epidemics 
at  the  London  Hospital  in  1848  and  186G,  and  many  others,  sporadically, 
at  most  of  our  hospitals — it  was  Dr.  William  Hunter  who,  in  1889,  by 
his  Arris  and  Gale  Lectures  ^  again  drew  the  attention  of  the  profession 
in  this  country"^  to  the  great  importance  of  the  injection  of  saline  fluid 
in  sustaining  life,  if  only  sufficient  fluid  was  employed  to  keep  it  in 
circulation.  Further,  it  was  Sir  Arbuthnot  Lane  who,  applying  the 
above  experiments  to  surgery  in  two  brilliantly  successful  cases,^  again 
drew  the  attention  of  the  profession  to  the  value  of  this  method  more 
forcibly  than  had  been  done  before. 

In  his  three  lectures,  Dr.  Hunter,  after  contrasting  the  advantages 
of  transfusion  and  infusion,  arrives  at  the  following  most  important 
conclusion  :  "  For  practical  purposes  all  the  advantages  to  be  gained 
by  transfusion  may,  I  believe,  be  equally  well  and  more  readily  obtained 
by  infusion  of  a  neutral  saline,  such  as  a  f  per  cent,  solution  of  common 
salt  (about  1  drachm  to  the  pint)."  With  regard  to  the  direct  transfusion  of 
blood,  he  clearly  shows  that  the  nutritive  value  of  serum  is  so  small 
that  its  chief  value  must  depend  upon  its  physical  properties,  and  these 
are  in  no  respect  greater  than  those  of  a  corresponding  quantity  of 
normal  saline  solution.  With  regard  to  the  red  corpuscles  the  same 
authority  writes  :  "  The  greater  the  quantity  of  blood  transfused,  the 
longer  are  red  corpuscles  likely  to  remain  within  the  circulation,  and 
the  more  likely  is  their  haemoglobin  and  the  iron  which  it  contains  to 
remain  within  the  system.  Over  this  factor,  however,  we  can  exercise 
but  little  control.  The  quantity  of  blood  transfusible  in  man  can  rarely 
be  more  than  about  5  per  cent,  of  the  bl  od  already  in  the  body.  And 
the  life  duration   of  the  red  corpuscles  under  such   circumstances   is 

1  See  Brit.  Med.Journ.,  vol.  ii,  1889,  pp.  117,  237,  305. 

2  About  the  same  time  the  late  Dr.  Woolridge,  in  experiments  unpublished  owing 
to  his  untimely  death,  was  also  proving  that  after  haemorrhage  suff  cicnt  to  be  fatal,  enough 
haemoglobin  still  remained  to  sustain  life,  if  only  sufficient  fluid  were  added  to  keep  it  in 
circulation.  Dr.  H.  Spencer,  who  successfully  infused  a  patient  the  subject  of  post-partum 
haemorrhage  as  long  ago  as  1888,  suggests  that  Golz  (Virch.  Arch.  Bd.  xxi  and  xxix), 
and  Kronecher  and  Sander  {Berl.  klin.  Woch.  1879,  No.  52),  were  the  first  to  suggest 
saline  infusion  and  explain  its  action. 

3  One  of  the  cases  is  published  {Lancet,  vol.  ii,  1891,  p.  626). 

3-t 


TXFT^SIOX  35 

probably  to  bo  rockonod  by  a  period  of  hours."'  After  the  greatest 
loss  of  blood  sufficient  red  corpuscles  always  remain  for  the  absorption 
of  oxvgen  from  the  lungs,  provided  that  the  circulation  is  maintained. 
After  a  sudden  loss  of  l)lood.  the  source  of  danger  is  not  the  want  of 
red  corpuscles,  but  the  disturbance  of  the  relation  between  the  vascular 
system  and  its  contents,  or,  in  other  words,  the  fall  in  the  blood  pressure 
to  a  point  where  the  circulation  is  unable  to  be  maintained.  These 
conclusions  have  been  amply  confirmed  by  modern  experience,  so  that 
direct  transfusion  of  blf)od  is  now  practically  never  employed,  its  place 
being  taken  1)\-  infusion  of  a  saline  solution.     The  chief  indications  are  : 

(1)  Acute  traumatic  anaemia,  such  as  occurs  as  the  result  of  excessive 
haemorrhage  after  operations,  or  after  accidents  where  a  large  vessel 
has  been  divided,  such  as  a  cut  throat,  or  as  the  result  of  a  ruptured 
extra-uterine  gestation,  or  post-partum  haemorrhage.  The  results  here 
are  particularly  satisfactory.  It  is.  of  course,  essential  that  the  source 
of  the  haemorrhage  should  be  found  and  the  bleeding  vessel  secured 
by  ligature,  or  in  some  other  way.  When  this  is  successfully  accom- 
plished judicious  treatment,  especially  infusion,  renders  recovery  possible, 
or  even  likely,  however  desperate  the  condition  of  the  patient. 

(2)  In  cases  of  collapse,  other  than  those  produced  by  a  sudden 
haemorrhage.  It  has  been  mentioned  before  (p.  28)  that  in  cases  of 
collapse  we  have  a  low  blood  pressure,  the  result  of  inhibition  of  the 
vaso-motor  centre,  in  many  instances  brought  about  by  the  loss  of 
fluid  from  the  blood,  a  severe  haemorrhage,  for  example.  Dr.  Beddard, 
in  "Some  remarks  on  Transfusion  and  Infusion"^  and  in  a  clinical 
lecture  on  "  Transfusion."  -  discusses  this  and  several  other  points 
in  a  very  helpful  way  and  with  the  authority  of  a  physiologist  as  well 
as  a  physician.  He  thus  explains  this  loss  of  fluid.  "  In  many  cases 
of  collapse,  however,  the  way  in  which  fluid  is  lost  from  the  vascular 
system  is  not  so  obvious  at  first  sight  as  in  the  case  of  haemorrhage. 
For  instance,  in  cases  of  burn  or  scald  it  is  a  familiar  fact  that  the 
prognosis  is  determined,  not  so  much  by  the  degree  as  by  the  area 
involved.  Thus,  a  patient  with  one  finger  badly  charred  and  another 
scalded  slightly  all  over  the  body  are  both  at  first  in  a  condition  of 
shock.  •  The  patient  with  the  severely  burned  finger  comes  out  from 
the  condition  of  shock  and  recovers  ;  the  scalded  patient  may  or  may 
not  recover  temporarily  from  the  shock,  but  passes  gradually  into  a 
condition  of  collapse  and  dies.  Again,  a  patient  has  a  blow  in  the 
abdomen  which  ruptures  his  gut.  he  may  recover  from  the  initial  shock 
and  even  keep  about  for  a  time  feeling  comparatively  well,  then  he 
passes  into  a  condition  of  collapse.  It  must  now  be  asked  how  have 
these  patients  lost  fluid  from  their  circulation  and  become  collapsed. 

Whenever  a  tissue  is  damaged,  whether  mechanically  or  by  inflam- 
mation, it  becomes  oedematous  \^^th  fluid  taken  from  the  vascular 
system.  Three  distinct  stages  can  be  distinguished.  (1)  Fluid  is 
rapidly  poured  out  into  the  damaged  tissues  from  the  vessels.  An  equal 
quantity,  however,  passes  from  the  miinjured  tissues  to  the  blood. 
(2)  During  the  second  stage  more  fluid  is  passing  to  the  injured  tissues 
than  can  be  got  from  the  uninjured  ones  :  hence  there  is  now  less  than 
the  normal  quantity  of  water  in  the  circulating  blood.  For  a  time  this 
condition  does  not'  affect  the  blood  pressure  and  pulse  because  it  is 

1  Guy's  Hosp.  Beps..  vol.  Iv.  p.  29. 

2  Guy's  Hosp.  Gazette,  July  29,  1905. 


36         OPERATIONS  ON  THE  UPPER  EXTREMITY 

temporarily  compensated  for  by  vaso-constriction  of  blood-vessels. 
(3)  In  the  third  stage,  the  drain  of  fluid  into  the  damaged  tissues  still 
goes  on,  the  specific  gravity  of  the  blood  rises  continuously,  the  vaso- 
motor centre  can  no  longer  keep  up  the  arterial  blood  pressure,  which 
falls  progressively  till  the  death  of  the  patient  from  failure  of  the  cerebral 
and  coronary  circulation.  It  is  very  important  to  note  that  this  final 
stage  may  set  in  with  great  suddenness  and  the  patient  die  before  any- 
thing can  be  done  for  him.  Collapse  may  develop  in  exactly  the  same 
way  from  the  continued  loss  of  fluid  by  severe  vomiting  and  diarrhoea, 
as  seen  in  cholera,  the  summer  diarrhoea  of  infants,  ulcerative  colitis, 
uraemia,  in  cases  of  irritant  poisoning,  and  many  other  like  conditions." 
Thus,  in  cases  of  collapse,  from  whatever  cause,  when  the  patient 
has  shrunken  features  pointing  to  loss  of  fluid,  whatever  other  treatment 
he  may  require,  he  certainly  requires  infusion. 

(3)  Shock.  It  has  been  shown  (p.  28)  that  shock  is  essentially  due 
to  exhaustion  of  the  vaso-motor  centre  as  the  result  of  excessive  afferent 
impulses  reaching  the  centre  :  The  blood  thus  stagnates  in  the  large 
veins  especially  those  in  the  splanchnic  area.  The  low  blood  pressure 
is  due,  not  to  there  being  too  little  fluid  in  the  vessels,  but  to  the  blood 
being  improperly  distributed.  If  salt  solution  be  infused  into  a  vein 
of  a  patient  suffering  from  shock,  it  may  improve  the  blood  pressure 
temporarily  since  it  increases  the  intake  of  fluid  by  the  heart  and  con- 
sequently its  output  into  the  arteries.  The  greater  part  of  the  fluid 
will  find  its  way  through  the  dilated  arteries  into  the  abdominal  veins 
and  accumulate  there,  or  it  may  pass  through  the  walls  of  the  capillaries 
into  the  tissues.  On  these  grounds  we  should  not  expect  infusion  to  be 
of  much  use  in  the  treatment  of  shock.  In  adrenalin,  however,  we 
have  a  drug  which  raises  the  blood  pressure  by  acting  upon  the  peri- 
pheral arteries  when  given  either  subcutaneously  or  intravenously. 
Adrenalin  is  quickly  oxidised  and  destroyed  by  the  tissues.  Crile 
therefore  suggests  the  infusion  of  saline  solution  to  which  adrenalin 
hydrochloride  has  been  added  to  the  proportion  of  1  in  50.000.  When 
given  intravenously  the  effect  of  adrenaline  is  instantaneous.  Dr. 
Beddard  recommends  that  it  be  given  subcutaneously.  when  a  dose  of 
from  20  to  30  minims  of  a  1  in  1000  solution  may  be  safely  employed.  Its 
effect  upon  the  blood  pressure  comes  on  within  a  very  few  minutes, 
and  disappears  in  about  an  hour,  therefore  the  injection  has  to  be 
repeated  hourly  until  the  shock  has  passed  off. 

(4)  Rarer  indications  are  diabetic  coma  and  septicaemia  ;  in  the  latter 
on  the  ground  that  it  facilitates  the  removal,  especially  by  the  kidneys, 
of  the  micro-organisms  and  their  toxins.  In  the  former  the  object  is 
to  neutralise  the  acid  intoxication  by  the  alkali  as  well  as  to  dilute  the 
poison  in  the  blood.  With  this  object  a  solution  of  sodium  bicarbonate 
is  employed.  The  strength  to  use  is  4  drachms  of  the  salt  to  a  pint  of 
water. 

(5)  In  the  case  of  certain  poisons,  e.g.  carbolic  acid,  Dr.  Oliver  of 
Newcastle^  drew  attention  to  the  insuificiency  of  washing  out  the  stomach 
when  once  a  poison  like  carbolic  acid  has  got  into  the  blood,  and  to  the 
need  of  infusing  with  saline  fluid,  as  this  is  in  great  part  rapidly  excreted 
by  the  kidneys  and  carries  much  of  the  poison  away  with  it.  Dr.  Powell 
describes  a  most  successful  case.^ 

1  Professor  AUbutt's /S?/5/em  o/'il/etii'cme,  vol.  ii,  pt.  I,  ]).  1017. 

2  Lancet,  1898,  vol.  ii,  p.  1326.' 


INFUSION  31* 

A  woman,  a^t.  21,  vvlio  had.  about  throc-quartors  of  an  hour  before  her  admission, 
swallowed  7  drachms  of  ordinary  eommercial  carbolic,  was  biought  in,  in  a  state 
of  coma  and  collapse.  While  the  stomach  was  being  washed  out,  the  left  internal 
saphenous  vein  was  o|)ened  and  8  ounces  of  blood  removed.  Four  pints  of  a  saline 
solution,  at  a  temi)erature  of  100"  were  then  injected.  The  pulse  and  respiration 
gradually  imjjroved.  Glycerine  in  drachm  doses  was  given  frequently  to  allay 
the  burning  sensation  in  the  pharynx  and  cesophagus.  For  three  days  the  urine 
was  dark  green,  but  never  contained  albumen.     Recovery  was  rapid  and  complete. 

(6)  Another  condition  which,  from  its  urgent  gravity,  deserves 
mention  here,  is  gas-poisoning. 

This  appears  to  be  more  common  in  America,  both  in  private  and  in  hospital 
practice,  than  with  us.  Dr.  Taylor  ^  gives  his  conclusions  from  ninety  cases,  in 
twelve  of  which  necropsies  were  obtained.  He  considers  that  venesection  and 
saline  infusion,  usually  combined,  should  be  promptly  employed.  Where  the  pulse 
is  vigorous,  venesection  followed  by  infusion  is  the  remedy.  Where  in  an  un- 
conscious patient  the  pulse  does  not  justify  venesection,  infusion  alone  should  be 
made  use  of.     How  the  two  remedies  act  is  uncertain. 

(7)  For  the  intravenous  induction  o£  anaesthesia.  This  method. 
which  is  still  on  trial,  certainly  seems  in  some  cases  to  offer  many  advan- 
tages. A  5  per  cent,  solution  of  ether  appears  to  be  more  satisfactory 
than  hedonal  or  isopral,  which  were  first  employed.  The  method  is 
certainly  convenient  in  operations  on  the  head,  neck,  and  mouth,  where 
the  ordinary  apparatus  may  be  very  much  in  the  way  of  the  operator. 
It  is  said  to  lessen  the  probability  of  pulmonary  complications  in  those 
patients  suffering  from  or  liable  to  bronchitis.  Also,  when  shock  is 
anticipated  or  is  already  present,  the  saline  will  be  beneficial  and  a 
small  quantity  of  anaesthetic  will  be  employed. 

Intravenous  ana'sthesia  was  first  employed  by  Burkhart.2  Rood,^  who  first 
employed  the  method  in  this  country,  describes  the  technique,  apparatus,  and 
mode 'of  induction.  He  gives  an  account  of  twenty-one  cases  in  which  it  was 
successfully  employed. 

Preparation  of  the  solution.  In  the  preparation  of  the  solution 
ordinary  boiled  tap  water  may  be  quite  safely  used.  Indeed,  this  is 
preferable  to  distilled  water,  which  is  usually  far  from  sterile  and  may 
contain  traces  of  deleterious  materials  derived  from  the  copper  stills 
into  which  it  is  generally  condensed. 

With  regard  to  the  materials  to  be  used.  Dr.  Beddard  regards  dextrose 
as  eminently  suitable,  being  a  normal  constituent  of  the  blood,  and 
sufficiently  non-poisonous  to  be  injected  in  large  quantities.  A  6  per 
cent,  solution  of  dextrose  is  theoretically  isotonic  with  human  blood- 
plasma.  The  material  most  frequently  employed  is  sodium  chloride,  the 
strength  of  which  should  be  1|  drachms  to  the  pint,  or  roughly  one  tea- 
spoonful.  This  has  the  advantage  of  always  being  readily  obtainable. 
Such  a  solution  is,  however,  far  from  being  non-toxic,  and  while  this 
fact  does  not  prevent  its  use,  the  symptoms  of  possible  poisoning  by  a 
sodium  salt  should  be  remembered.  "  They  are  stimulation  of  the 
nerves  and  muscles  from  slight  twitchings  up  to  severe  con\^lsions, 
pyrexia  up  to  hyper- pyrexia,  rigors,  feeble  and  rapid  pulse."  It  is 
further  pointed  out  that  certain  cases  are  much  more  liable  to  poisoning 
bv  sodium  chloride  than  others.  "  All  the  serious  cases  of  sodium 
chloride  poisoning  which  I  have  seen  have  been  cases  of  uraemia,  diabetic 
coma,  or  cholaemia,  and  it  is  easy  to  understand  why.     In  these  toxaemias 

1  Med.  Record,  July  9.  1904.  -  Mun.  Med.  WocL,  1909,  No.  W. 

3  Brit.  Med.  Journ.,  1911,  vol.  ii,  p.  974. 


38         OPERATIONS  ON  THE  UPPER  EXTREMITY 

the  patient  has  lost  no  salts  from  his  vascular  system  ;  he  has  all  he 
ought  to  have,  and  you  by  treatment  make  a  considerable  addition  to 
this  amount.  Therefore  he  is  comparatively  easily  poisoned.  But  in 
cases  of  collapse,  such  as  peritonitis,  diarrhoea,  and  vomiting,  &c.,  the 
patient,  besides  water,  has  lost  large  quantities  of  salts  as  well,  and 
therefore  you  would  have  to  inject  very  large  quantities  of  sodium 
chloride  to  poison  him  severely." 

Better  than  a  solution  of  common  salt  is  a  physiological  solution 
which  is  iso-tonicwith  bloodrplasma.  The  following  fulfil  this  requirement: 
Locke's  solution.  Sod.  Chlor.  -9  grm.,  Calc.  Chlorid.  -024:  gim..  Potass. 
Chlorid.  •042  grm..  Sod.  Bicarb.  -01  gim.,  Dextrose  -1  gim..  Aqua  100  c.c. 
(2)  Sod.  Chlorid.  -9  grm..  Potass.  Chloras.  -03  grm.,  Calc.  Chlorid.  -01 
grm.,  Aq.  100  c.c.  These  should  be  used  with  distilled  water.  The 
following  forms  a  physiological  solution  when  added  to  tap  water  :  Sod. 
Chlorid.  80  grs..  Potass.  Chloridi.  3|  grs..  Dextrose  9  grs.,  Aq.  Dest. 
ad  4  drachms.  The  ingredients  are  dissolved  in  distilled  water  and 
then  sterilised  by  boiling.  One  tablespoonful  added  to  each  pint  of 
boiled  tap  water  gives  a  solution  ecjuivalent  to  Locke's  solution. 

In  any  case  the  fluid  should  be  sterilised  by  boiling  and  then  cooled 
to  a  temperature  of  115°  F.  by  the  addition  of  sterilised  water,  or,  in 
cases  of  emergency,  of  ordinary  cold  tap  water.  The  greatest  care 
must  be  taken  to  see  that  the  solution  is  not  too  cold  when  it  reaches 
the  patient. 

The  method  of  infusing.  There  are  three  possibilities  :  (1)  Directly 
into  a  vein  ;  (2)  subcutaneously  ;  (3)  into  the  bowel.  The  alimentary 
canal  is  often  impossible  for  obvious  reasons.  When  the  circulation 
has  almost  failed,  absorption  will  be  too  slow  "and  imperfect  to  be  of 
any  real  value.  In  less  serious  cases,  however,  when  it  is  employed 
more  as  a  precaution  to  guard  against  a  comparatively  slight  circulatory 
failure  becoming  more  severe,  it  may  be  employed  with  advantage. 
Under  these  circumstances  it  is  better  to  slowly  inject  a  pint,  and  then 
should  the  condition  of  the  pulse  render  it  advisable,  repeat  the  injection 
after  an  hour's  interval.  The  fluid  should  slowly  flow  through  a  soft 
rubber  catheter  passed  well  into  the  bowel.  Subcutaneous  injection  is 
open  to  somewhat  similar  objections  :  when  severe  circulatory  failure 
has  occurred  the  fluid  may  not  be  absorbed  at  all.  On  the  other  hand, 
in  less  severe  cases,  the  solution  is  absorbed  with  remarkable  rapidity 
and  the  pulse  quickly  improves.  In  urgent  cases  then,  after  a 
severe  haemorrhage  for  instance,  when  it  is  essential  to  get  fluid  into 
the  circulation  with  the  least  possible  delay,  the  intravenous  method 
is  indicated.  In  other  cases  infusion  by  the  subcutaneous  or  ali- 
mentary routes  may  be  preferred.  The  rate  at  which  fluid  should  be 
allowed  to  flow  into  a  vein  is  an  important  question.  Dr.  Beddard, 
in  his  paper,  quoted  above,  directs  attention  to  the  danger  of  over- 
distending  the  right  side  of  the  heart.  "  I  have  certainly  seen  cases 
where  intravenous  infusion  has  caused  death  in  this  way.  It  is  difficult 
to  say  at  what  rate  fluid  can  be  run  into  a  vein  without  this  danger 
to  the  heart.  That  an  apparently  small  difference  in  the  blood-flow 
along  the  veins  may  make  a  great  dift'erence  to  the  right  heart  is  clearly 
shown  by  venesection.  Here,  in  the  course  of  several  minutes,  we 
abstract  at  most  a  pint  of  blood  from  the  arm  and  produce  a  very  real 
effect  upon  the  condition  of  the  right  ventricle.  Conversely,  it  is  easy 
to  understand  that  the  injection  of  fluid  into  a  vein  may  be  serious  to 


INFUSION 


.39 


tlic  heart.  There  can  he  no  douht  that  the  moic  slowlv  the  fluid  is 
run  ill  the  better,  and  as  a  maxinial  rate  I  would  su<^<^est  a  pint  in  ten 
minutes.  This  rate  may  appear  to  err  on  the  side  of  safety,  but  I  do 
not  think  it  does.  It  is  necessary  to  remember  that  often  when  intra- 
venous infusion  is  used  the  right  heart  is  far  from  normal."  He  next 
points  out  tiiat  the  choice  of  route  also  de])en(ls  upon  the  solution  to 
be  used.  "A  solution  of  dextrose  is  not  suitable  for  any  but  intra- 
venous injection.  Large  (piantities  given  by  the  bowel  may  not  be 
retained  or  may  set  up  diarrha^a.  and  when  injected  subcutaneously 
may  cause  sloughing.  A  solution  of  sodium  chloride  may  be  given 
ill  any  of  the  three  ways.  It  is  the  best  to  use  for  subcutaneous  or  rectal 
infusion.  In  diabetes,  a  solution  of  sodium  bicarbonate  should  not  be 
given  subcutaneously  because  of  its  liability  to  produce  sloughing." 

Method.  Now  that  the  indications  for  saline  infusion  are  known 
to  be  so  numerous,  and  are  so  often  followed  by  excellent  results,  every 
practitioner  should  be  prepared  to  employ  this  mode  of  treatment, 
remembering  the  critical  nature  of  the  cases  which  call  for  it,  and  the 
suddeni\ess  with  which  the  call  is  liable  to  come.  The  apparatus  should 
be  as  simple  as  possible.  A  glass  funnel,  several  feet  of  rubber  tubing 
of  suitable  size,  and  blunt  cannula?  and  sharp-pointed  hollow  needles 
of  various  sizes  are  all  that  are  essential.  All  these  can  be  readily 
sterilised  by  boiling.  If  the  subcutaneous  method  is  to  be  employed, 
the  skin  is  cleansed  and  a  sharp  needle  pushed  through  the  deep  fascia 
into  the  lax  tissues  of  the  axilla.  A  Y-shaped  junction  may  be  used 
so  as  to  permit  of  simultaneous  infusion  into  both  axillae.  In  intra- 
venous infusion  the  skin  over  the  vein  selected  is  first  sterilised.  The 
vessel  chosen  is  usually  the  median  basilic  or  the  cephalic.  Either  is 
exposed  by  an  oblique  incision  to  the  inner  or  the  outer  side  of  the 
biceps    tendon.      Where 

there    is    any    difficulty  <'^ 

in  finding  a  vein  here, 
owing  to  their  collapsed 
state  or  to  the  arrange- 
ment not  being  normal, 
a  skin  flap  should  be 
turned  up,  or  gentle 
pressure  made  on  the 
basilic  or  the  cephalic  a 
little  higher  up,  and  the 
trunk  exposed  here.  Or 
the  patient's  leg  may  be 
allowed  to  hang  down 
and  the  internal  saphe- 
nous opened  just  in  front  of  the  malleolus.  Two  catgut  ligatures  are  now 
passed  beneath  the  exposed  vein.  One  is  drawn  to  the  lower  angle  of 
the  wound,  tied  round  the  vein  and  cut  short.  The  freed  portion  of  the 
vein  being  raised  with  dissecting  forceps,  a  small  nick  is  made  in 
it  with  scissors,  care  being  taken  not  to  sever  it  completely.  The 
cannula  is  next  introduced  into  the  vein  in  an  upward  direction  and 
tied  by  the  upper  ligature,  the  ends  of  which  are  left  long  (Fig.  2). 
The  blood  now"  flows  down  the  cannula,  and  when  it  is  full,  the  tubing, 
previously  attached  to  the  funnel  and  filled  with  saline  solution  at  a 
temperature  of  1 10°  to  1 1 5°  F.  and  prepared  in  one  of  the  above-described 


Fig.  2. 


Method  of  inserting  the  cannula  for  intra- 
venous infusion. 


40 


OPERATIONS  ON  THE  UPPER  EXTREMITY 


ways,  is  fixed  to  it.  The  funnel  is  now  raised  to  a  height  of  about 
4  feet,  and  as  the  solution  flows  it  is  replaced  by  more  poured  from  a 
jug  held  close  to  the  funnel  to  avoid  the  formation  of  bubbles.  When 
sufficient  has  been  infused  the  cannula  is  removed.  The  vein  is  cut 
completely  across,  and  the  upper  end  tied  with  the  ends  of  the  ligature 
which  have  been  left  long. 

From  four  to  six  pints  of  the  infusion  fluid  should  be  at  hand.  It 
should  take  at  least  from  20  to  30  minutes  to  inject  two  to  three  pints, 
the  amount  usually  required.  Occasionally  five  or  six  pints  are  needed  : 
the  more  slowly  the  fluid  is  then  infused  the  better.  Two  or  three 
infusions  of  a  smaller  amount  are  often  better  than  the  single  rapid 
injection  of  a  large  quantity.  The  chief  guides  are  the  return  of  the 
pulse,  with  increase  in  volume  and  diminution  in  rate  (say,  a  fall  from 
130°  to  90"").  return  of  colour  and  fulness  to  the  face,  increase  in  con- 
sciousness, &c.  Care  must  be  taken,  while  the  fluid  is  being  injected, 
that  no  air  enters,  and  that  there  is  no  blocking  of,  or  leakage  from, 

the  apparatus  employed.  The 
rate  of  flow  may  be  regulated 
by  the  height  above  the 
patient  at  which  the  funnel  is 
held. 

Though  the  apparatus  de- 
scribed above  has  the  ad- 
vantages of  simplicity  and 
portability,  it  has  certain  dis- 
advantages, especially  for 
subcutaneous  infusion.  This 
is  naturally  a  longer  process, 
and  unless  great  care  is  taken 
the  temperature  of  the  fluid 
will  fall  very  considerably  be- 
fore it  reaches  the  patient's 
tissues.  To  overcome  this 
and  other  disadvantages, 
various  other  forms  have  been 
devised. 

(1)  The  vessel  containing 
the  fluid  stands  in  a  water  bath,  the  temperature  of  which  is  indi- 
cated by  a  thermometer,  or,  as  suggested  by  Moynihan,  is  heated  by  a 
spirit-lamp  placed  beneath.  The  apparatus  rests  on  a  stand  at  the 
side  of  the  patient's  bed,  the  height  of  which  can  be  adjusted. 

(2)  Lane's  apparatus  (Figs.  3  and  4).  This  consists  of  a  rubber  bag 
containing  the  infusion  fluid.  It  can  be  suspended  from  a  hook  at 
any  desired  height  above  the  bed  or  operating  table. 

^  (3)  The  principle  of  the  "  Thermos  flask  "  has  been  applied  to  the 
construction  of  a  receptacle  for  the  fluid,  which  is  thus  kept  at  a  prac- 
tically constant  temperature  for  a  considerable  time. 

Mr.  N.  S.  Carruthers,  writing  on  this  subject  ^  insists  on  the  importance  of  the 
fluid  being  hot,  especially  when  children  are  infused  for  collapse  after  epidemic 
summer  diarrhcea.  He  finds  that  though  the  temperature  of  the  fluid  in  the  receiver 
"is  120°,  that  it  may  be  only  "5°  when  it  reaches  the  neetUe  in  the  course  of  a  slow 
infusion.     This  may  lead  to  an  increase  in  the  collapse.     To  remedy  this  he  has 


Fig.  3. 


Lane's  !subciitanet)us  Infusion 
Appai-atus. 


1  Brit.  Med.  Joum.,  1911.  vol.  ii,  p.  725. 


INFUSION 


41 


dosigncd  the  foUowiiifj;  a!)i>;ira(us.  "The  essential  part  is  a  vacuum  flask,  tlio 
ncH^k  of  whicl*  is  fitted  with  a  rubber  cork  and  three  glass  tubes,  one  long  and 
extending  to  the  bottom  of  t!ie  bottle,  the  other  two  short.  The  case  in  which  the 
flask  is  lield  is  fitted  with  a  handle,  and  on  each  side  a  glass  tube  is  securely  fixed 
and  graduated  by  exi)eriment  in  ounces.  To  one  of  the  short  glasses  passing  through 
the  cork  a  piece  of  rubber  ])ressure  tubing  is  attached  to  convey  the  saline  to  the 
])atient.  To  the  other  glass  tubes  fitted  in  the  cork 
suiall  i)ieees  of  rubber  tubing  are  attached,  and  when 
the  bottle  is  filled  and  corked  these  short  tubes  are 
connected  uj)  with  the  graduated  glasses,  oik;  on  each 
side.  The  result  of  having  them  both  graduated  is 
that  it  matters  little  which  tube  is  attaclied  to  which 
glass,  for  either  will  register.  This  simplifies  the  appli- 
ance somewhat. 

"  When  till' flask  is  inverted  and  the  saline  running, 
air  is  carried  to  the  top  of  the  bottle  by  jneans  of  the 
long  glass  tube,  and,  the  fluid  escaping  into  the  glass 
tube  of  the  opposite  side,  acts  as  a  i-egister.  The 
register  can  be  graduated  to  record  the  amount  in  the 
flask,  or,  as  i  prefer  it,  the  amount  the  patient  has 
received.  The  solution  is  conducted  to  the  patient  by 
a  short  length  of  rubber  pressure  tubing  which  prevents 
the  loss  of  heat,  since  rubber  is  a  poor  conductor. 

"  This,  like  most  appliances,  is  fitted  with  a  Y-piece, 
so  that  it  can  be  connected  to  two  needles  and  the 
patient  infused  in  two  places  at  the  same  time. 
Ordinary  infusion  needles  are  used,  and  screw  clips  to 
regulate  the  rate  of  flow.  The  total  length  of  the 
rubber  tubing  to  each  needle  should  not  exceed  ten 
inches.  When  in  use  the  apparatus  is  hung  on  a  hook, 
or  it  may  be  put  on  a  suitable  stand." 

Infusion  is  now  employed  so  often  and  in 
such  a  variety  of  cases  that  it  will  be  well  to 
point  out  that  if  injudiciously  used  it  may  be 
actually  harmful.  In  all  cases  a  watch  must 
be  kept  on  the  pulse  and  on  the  general  con- 
dition of  the  patient.  Possible  dangers  are  as 
follows  : 

(1)  Sepsis.  It  is  of  course  essential  that  the 
fluid  injected  shall  be  sterile.  Care  must  also 
be  taken  to  keep  the  small  wound  in  front  of 
the  elbow  aseptic.  Any  thick  scar  in  front 
of  the  elbow- joint  will  embarrass  its  move- 
ments,  and  infection  may  lead  to  thrombosis   Fm.  4.    Lane's  Infusion  Bag 

and  embolism.     In  subcutaneous  infusion  anv  suspended   from   a   stand, 

...  .  ....  ,  ,      .  1  1  •"  with    Y    junction   and    two 

failure  m  sterdismg  the    solution  or  the  skm  needles    for    simultaneous 

may  lead  to  extensive  cellulitis  or  sloughing.  infusion  into  both  axilla;. 

(2)  As     already     pointed    out,    too    rapid 

intravenous  infusion   may  lead  to  dilatation  of  the  right  side  oi  the 
heart. 

(3)  (Edema  of  the  lungs  occasionally  occurs,  and  may  be  the  cause 
of  a  fatal  result.  It  is  especially  likely  to  occur  when  very  large  quantities 
are  injected.  Any  development  of  dyspnoea  is  an  indication  for  at  once 
stopping  the  infusion. 

(4)  If  too  weak  a  solution  of  salt  is  employed  the  tissues  will  attract 
more  fluid  from  the  blood-vessels,  the  very  thing  that  infusion  is  meant 
to  correct.  A  weak  solution  is  also  likely  to  cause  the  breaking  up 
of  a  number  of  the  red  blood  corpuscles. 


42         OPERATIONS  OX  THE  UPPER  EXTREMITY 

Transfusion.  Direct  transfusion  of  blood  from  a  healthy  individual  to  the 
patient  has  been  replaced  by  infusion  of  a  saline  solution.  As.  however,  in  recent 
years  traiLsfusion  has  been  employed  in  a  few  cases  of  pernicious  anaemia,  a  brief 
account  of  the  method  will  be  given  here. 

Dr.  Avelings  method,  modified  by  Mr.  Cripps,  is  .simple,  inexpensive,  and  has  the 
advantage  of  measuring  the  blood  sent.  viz.  2  drachms  at  each  squeeze  of  the  bulb. 
The  apparatus  (Fig.  5)  consists  of  twocannulse  connected  by  a  short  length  of  rubber 
tube  in  the  centre  of  which  is  a  rubber  bulb,  the  capacity  of  which  is  2  drachms. 
The  skin  ha\ing  been  cleansed,  the  veins  exposed  and  probes  passed  beneath  them, 
the  apparatus  is  filled  with  a  warm  sterihsed  normal  saline  solution,  and  a  clip 
placed  at  either  end.  The  arms  of  receiver  and  donor  being  brought  close  together, 
the  vein  of  the  receiver  is  opened  with  sharp  scissors,  and  pressure  being  made  just 
below  the  opening  in  the  vein,  so  as  to  prevent  blood  obscuring  the  opening,  the 
cannula  is  inserted.  The  other  cannula  is  then  inserted  into  the  vein  of  the  giver, 
and  both  are  held  steadily  by  an  assistant.  Traasfusion  is  then  performed  as 
follows  : 

"  The  chips  having  been  removed  from  the  tube  at  either  end,  the  operator 
makes  the  necessary  valve  to  prevent  regurgitation  by  compressing  with  the  finger 
and  thumb  of  one  hand,  the  tube  between  the  central  ball  and  the  giver.     He  then 


Fig.  5.     Aveling's  Transfusion  apparatus  with  two  cannulse  and  two  niotal  stopcocks. 

slowly  squeezes  the  ball,  with  the  effect  of  driving  the  water  it  contains  gently  into 
the  vein  of  the  recipient  ;  then,  ha\ing  compressed  the  tube  between  the  ball  and 
the  recipient,  he  removes  the  finger  and  thumb  from  off  the  tube  on  the  opposite 
side,  allowing  the  ball  to  expand  with  the  blood  coming  into  it  from  the  arm  of  the 
giver.  When  the  ball  is  full  the  manipulation  just  described  is  repeated,  and  the 
blood  passers  into  the  vein  of  the  receiver.  In  this  manner,  each  time  the  ball  is 
compressed,  2  drachms  of  blood  are  injected  into  the  veins  of  the  patient.  Should 
the  syringe  appear  to  become  blocked,  or  work  unsatisfactorily,  it  can  be  detached 
and  washed  out  without  removing  the  cannulfe  from  the  veins.'" 

Needless  to  say  the  operation  is  accompanied  bj'  considerable  risk,  especially 
from  thrombosis  and  embolism. 

II.  SKIN-GRAFTING 

Skin-graftmg  is  employed  in  the  treatment  of  ulcerating  or  granu- 
lating surfaces,  with  a  \'iew  to  obtain  rapid  and  sound  healing  with  a 
minimum  amount  of  contraction.  Three  methods.  Thiersch's.  Reverdin's, 
and  Wolfe's,  will  be  described. 

(1)  Thiersch's  method  is  often  called  for  where  large  open  surfaces 
are  left  to  heal,  e.g.  after  burns,  removal  of  the  breast  on  wide  lines 
for  carcinoma,  ulcers  of  the  leg.  extensive  lupus,  and  the  like.  The 
following  steps  must  be  considered  : 

(a)  Preparation  of  the  patient  and  the  surface  to  he  grafted.  The 
patient  must  be  in  a  satisfactory  condition,  and  one  who  can  be  relied 
upon  to  keep  the  affected  parts  at  rest.  The  surface  must  be  either  a 
recently  made  wound,  or.  if  an  ulcer  of  anv  kind,  one  in  which  healing  has 


SKIN-GRAFTING 


43 


begun.  It  is  useless  to  graft  while  active  ulceration  is  going  on.  Above 
all.  the  surface  must  be  aseptic.  Should  the  raw  area  be  covered  with  foul 
discharging  granulations,  there  is  nothing  better  than  curetting  once 
or  twice  with  the  aid  of  eucaine  if  needful,  followed  by  the  use  of  hot 
boracic  fomentations  and  the  occasional  application  of  silver  nitrate 
or  pure  carbolic  acid.  In  any  case  the  ulcer  and  surrounding  surface  must 
be  carefully  prepared.  The  adjacent  skin  nuist  be  shaved  over  a  sufficient 
distance  from  the  ulcer,  and  then  thoroughly  scrubbed  and  cleansed. 
Hot  fomentations,  which  are  changed  four-hourly,  are  applied  to  the 
prepared  area.  This  treatment  is  continued  until  the  ulcerated  surface 
is  covered  with  healthy  granulations,  when  it  is  fit  for  grafting. 

{b)  Preparation  of  the  area  from  which  the  grafts  are  to  be  taken.  The 
grafts  may  be  taken  from  the  skin  of  the  arm,  the  forearm,  or  the  thigh. 
The  first  two  have  the  advantage  that  the  skin  is  usually  less  hairy, 
but  in  extensive  cases,  e.g.  burns,  grafts  will  be  required  from  more  than 
one  region.  The  surgeon  should  always  see  that  the  area  prepared  is  con- 
veniently situated  in  relation  to  the  surface  to  be  grafted.  The  day 
before  the  operation  the  selected  area  is  carefully  shaved  and  cleansed, 
and  is  then  covered  by  sterilised  pads  which  are  not  removed  until  the 
time  of  the  operation. 

(e)  The  actual  grafting.  The  patient  having  been  anaesthetised,  the 
prepared  skin  and  tho  ulcor  are  exposed  with  all  aseptic  precautions. 


Fig.  G. 


Scale  2 
Thiersch's  skin  grafting  knife. 


Should  the  former  be  covered  with  red,  healthy,  non-exuberant  granu- 
lations, the  grafts  may  be  directly  applied.  It  is  better,  however,  to 
remove  by  gently  curetting  with  a  sharp  spoon  all  the  watery  super- 
ficial layer  of  granulations  until  the  deeper,  firmer  layer  of  newly  formed 
fibrous  tissue  is  reached.  The  healing  edge  of  the  ulcer  should  also  be 
scraped  away.  These  proceedings  are  followed  by  free  oozing  which 
must  be  stopped  by  pressure  with  sterilised  swabs  wrung  out  from 
saline  at  a  temperature  of  120^.  Should  removal  of  the  pads  cause 
fresh  haemorrhage  a  piece  of  sterile  green  protective,  which  is  non- 
adherent, may  be  used  to  cover  the  surface  before  the  pressure  is  applied. 
(n  troublesome  cases  a  few  drops  of  adrenalin  hydrochloride  (1  in  1000) 
may  be  poured  on  the  oozing  surface.  The  prepared  area  of  skin  is 
now  moistened  with  sterile  normal  saline  solution.^  and  the  grafts  are 
cut  as  follows  :  The  operator,  with  his  hand  placed  under  the  hmb, 
stretches  the  skin  from  side  to  side,  while  assistants,  if  necessary,  keep 
it  on  the  stretch  above  and  below.  With  a  broad  and  heavy  razor 
(Fig.  6)  the  grafts  are  now  cut.  The  blade,  which  is  kept  wet  with 
sterile  saline  solution,  is  placed  at  such  an  angle  to  the  skin  that 
when  it  is  entered  and  carried  along  it  will  remove  a  very  thin 
shaving  of  the  epidermis,  filmy  and  greyish-white,  falling  at  once  into 
delicate  folds  as  it  is  cut,  and  exposing,  and  only  just  exposing,  the 

1  The  usual  strong  antiseptic  lotions  may  injure  the  vitality  of  the  grafts  and  hence 
should  not  be  used.  If  any  have  been  used  in  the  jireparation  of  skin  or  instruments  they 
must  be  removed  bv  freelv  washing  with  saline  solution. 


44         OPERATIONS  OX  THE  I  PPER  EXTREMITY 

tops  of  the  papillaD.  It  is  then  carried  on  with  a  rapid  to  and  fro  lateral 
sawing  movement.  Both  the  skin,  which  must  be  kept  carefully  en 
the  stretch  the  whole  time,  and  the  razor  must  from  time  to  time  be 
wetted  with  a  few  drops  of  sterile  salt  solution.  With  practice  grafts 
may  be  cut  four  or  five  inches  long  and  one  or  two  inches  wide.  They 
should  consist  of  the  horny  and  the  superficial  part  of  the  malpighian 
layer,  the  tops  of  the  papillae  being  only  just  trenched  upon.^  When 
the  cutting  of  each  graft  is  finished,  an  assistant  should  set  it  fi-ee  by 
one  cut  with  a  sharp  pair  of  scissors.  All  layers  of  clot,  oozing,  or 
other  liquid  must  be  carefully  removed  from  the  surface  to  be  grafted, 
with  dossils  of  sterilised  gauze.  The  grafts  should  then  be  transferred 
directly  on  the  razor,  or  on  a  histological  section-lifter,  laid  down 
each  with  their  cut  surface  in  contact  with  the  raw  area,  and  then 
gently  and  evenly  flattened  out  with  needles.  Sir  W.  Watson  Cheyne 
and  Mr.  Burghard  give  the  two  following  useful  hints  :  "  The  grafts 
should  overlap  the  edges  of  the  skin,  and  also  each  other,  so  that 
no  part  of  the  raw  surface  is  left  exposed,  for  granulations  always 
spring  up  on  the  uncovered  parts  ;  furthermore,  a  thin  scar,  which 
may  subsequently  break  down,  is  left  at  these  points.  In  spreading 
out  the  gi'aft  it  will  be  found  that  air  bubbles  collect  beneath  it.  and 
also  that  some  amount  of  oozing  goes  on,  and  the  bubbles  and  clot 
may  prevent  complete  adhesion  of  the  graft.  Hence,  the  next  pro- 
cedure is  to  get  rid  of  them  by  pressure.  If  that  be  attempted  by  means 
of  sponges  the  grafts  are  apt  to  be  displaced.  The  following  is  the 
best  plan  :  strips  of  protective  about  an  inch  in  breadth,  and  long 
enough  to  overlap  the  edges  of  the  woimd,  sterilised  in  1  in  20  carbolic 
lotion,  and  subsequently  rinsed  in  saline,  are  applied  firmly  over  the 
grafted  surface,  begiiming  at  the  lower  part.  Each  strip  should  overlap 
the  one  below,  just  as  in  the  case  of  strapping,  and  they  should  extend 
well  on  to  the  skin  at  each  end.  If  each  strip,  as  it  is  put  on,  be  grasped 
by  the  two  ends  and  firmly  pressed  down,  the  pressure  thus  applied 
suffices  both  to  expel  the  air  bubbles  and  blood,  and  also  to  arrest  further 
oozing."  A  dressing  of  iodoform  or  cvanide  oauze  and  absorbent  wool 
is  then  applied  with  firm  even  pressure.  If  the  surface  be  on  a  Hmb, 
this  must  be  kept  at  rest  on  a  splint.  When  the  oozing  has  been  stopped 
satisfactorily  before  the  grafts  are  appHed,  so  that  risk  of  their  dis- 
placement on  this  account  does  not  exist,  the  follo-^Tug  dressing  will 
give  excellent  results.  Two  thicknesses  of  sterilised  gauze  are  cut  of 
such  a  size  and  shape  as  to  cover  the  grafted  area  and  extend  in  every 
direction  for  two  inches  on  to  the  healthy  skin.  The  gauze,  evenly 
spread  out,  is  placed  over  the  grafts,  and  is  secured  in  position  by 
painting  its  edges  'U'ith  collodion,  none  of  which  should  come  within 
half  an  inch  of  the  wound.  When  the  collodion  has  set,  a  warm  saline 
fomentation  is  put  on.  Any  discharge  from  the  wound  can  readily 
escape  through  the  meshes  of  the  gauze  and  is  absorbed  by  the  fomenta- 
tion which  can  be  changed  as  often  as  is  necessary  without  danger  of 
disturbing  the  grafts.  In  either  case  the  dressing  on  the  grafted  surface 
should  be  left  for  five  or  more  days,  if  possible.  Its  removal  must  be 
effected  with  much  care.  If  successful  the  grafts  should  have  a  pink 
colour  and  be  adherent.  If  white  or  greyish  in  tint  they  are  no  longer  alive. 

1  A  test  of  the  proper  depth  cut  into  by  the  razor  is  shown  bj-  the  nature  of  the 
bleeding,  and  the  rate  at  which  this  occurs.  It  should  be  minutely  punctiform,  very 
slight,  and  slow  in  making  its  appearance. 


SKIN  (iUAFTIXU  45 

The  surface  from  which  the  grafts  were  taken  may  be  dressed  with 
a  roll  of  sterilised  gauze,  which  may  be  removed  after  a  week  or  ten  days. 

Should  it  be  necessary,  grafts  will  retain  their  vitality  for  a  con- 
siderable time  in  normal  saline  at  a  temperature  of  100,  and  may  be 
conveyed  in  this  solution  to  be  used  for  a  patient  at  some  distance  from 
the  one  from  whom  the  grafts  were  taken. 

The  technique  of  grafting  a  fresh  wound  is  in  all  essential  points 
similar  to  the  above.' 

(2)  Reverdins  method.  While  undoubtedly  inferior  to  that  of 
Thiersch,  this  method  has  still  a  place  in  surgery  as,  for  example,  in 
completing  the  healing  of  a  large  burn  or  lupus  of  the  face.  Owing  to 
its  not  needing  an  anaesthetic  it  may  be  employed  for  elderly  patients, 
or  when  an  anaesthetic  is  considered  undesirable.  A  small  portion  of 
the  skin,  which  has  been  sterilised,  is  picked  up  with  a  needle  and  is 
quickly  removed  with  small,  sharp,  curved  scissors.  The  tiny  grafts 
thus  obtained  are  arranged  at  close  intervals  over  the  granulating 
surface.  Otherwise,  as  in  the  case  of  Thiersch's  grafts,  granulations 
will  spring  up  in  the  intervals  between,  and  gradually  destroy  them. 
The  epithehum  from  each  graft  may  be  expected  to  grow  to  about  the 
size  of  a  sixpence  and  then  stop,  so  that  unless  they  are  sufficiently 
close  complete  heahng  of  the  area  will  not  be  attained. 

A  useful  and  convenient  way  of  cutting  these  small  grafts  is  to  freeze 
the  skin  by  means  of  an  ethyl  chloride  spray,  and  then  to  remove  small, 
thin  portions  of  the  frozen  skin  by  a  sharp  razor.  Freezing  does  not 
interfere  with  the  ^dtaUty  of  the  grafts,  and  owing  to  its  anaesthetic 
action,  renders  the  operation  practically  painless. 

In  either  case  a  gauze  and  collodion  dressing  may  be  employed  as 
described  for  Thiersch's  method. 

(3)  Wolfe's  method.  Here  the  whole  thickness  of  the  skin  and  sub- 
cutaneous fat  is  removed  without  any  pedicle  from  the  most  vascular 
area  available.  While  the  percentage  of  failures  is  much  greater  than 
in  Thiersch's  method,  cases  occasionally  present  themselves  in  which 
a  trial  of  this  method  is  indicated,  e.g.  when  a  thicker  covering  is  required 
than  is  afforded  by  Thiersch's  method,  as  in  the  palm  of  the  hand. 
When  this  method  is  successful,  its  results  are  most  satisfactory.  While 
part  of  such  a  flap  may  perish,  enough  may  sur^dve  for  the  surgeon's 
purpose.  Mr.  Keetly  thus  describes  Wolfe's  method.^  When  such  a 
graft  has  been  cut  out,  half  a  dozen  Lane's  tissue  forceps  should  be 
attached  around  its  edges.  ''  Place  it,  raw  surface  upw^ards,  on  a 
sterilised  towel  and  a  convex  surface,  usually  the  thigh  or  chest  of  the 
patient.  Stretch  the  flap  in  every  direction  by  pulling  at  the  forceps. 
Shave  off  all  the  fat.  Stretch  the  flap  again  to  take  the  tendency  to 
curl  up  out  of  it.  Swing  it  into  place.  Secure  it  with  a  few  sutures. 
But  cut  away  all  the  forceps  with  sharp  scissors  so  as  to  leave  no  bruised 
skin  behind,  the  most  rigid  asepsis  being  desirable  to  secure  success." 
Mr.  Kennedy,  of  Glasgow,  has  published^  some  figures  which  show 
excellently  what  Wolfe's  method  may  effect  in  cases  where  it  has  been 
necessary  to  fill  up  gaps  left  by  the  removal  of  cicatrices  from  the  fingers 
and  hand. 

^  To  take  one  particular  instance.  Any  one  who  has  to  face  the  diiBculties  presented 
by  a  case  of  avulsion  of  the  scalp  will  find  useful  information  in  a  paper  by  Dr.  Mellisb 
{Ann.  of  Surg.,  1904,  p.  664). 

2  Lancet,  March  4,  1905.  »  Brit.  Med.  Journ.,  April  29,  1905. 


CHAPTER  III 

SOME  GENERAL  POINTS  WITH  REGARD  TO  AMPUTA- 
TIONS, THE  LIGATURE  OF  ARTERIES,  AND  THE 
SURGERY   OF   BLOOD-VESSELS   AND   LYMPHATICS 

Owing  to  the  improvements  in  modern  surgery,  especially  the  general 
adoption  of  the  principles  of  asepsis,  amputations  are  less  frequently 
called  for,  and  occupy  a  position  of  far  less  prominence  than  in  former 
days.  This  is  largely  owing  to  the  fact  that,  with  modern  methods, 
conservative  treatment  is  possible  after  even  very  severe  injuries,  and 
also  in  many  cases  of  disease,  of  bones  or  joints.  Amputations,  how- 
ever, are  still  necessary  in  a  number  of  conditions,  chief  among  which 
are  the  following:  (1)  For  severe  injuries,  especially  bad  crushes  with 
compound  comminuted  fractures  involving  articular  surfaces,  or 
associated  with  injuries  to  main  vessels  and  nerves.  (2)  In  many  cases 
of  gangrene.  (3)  For  malignant  growths,  especially  of  bone.  (4)  For 
some  cases  of  suppuration,  such  as  acute  septic  osteomyelitis  with 
threatening  pyaemia  or  septicgemia.  (5)  For  advanced  and  intractable 
cases  of  tuberculous  disease  of  bone  or  joint. 

In  every  amputation  the  aim  of  the  surgeon  should  be  to  secure  a 
sound  stump,  free  from  disease,  and  capable  of  supporting  a  suitable 
artificial  limb.  The  soft  parts  should  form  an  ample  covering  for  the 
bone  and  the  scar  should  be  so  placed  as  to  escape  all  unnecessary 
pressure.  These  ideals  must  be  borne  in  mind  in  every  amputation. 
In  former  days  "  set  "  amputations  were  the  rule.  At  the  present  time 
it  is  usual  to  consider  the  merits  of  each  individual  case  according  to  the 
situation  of  the  disease  and  the  position  of  healthy  tissues  in  the  forma- 
tion of  the  flaps.  A  satisfactory  stump,  then,  should  be  composed 
of  healthy  tissues  ;  it  should  be  painless,  capable  of  supporting  an 
artificial  limb,  and  in  the  case  of  the  lower  extremity,  able  to  bear  very 
considerable  pressure. 

It  will  now  be  necessary  to  consider  some  of  the  causes  of  painful 
or  otherwise  unsatisfactory  stumps.  First  of  all,  the  scar  may  be 
■painful,  tender,  and  prone  to  ulcerate.  This  is  especially  likely  to  be  the 
case  if  the  flaps  were  cut  too  short,  so  that  there  was  some  tension  on 
them  as  they  were  brought  together  over  the  divided  bone.  Under 
these  circumstances  the  scar  is  likely  to  be  adherent  to  the  deeper 
structures,  and  is  then  very  apt  to  break  down.  It  must  therefore  be 
remembered  in  all  amputations  that  the  flaps  must  be  cut  long  so  that 
they  come  together  quite  loosely  and  without  the  slightest  tension,  and 
that  as  far  as  possible  they  must  be  so  shaped  that  the  scar  is  not 
subjected  to  pressure. 

The  opposite  fault  is,  of  course,  also  to  be  avoided,  for  if  the  flaps 
be  cut  too  long,  the  blood-supply  is  likely  to  be  inadequate  ;   sloughing 

46 


AMPI'TATIOXS  47 

may  tliou  occur  and  ajzain  lead  to  a  painful  ami  aillierent  cicatrix.  Sliould 
the  severed  ends  of  the  hirge  nerve  trunks  be  involved  in  the  scar,  the 
latter  will  be  extremely  tender  and  sensitive  on  even  the  slightest 
pressui'c.  In  other  cases  the  ends  of  the  large  nerves  may  become 
swollen  and  bulbous,  a  condition  sometimes  known  as  a  "  traumatic 
neuroma,  "  ;  such  a  swelling  will  also  probably  render  the  stump  in- 
capable of  bearing  any  pressure.  Both  these  troubles  may  be  avoided 
by  cutting  the  large  nerves  as  short  as  possible.  Pain  may  also  be 
caused  by  chronic  osteitis,  usually  due  to  sepsis.  To  avoid  this  it  has 
been  advised  to  cut  a  flap  of  periosteum  so  as  to  provide  a  covering 
for  the  sawn  surface  of  the  bone. 

Conical  Stump.  In  this  condition,  which  often  renders  the  stump 
painful  and  useless,  its  extremity  is  shrunken  and  pointed  so  that  it 
has  a  conical  shape,  the  end  of  the  bone  projecting  at  the  apex  of  the 
stum])  where  the  superficial  tissues  are  tightly  stretched  over  it.  Conical 
stump  may  be  the  result  of  sloughing  of  the  flaps,  or  these  may  have 
been  cut  too  short  at  the  operation.  It  not  infrequently  occurs  in 
children  as  the  result  of  the  continued  growth  in  length  of  the  bone 
from  the  epiphyseal  line  after  the  operation.  The  treatment  for  this 
condition  is  re-amputation  at  a  higher  level,  care  being  taken  that  the 
flaps  are  of  sufficient  length  and  that  the  bone  is  sawn  through  as  high 
as  possible.  An  otherwise  excellent  stump  may  occasionally  be  func- 
tionally a  failure  owing  to  stiffness  or  want  of  mobility.  This  is  especially 
seen  in  amputations  of  the  fingers  through  the  first  inter-phalangeal 
joint,  where  the  want  of  any  attachment  of  the  flexor  tendons  may 
result  in  a  stift"  projecting  stump  which  is  useless  or  even  a  source  of 
annoyance  to  the  patient. 

METHODS  OF  AMPUTATING 

These  will  naturally  depend  upon  the  situation  and  nature  of  the 
disease  requiring  treatment  and  also  upon  the  position  of  healthy  tissues. 
The  various  methods  will  be  described  in  detail  in  the  descriptions  of 
amputations  in  the  different  regions.  A  brief  summary  of  the  chief 
methods  may,  however,  be  given  here  : 

(1)  The  circular  method  (Fig.  87).  This  is  the  simplest  of  all  am- 
putations. The  skin  and  the  superficial  fasciae  are  divided  by  a 
circular  cut  round  the  limb  in  a  plane  at  right  angles  to  its  axis. 
With  a  few  touches  of  the  knife  a  cuff,  consisting  of  skin  and 
fascia,  is  turned  up  for  a  distance  of  about  two  inches  in  the  case 
of  the  upper  limb,  and  for  three  or  four  inches,  according  to  its  size, 
in  the  case  of  the  lower.  The  muscles  are  then  divided  by  a  similar 
series  of  circular  cuts  at  the  level  of  the  upper  limit  of  the  cuff.  The 
soft  parts  are  thoroughly  retracted  and  the  bone  sawn  through  at  as 
high  a  level  as  possible.  The  circular  method  is  especially  adapted  to 
those  situations  where  there  is  a  single  bone  uniformly  surrounded 
by  a  thick  layer  of  soft  tissues,  as  in  the  thigh  and  the  arm.  Such  an 
amputation  can  be  performed  quickly,  and  gives  a  good  covering  to 
the  end  of  the  bone  ;  the  chief  objection  is  that  the  scar  necessarily  is 
placed  at  the  end  of  the  stump. 

(2)  The  modified  circular  method.  Here  two  small,  equal  flaps  of 
skin  and  subcutaneous  tissues  are  cut  in  place  of  the  cuff  described 
above.     A  reference  to  Fig.  89  will  make  this  modification  clear. 


48       opp:rations  on  the  upper  extremity 

(3)  The  elliptical  method.  This  resembles  the  circular,  but  the  knife 
instead  of  passing  transversely  round  the  limb  is  made  to  divide  the 
tissues  obliquely.  The  advantages  of  the  modification  are  :  the  scar  can 
be  made  to  occupy  a  position  where  it  will  escape  pressure ;  and 
healthy  tissues  on  one  side  of  a  limb  can  be  utilised  when  an  injury 
has  extended  more  on  one  side  of  the  limb  than  the  other.  This 
method  can  be  employed  for  disarticulation  through  a  joint. 

(4)  The  racket  incision.  This  is  very  commonly  employed  for  dis- 
articulations. Aji  incision  is  made  in  the  longitudinal  axis  of  the  limb, 
commencing  above  the  joint  and  extending  vertically  down  to  a  sufficient 
distance  below  it.  It  is  then  carried  in  an  elliptical  fashion  round  the 
limb  back  to  the  point  from  which  it  originally  diverged  from  the 
longitudinal  incision  (Figs.  16,  17  and  99).  It  will  thus  be  seen  that 
the  racket  incision  is  a  combination  of  a  longitudinal  and  an  oval 
incision. 

(5)  Flap  methods.  Here  flaps  fashioned  from  the  soft  parts  are 
employed  to  cover  the  sawn  end  of  the  bone.  They  are  of  various 
shapes  and  sizes,  and  can  be  cut  according  to  the  situation  of  the  injury 
or  disease,  and  also  in  such  a  way  as  to  secure  a  satisfactory  covering 
to  the  bone  and  a  convenient  position  of  the  scar.  Flaps  may  be  equal 
or  one  may  be  larger  than  the  other.  They  may  be  antero-posterior, 
or  lateral,  or  intermediate  between  these. 

In  cutting  flaps  care  must  be  taken  that  they  are  not  pointed.  They 
should  be  broadly  rectangular  with  the  angles  rounded  off,  or  U-shaped. 
They  must  be  of  sufficient  length  to  come  together  ^vdthout  tension, 
but  must  not  be  too  long,  for  then  the  blood-supply  may  be  inadequate 
and  sloughing  is  likely  to  occur.  The  tendency  for  the  muscles  to 
retract  must  also  be  remembered  and  also  that  the  flexors  retract  more 
than  the  extensors. 

Flaps  are  usually  cut  so  that  at  first  only  skin,  superficial  and  deep 
fascise  are  taken  up  ;  the  knife  then  is  made  to  enter  the  muscle  obliquely 
so  that  at  the  base  of  the  flap  the  whole  thickness  of  the  muscle  down 
to  the  bone  is  included. 

In  other  cases  skin  flaps  are  employed.  Here  the  flap  is  composed 
of  skin,  superficial  and  deep  fasciae  only  ;  special  care  must  be  taken 
to  include  the  latter  in  order  to  ensure  a  good  blood-supply.  To  make 
certain  of  this,  a  few  muscle  fibres  should  be  seen  on  the  deep  aspect 
of  the  flap.  The  muscles  are  then  divided  at  a  higher  level  by  a  circular 
sweep  of  the  knife. 

Flaps  are  occasionally  cut  by  transfixion,  i.e.  by  passing  a  long  knife 
through  the  thickness  of  the  limb  at  the  situation  of  the  base  of  the 
proposed  flap  and  then  cutting  from  within  outwards  so  that  the  skin 
is  divided  after  the  other  soft  parts.  This  is  a  very  rapid  method,  and, 
before  the  days  of  anaesthesia  was  on  this  account  much  employed. 
Though  seldom  made  use  of  at  the  present  day,  when  rapidity  is  of 
less  importance  than  the  certainty  of  a  satisfactory  stump,  it  can 
occasionally  be  made  use  of  \\'ith  advantage,  for  instance,  when  the 
flap  contains  numerous  tendons  and  but  little  muscle  as  in  the  forearm 
(Fig.  72). 

When  flaps  are  cut  by  tran.sfixion  a  long  knife  measuring  one  and 
a  half  times  the  diameter  of  the  limb  is  required.  In  all  other  cases 
a  shorter  knife,  not  more  than  three  or  four  inches  in  length,  is  all  that 
is  necessary. 


LIGATURE  OF  ARTKKTKS  49 

111  all  amputations  care  must  be  taken  to  control  tiie  bleeding  during 
the  operation.  Generally  this  is  elTected  by  some  form  of  tourniquet. 
In  some  instances  where  the  amputation  is  close  to  the  junction  of  the 
limb  and  the  trunk  for  example,  a  tournicjuet  cannot  be  employed. 
The  means  for  controlling  haemorrhage  under  these  circumstances 
is  described  in  the  accounts  of  amputations  through  the  shoulder 
and  hip  joints.  As  a  general  rule  in  amputations,  drainage  should 
be  secured  by  a  tube  inserted  between  the  flaps. 

LIGATURE  OF  ARTERIES 

Ligature  of  an  artery  in  its  continuity  is  another  operation  which, 
owing  to  the  developments  of  surgery,  does  not  occupy  the  position  of 
importance  which  it  formerly  held.  As  a  test  of  manipulative  skill,  and  for 
the  knowledge  of  surgical  anatomy  for  which  it  calls,  it  is  a  favourite  ex- 
amination test  and  nnist  on  that  account  receive  clos3  attention  in  the 
operative  surgery  class-room.  It  will  be  well  therefore  to  give  some 
general  rules  for  the  ligature  of  arteries.  Generally  speaking,  though 
there  are  exceptions  to  this  rule  as  in  ligature  of  the  posterior  tibial, 
the  incision  should  be  made  in  the  line  of  the  artery.  The  length  of  the 
incision  ^vill  depend  upon  the  depth  of  the  vessel  to  be  secured.  Though 
it  must  not  be  unnecessarily  long  it  should  be  of  sufficient  length  to 
allow  of  the  ready  identification  of  the  deeper  structures.  This  is  of 
special  importance  when  the  artery  is  deeply  placed,  as,  for  instance, 
the  lingual.  Fascia)  should  be  divided  by  clean  cuts  with  the  knife  ; 
muscles  should,  when  possible,  be  separated,  deeper  planes  being  reached 
through  the  intermuscular  septa.  If  it  is  necessary  to  divide  a  muscle 
it  should  not  be  cut  across,  but  its  fibres  should  be  separated  by  a  blunt 
instrument.  If  the  artery  to  be  ligatured  is  situated  in  the  forearm  or  in 
the  leg  below  the  knee,  it  is  accompanied  by  companion  veins  which 
form  a  more  or  less  complicated  anastomosis  around  it.  Any  attempt 
to  separate  the  veins  from  the  artery  is  sure  to  result  in  injury  to  and 
troublesome  haemorrhage  from  the  former  structures.  They  should 
therefore  be  included  in  the  ligature.  In  the  larger  arteries  it  is  of  the 
utmost  importance  that  the  companion  vein  should  not  be  injured.  In  the 
case  of  these  larger  arteries  the  sheath  should  be  opened  by  a  short 
longitudinal  incision,  and  the  vessel  cleared  from  this  by  a  blunt  instru- 
ment. An  aneurysm  needle  of  suitable  curve  and  shape  is  then  gently 
insinuated  around  the  vessel,  care  being  taken  that  the  instrument  is 
between  the  vessel  and  its  sheath,  and  that  it  does  not  pierce  the  latter. 
Generally  speaking,  the  needle  should  be  passed  from  the  side  on  which 
the  companion  vein  is  situated,  in  order  to  minimise  the  possibility 
of  injury  to  this  structure.  The  aneurysm  needle  should  be  passed 
unthreaded.  An  examination  is  made  with  the  finger  to  ensure  that 
the  artery,  and  the  artery  alone,  has  been  included.  The  needle  is 
then  threaded  with  a  thread  of  the  material  to  be  employed.  Carefully 
sterilised  silk  or  catgut  may  be  employed,  the  former  is,  perhaps,  prefer- 
able for  a  large  artery  in  an  aseptic  wound.  In  the  case  of  a  small  vessel 
when  the  needle  has  been  withdrawn,  the  thread  is  tied  tightly  so  as 
to  divide  the  internal  and  the  middle  coats.  In  the  case  of  large  arteries 
Ballance  and  Edmunds  {see  p.  714)  advise  that  the  thread  should  be  tied  so 
as  to  occlude  the  artery  without  division  of  the  coats.  They  advise  that 
the  first  thread  should  be  tied  so  as  to  arrest  the  circulation.  One  or  more 
further  strands  are  then  passed  and  again  tied  in  a  single  knot  so  as 

SURGERY  I  4 


50  OPERATIONS  ON  THE  UPPER  EXTREMITY 

to  occlude  the  artery  without  division  of  its  coats.  The  two  ends  of 
each  of  the  two  threads  are  then  taken  and  tied  together  so  as  to  com- 
plete the  knot. 

In  the  living  subject  an  artery  can  be  easily  recognised  by  its  pulsa- 
tion. In  the  dead  body  this  help  is,  of  course,  absent.  In  this  case, 
when  there  is  any  doubt,  the  artery  may  be  recognised  by  compressing  it 
between  the  finger  and  the  aneurysm  needle.  An  artery  may  then  be  recog- 
nised by  the  way  in  which  it  flattens  out.  like  a  ribbon,  with  a  distinct 
longitudinal  groove.     A  nerve-trunk  feels  like  a  rounded  solid  cord. 

ARTERIORRHAPHY 

It  is  now  realised  that  it  is  possible  to  close  wounds  in  arteries,  or 
even  to  unite  the  ends  of  completely  severed  vessels,  by  means  of  sutures, 
without  obliteration  of  the  lumen,  and  without  permanent  interference 
with  the  circulation.  The  feasibility  of  suture  of  arteries  has  been 
amplv  proved  by  the  experimental  work  on  animals  of  a  number  of 
workers,  especially  Carrel  and  Guthrie,^  and  Watts.^  The  possibility  of 
suture  was  first  indicated  by  Murphy  and  Senn.  It  is  obviously  of 
the  greatest  importance  to  know  from  the  clinical  point  of  \dew  that 
this  procedure  is  possible.  An  injured  vessel  may  be  of  such  magnitude 
and  importance  that  its  obUteration  may  mean  the  practical  certainty 
of  gangrene,  or  death  from  disturbance  to  the  circulation.  There  is 
still  a  great  deal  to  be  done  vnth.  regard  to  the  employment  of  arterior- 
rhaphv  in  clinical  surgery,  but  it  has  been,  or  may  be,  of  use  mider  the 
following  circumstances  : 

(1)  Wounds  of  large  vessels,  e.g.  the  carotid,  femoral,  or  iliacs.  Thus 
Dr.  Lund,  of  Boston,^  reports  a  case  in  which  he  successfully  sutured 
the  femoral  artery  and  the  femoral  vein  in  a  girl  set.  14,  both  vessels 
having  been  perforated  by  a  stab  from  a  knife.  Dr.  Lund  considers  that 
suture  of  the  vessels  undoubtedly  saved  the  leg  and  foot  of  the  patient. 

(2)  A  large  artery  may  be  incised  for  the  purpose  of  remo\dng  an 
embolus  and  the  wound  subsequently  sutured.  Mr.  Handley  describes 
an  interesting  case  in  which  he  attempted  the  removal  of  an  embolus 
from  the  femoral  artery  in  the  Brit.  Med.  Journ.,  vol.  ii,  1907,  p.  702. 

(3)  The  reversal  of  the  circulation  in  a  limb  for  threatened  or  actual 
gangrene  where  this  is  due  to  interference  with  the  arterial  blood-supply 
as  in  senile  gangrene.  In  such  cases  it  is  possible  that  more  blood 
could  reach  the  extremity  through  the  healthy  vein  than  through  the 
diseased  artery,  and  that  in  this  way  extension  of  the  gangrene  could 
be  prevented.  That  this  operation  can  be  carried  out  in  dogs  has  been 
proved  by  Carrel  and  Guthrie.^  It  has  also  been  performed  on  several 
occasions  on  patients  viith  gangrene  with  some  success.^  It  is,  however, 
open  to  question  to  what  extent  and  in  what  cases  it  should  be 
employed.^ 

(4)  In  Matas's  operation  for  aneurysm  {vide  infra). 

1  Johns  Hopkins  Hosp.  Btdl.,  vol.  xviii,  January  1907. 

2  Ann.  of  Surg.,  1907,  vol.  xlvi,  p.  373. 

3  Ann.  of  Surg.,  1909,  vol.  xlix,  p.  394.  *  Ibid.  1906,  vol.  xliii.  p.  203. 

5  Hubbard,  Ann.  Surg.,  1906,  vol.  xliv,  p.  559;  Wieting.  Deutsch.  Med.  Woch.,  1908, 
July  9;  G.  P.  Muller,  Ann.  Surg.,  1910,  vol.  li,  p.  256 ;  Morriston  Davies,  .47in.  Swr^., 
1912,  vol.  Iv,  p.  864. 

*  A  paper  by  Dr.  Bertram  Bernheim  (Am.  Surg.  1912,  vol.  Iv,  p.  195.  may  be  consulted. 
Here  will  be  found  a  review  of  the  literature  of  the  subject  with  an  account  of  a  number  of 


SUTURE  OF  ARTKRIKS  51 

(5)  Carrel  aucl  Llutliiie  {vide  supra)  have  shown  experimentally  that 
a  portion  of  vein  may  be  grafted  so  as  to  form  a  junction  between 
the  widely  separated  ends  of  a  divided  artery. 

(())  For  arterio-venous  aneurysm,  as  in  case  described  by  Dr.  Gilbert 
Kemp.' 

The  operation.  In  the  suture  of  arteries  the  most  rigid  asepsis  is 
absolutely  essential.  The  vessel  must  be  exposed  for  a  distance  of 
two  inches  above  and  below  the  injured  spot.  Ha;morrhage  must  be 
controlled  by  some  method  which  avoids  injury  to  the  wall  of  the  artery. 
Crile's  clamps  may  be  employed  (Fig.  7)  or  a  piece  of  sterilised  tape 
may  be  slipped  beneath  the  artery  ;  an  assistant  then  places  the  tip 
of  his  finger  on  the  artery  and  by  gently  drawing  on  the  ends  of  the 
tape  controls  the  flow  of  blood.  The  outer  connective-tissue  coat  is 
first  gently  clipped  away,  as  otherwise  shreds  of  this  are  certain  to  be 
drawn  in  between  the  other  coats,  thus  preventing  their  exact  approxi- 
mation. The  finest  rounded  needles  must  be  used  ;  both  straight  and 
curved  should  be  at  hand,  though  the  former  are,  as  a  general  rule,  to  be 
preferred.  The  material  for  the  suture  should  be  extremely  fine  silk, 
which  should  be  impregnated  with  sterilised  vaseline  in  order  to  facilitate 


FullSize 
Fig.  7.     Crile's  artery  clamp. 

its  passage  through  the  vessel  wall.  The  artery  must  always  be  handled 
with  the  utmost  gentleness,  any  rough  treatment  from  forceps  being 
especially  undesirable.  The  sutures  must  be  passed  so  as  to  bring  the 
surfaces  of  the  inner  coat  into  absolute  apposition  and  at  the  same  time 
to  avoid  the  projection  of  the  silk  into  the  lumen  of  the  vessel.  This 
may  be  accomplished  in  one  of  the  following  ways  : 

(a)  Dorrance's  methodr  The  following  description  is  taken  from 
Burghard's  "  System  of  Operative  Surgery,"  vol.  i,  p.  263  : 

"  When  suturing  a  longitudinal  incision  the  thread  is  first  entered  about  an 
eighth  of  an  inch  from  one  end  of  the  incision,  made  to  penetrate  only  the  outer 
and  middle  coats,  brought  out  again  and  tied,  the  free  end  being  left  long.  The 
needle  is  now  made  to  penetrate  all  the  coats  of  the  vessel  from  without  inwards 
on  one  side  of  the  rent  and  as  near  the  edge  as  possible  ;  it  is  then  carried  through 
the  walls  of  the  vessel  on  the  opposite  side  of  the  rent  from  within  outwards.  It 
then  re-enters  the  arterial  wall  from  without  inwards,  passes  across  the  incision  and 
penetrates  the  opposite  side  from  within  outwards,  thus  making  a  mattress  stitch. 
The  sutiu'e,  however,  is  not  tied  in  the  usual  way,  but  is  continued  as  shown  in  the 
diagram  throughout  the  length  of  the  wound  ;  at  every  third  loop  the  suture  is 
carried  back  a  stitch's  breadth,  as  shown  in  the  diagram,  in  order  to  maintain  the 
steadiness  of  the  approximation.  On  emerging  at  the  other  end  of  the  incision  the 
thread  is  passed  through  the  outer  two  coats  of  the  vessel  (Fig.  8)  and  there  is 
tied  in  a  single  knot.  The  continuous  mattress  suture  thus  formed  is  reinforced  by 
a  second  continuous  runrung  stitch  taking  up  the  edges  of  the  incision  between  the 
loops  of  the  mattress  sutiu-e  ;  when  this  reaches  the  point  at  which  the  original 
suture  commenced,  the  two  ends  are  tied  together  and  the  suture  is  complete. 

"  When  an  end-to-end  suture  has  to  be  made,  the  first  suture  is  a  mattress 
suture,  the  needle  being  passed  through  all  coats  of  the  vessel  from  without  inwards 
on  the  proximal  side,  and  from  within  outwards  on  the  distal  side,  and  back  in  the 

1  Proc.  Roy.  Soc.  Med.  (Surg.  Sec.)  1913,  vol.  vii,  p.  83. 

2  Ann.  of  Surg.,  1906,  vol.  xlv. 


52  OPERATIONS  OX  THE  T'PPKR  EXTREMITY 

reverse  direction.  This  gives  a  mattress  suture  with  the  ends  projecting  from  the 
distal  end  ;  these  are  fimJy  fastened  together  so  as  to  evert  the  ends  of  both  seg- 
ments. The  remainder  of  the  suture  is  comj^Ieted  by  the  continuous  mattress  stitch 
ah-eady  described  with  the  throw-back  at  every  third  stitch.  When  this  has  com- 
pletely encircled  the  vessel  the  end  of  the  suture  is  fastened  to  the  free  end  of  the 
first  mattress  stitch.  A  continuoas  running  stitch  is  carried  all  round,  joining 
together  the  lips  of  the  wound  outside  the  first  suture." 


Fig.  8.     Dorrance's  method  of  suture  of  a  longitudinal  wound  of  an  artery. 

(b)  Dr.  Sweet^  gives  the  following  technique  for  end-to-eud 
anastomosis  of  vessels : 

'■  Three  tension  sutures  of  fine  silk  are  then  laid  at  equidistant  points  of  the  circum- 
ferences of  the  ve.ssel  ends.  An  assistant  then  applies  traction  to  two  of  these  guides 
in  turn,  stretching  the  portion  between  the  two  sutures  into  a  straight  line,  facilitating 
the  lading  of  the  continuous  suture,  and  preventing  a  narrowing  of  the  lumen.  If 
at  this  time  the  third  tension  suture  is  weighted  by  a  ha-mostat  the  circumference  of 
the  vessel  will  be  arranged  in  the  form  of  a  triangle,  the  points  of  which  are  deter- 
mined by  the  three  traction  sutures,  and  there  will  be  no  danger  of  catching  the 
opposite  wall  while  inserting  the  suture.  The  suture  is  a  continuoiLS  overhand 
stitch,  through  all  the  coats  ;  the  separate  stitches  should  be  drawn  just  tightly 
enough  to  secure  absolute  approximation,  but  not  too  tightly  lest  the  tissues  be 
everted  ;  they  must  be  placed  verj-  close  together.  After  the  completion  of  the; 
sutuje  and  the  removal  of  the  clamps  there  will  often  be  some  haemorrhage  ;  if  this 
is  too  free  a  few  interrupted  stitches  may  be  inserted,  but  a  considerable  hjemorrhage 
will  almost  always  stop  under  gentle  digital  compression." 

1  Ann.  of  Surg.,  1907,  vol.  xlvj,  p.  358. 


MATASS  OPKKATION 


53 


Matass  Operation,  or  Endo-aneurysmorrhaphy.  This  operation,  since 
it  involves  tlio  principal  of  arterial  sutnre,  may  be  described  here.  It  was 
first  described  bv  Dr.  Matas^  in  li)0."5  after  an  experience  of  four  cases. 


Tit,.  9.     Dorrance"s  uk  thud  ..f  ciid-to-cnd  anastomosis  of  vessels. 

Since  then  it  has  been  ^^^dely  adopted,  especially  in  America,  and  has 
given  very  satisfactory  results.  In  this  operation  the  sac,  after  the 
circulation  has  been  controlled  by  a  tourniquet  or  other  convenient 
form  of  pressure,  is  laid  freely  open.  Xo  ligatures  are  applied  to  the 
main  artery,  but  the  circulation  in  the  sac  is  arrested  and  haemostasis 
is  secured  solely  by  suturing  the  arterial  orifices  fomid  in  the  interior  of 
the  sac.  The  ca\dty  of  the  aneurysm  is  then  obliterated  by  inverting  or 
infolding  the  walls,  with  the  attached  over- 
lying skin.  The  flaps  thus  formed  are 
sutured  to  the  bottom  of  the  cavity,  so 
that  no  space  is  left  to  in^"ite  suppuration 
or  secondary  complications.  Dr.  Matas 
states  that  the  operation  is  applicable  to 
all  aneurysms  in  which  there  is  a  dis- 
tinct sac  and  in  which  the  cardiac  end 
of  the  main  artery  can  be  provisionally 
controlled.  "It  is  especially  applicable 
to  all  forms  of  peripheral  aneurysms  of 
the  larger  arterial  trunks  (carotid,  axillary, 
iliac,  brachial,  popliteal)  ;  and.  while  the 
author  has  had  no  experience  with  similar 
lesions  of  the  large  visceral  trunks,  the 
principle  suggested  would  appear  to  be 
applicable  to  aortic  abdommal  and  other 
accessible  forms  of  abdominal  aneurysms." 
The  operation  is  based  upon  the  follow- 
ing principles  :  (1)  The  sac  is  regarded  as 
a  large  diverticulum  or  prolongation  of 
the  parent  artery  ;  (2)  the  fining  membrane  of  the  sac  is  a  continua- 
tion of  the  intima  which  lines  the  interior  of  the  artery ;  (3)  that  the 
sac  itself,  when  not  disturbed  from  its  vascular  connections,  is  capable 
^  Ann.  of  Surg.,  1903,  vol.  xxxvii,  p.  161. 


Fig.  10.     Endo-aneurysmor- 
rhaphy, (Matas.) 


54 


OPERATIONS  ON  THE  UPPER  EXTREMITY 


of    exhibiting    all    the    reparative    and    regenerating    reactions    which 
characterise  the  endothelial  surfaces  in  general. 

The  operation  is  described  by  Dr.  Matas  under  the  following  heads  : 

(1 )  Prophylactic  hsemostasis.  This  may  be  effected  by  a  tourniquet  or  Esmarch's 
bandage,  by  compression  by  Crile's  clamps  (Fig.  7),  by  a  traction  loop  {see  p.  51), 
or  by  direct  pressure  from  the  finger  of  an  assistant. 

(2)  Incision  of  the  skm  and  exposure  of  the  sac.  This  must  be  thoroughly  ex- 
posed by  a  free  incision  exhibiting  it  from  one  end  to  the  other. 

(3)  Opening  of  the  sac  and  evacuation  of  its  contents,  recognition  of  the  type  of  sac, 
number  of  openings,  &c.  A  free  incision  is  now  made  opening  the  sac  from  one  end 
to  the  other.  The  contained  blood  and  clots  are  evacuated  and  the  interior  of  the 
cavity  displayed  by  free  retraction  of  its  edges.  In  a  fusiform  aneurysm  two  large 
openings  will  be  seen  separated  by  a  variable  distance,  though  often  connected  by 

a  shallow  groove  representing  the 
floor  of  the  parent  artery.  A  sac- 
cular aneurysm  shows  a  single  open- 
ing which  connects  the  sac  with  the 
main  artery.  Search  must  also  be 
made  for  the  openings  of  branches 
springing  from  the  sac,  which  if  not 
sutured  would  give  rise  to  trouble- 
some haemorrhage.  If  there  is  any 
l)leeding  from  the  orifices  as  a  result 
of  the  free  collateral  supply,  the 
closure  of  these  openings  by  suture 
should  be  at  once  proceeded  with. 
Laminated  clot  is  then  cleared  away 
by  gently  scrubbing  the  interior  with 
sterile  gauze  soaked  in  saline  solution. 
(4)  Closure  of  the  orifices  in  the 
fusiform  type  of  sac  (Fig.  10).  The 
systematic  closure  of  all  visible  orifices 
should  nov/  be  proceeded  with. 
Either  silk  or  chromicised  cat-gut 
may  be  employed.  Full  curved  intestinal  needles  are  best.  In  the  larger  openings 
the  needle  should  penetrate  at  least  one-sixth  or  a  quarter  of  an  inch  beyond  the 
margin  of  the  orifice,  and  then,  after  reappearing  at  the  margin,  dip  again  into  the 
floor  of  the  artery,  and  continue  to  the  opposite  margin  as  in  the  start.  When 
the  openings  must  be  closed  qiiickly  the  dip  of  the  needle  into  the  floor  of  the 
vessel  may  be  omitted,  and  the  margins  brought  quickly  together  with  a  con- 
tinuous suture.  In  all  cases  intima  must  be  brought  into  exact  contact  with 
intima.     A  second  row  of  sutures  to  bury  the  first  is  often  advantageous. 

(5)  The  saccular  aneurysm  with  a  single  orifice.  Reconstructive  suture  with  the 
view  of  preserving  the  lumen  of  the  parent  artery  (Fig.  12).  The  intrasaccular 
euture  of  the  orifice  not  only  permits  of  the  radical  cure  of  the  aneurysm  by  closing 
its  orifice  but  also  allows  the  restoration  of  the  affected  artery  to  its  functional 
and  anatomical  integrity.  The  same  needles  and  materials  should  be  used  as  in 
the  previous  case.  The  sutures  should  be  inserted  at  a  sufficient  distance  from  the 
usually  thick  and  smooth  margins  of  the  opening  in  order  to  secure  a  firm  and  deep 
hold  of  the  fibrous  basal  membrane.  The  needle  should  be  made  to  appear  just 
within  the  lower  edge  of  the  margin,  care  being  taken  that  when  the  sutures  are 
tightened  the  calibre  of  the  artery  will  not  be  encroached  upon  so  as  to  obstruct 
its  lumen,  and  that  the  threads  will  not  be  brought  in  contact  with  the  blood  in  the 
lumen  of  the  vessel.  Greater  care  must  be  exercised  in  securing  accurate  co-aptation 
in  this  class  of  cases  than  in  the  fusiform  type. 

(6)  Removal  of  constrictor  and  test  of  sutures.  When  all  visible  orifices  have 
been  closed  the  provisional  expedient  for  controlling  the  circulation  is  removed. 
The  interior  of  the  cavity  should  now  be  perfectly  dry.  If  there  be  any  oozing  of  the 
capillary  points  these  will  usually  be.  stopped  by  pressure  and  by  the  means  adopted 
to  obliterate  the  cavity. 

(7)  Obliteration  of  the  sac.  This  is  effected  by  turning  the  relaxed  flaps  of  skin 
into  the  interior  of  the  cavity.  If  the  sac  has  not  been  previously  dissected  from  its 
surroundings,  the  skin  flaps  will  be  lined  on  their  inner  surfaces  by  the  smooth 
sac   walls   thus   constituting  an  aneurysmo-cutaneous   flap   on   each   side.     These 


Fig.  II.     Endo-aneurysmorrhaphy.     (Matas.) 


LYMPHANGIOPLASTY 


flaps  can  tlun  be  ''.eld  douii  in  the  bottom  of  the  cavity  by  two  relaxation  sutures 
on  each  sith;.  These  salures  are  best  applied  by  a  large  full-curved  intestinal 
needle  which  should  penetrate  the  entire  thickness  of  the  sao  gras[)ing  a  consideraljlc 
portion  of  the  sac  wall.  In  this  way  a  loop  is  forincHl,  tlu;  two  ends  of  which  arc 
carried  through  the  skin  flaps  by  transfixion  with  a  straight  Reverdin's  needle, 
and  then  tied  firmly  over  a  pad  of  gauze  after  the  flaps  have  been  carefully 
in  position  The  edges  of  the  skin  which  then  come  into  contact  in  the  adjusted 
mid-line  arc  united  by  a  few  interrupted  sutures.  Where  the  bulging  tumour 
previously  existed  there  will  be  a  dej)ression  varying  in  depth  according  to  the 
size  of  the  original  sac  ;  no  cavity  is  left  and  there  is  no  need  for  drainage.  The 
collateral  circulation,  which  is  usually  important  in 
the  vicinity  of  an  aneurysm,  is  also  respected,  and  in 
this  way  the  best  condition  for  the  maintenance  of  a 
healthy  nutrition  in  the  sac  and  in  the  parts  beyond 
the  aneurysm  are  assured.  Dr.  Matas  suggests  that 
in  iliac  and  other  abdominal  aneurysms  the  peri- 
toneum covering  the  sac  should  be  utilised  in  the 
same  way  as  the  skin  in  external  aneurysms  in  the 
process  of  obliterating  the  sac. 

Residls  of  the  Operation.  A  number  of  successful 
cases  have  been  recorded  in  the  various  medical 
journals.  Dr.  Matas,  in  a  paper  read  before  the 
American  Medical  Association  in  190*^,'-  collected  a 
total  of  85  cases.  Of  these  7  died  after  the  opera- 
tion, though  in  5  of  these  the  operation  was  only  very 
indirectly  the  cause  of  death.  Of  the  remaining  78 
cases  there  were  only  2  cases  of  secondary  haemor- 
rhage, 4  of  gangrene  and  only  4  relapses,  all  in  re- 
constructive operations. 


u 


OPERATIONS  ON  THE  LYMPHATICS 

The    operation  of  lymphaiigioplasty  may 
be  described  here.     This  was  originally  intro-     ^^«-  ^^ha  S"''%aTa7f '"°'" 
duced  by  Mr.  Sampson  Handley  in  1908^  for  napiy-  I   a  as.) 

the  relief  of  the  condition  known  as  "  brawny  arm,"  which  not  infrequently 
appears  in  the  late  stages  of  carcinoma  of  the  breast  and  is  the  source 
of  great  suffering  to  the  patients.  Mr.  Handley  points  out  that  the 
lymphatic  obstruction  is  due  to  the  permeative  spread  of  growth  cells 
along  the  lymphatics  and  a  peri-lymphatic  fibrosis  which  is  thus 
produced.  "  The  plug  of  cancer  cells  within  the  lymphatic,  continuing 
to  proliferate,  finally  splits  up  the  lymphatic.  Around  the  micro- 
scopic trauma  thus  caused  a  vigorous  round-celled  infiltration  occurs, 
to  be  replaced  later  by  a  capsule  of  newly  formed  fibrous  tissue, 
which  contracts  upon,  and  ultimately  strangles,  the  enclosed  cylinder 
of  cancer  cells.  The  original  lymphatic  vessel  is  replaced  by  a  solid, 
microscopic,  fibrous  cord,  and  the  process  of  peri-lymphatic  fibrosis  is 
complete."  The  method  which  Mr.  Handley  employs  consists  in  intro- 
ducing into  the  subcutaneous  tissues  of  the  affected  limb  a  number  of 
buried  silk  threads,  running  upwards  from  the  wrist  and  terminating 
above  in  the  healthy  tissues  in  or  beyond  the  axilla.  "  The  operation 
is  closely  analogous  to  the  drainage  of  a  marshy  field  by  lines  of  buried 
pipes."  The  operation  is  a  simple  one.  An  incision  is  made  near  the 
wrist.     Through  this  a  long  probe  provided  with  an  eye  is  thrust  upwards 

^  Journ.  Amer.  Med.  Assoc,  vol.  li,  p.  1667.  Dr.  Matas  has  also  published  a  later  and 
more  complete  list  of  cases  {Trans.  Amer.  Surg.  Assoc,  1910,  vol.  xxviii,  p.  4).  A  dis- 
cussion on  the  Surgical Teratment  of  Aneurysm,  opened  by  Mr.  Gilbert  Barling  before  the 
Surgical  Section,  Roy.  Soc.  Med,  (Travis.  Roy.  Soc.  3Ied.,  Snrg.  Sect.,  June,  1912,  p.  159) 
may  also  be  read  with  advantage. 

2  Hunterian  Lectures,  Lancet,  1908,  vol.  i,  p.  1207. 


56  OPERATIONS  ON  THE  UPPER  EXTREMITY 

as  far  as  possible  through  the  subcutaneous  tissues.  The  point  is  then 
cut  down  upon.  A  long  silk  thread  is  threaded  through  the  eye  of 
the  probe,  which  is  drawn  through  the  upper  incision.  The  end  of 
the  thread  at  the  lower  incision  is  then  secured  by  a  pair  of  forceps  to 
prevent  it  being  pulled  out  of  view.  The  probe  is  then  again  introduced 
for  its  whole  length  in  an  upward  direction  and  the  silk  again  drawn 
upwards.  The  process  is  repeated  until  the  upper  end  of  the  silk  reaches 
healthy  tissues.  The  wounds  are  then  all  closed  and  the  silk  thread 
is  left  completely  embedded.  Any  number  of  threads  can  be  introduced 
by  repeating  the  process.  Stout  silk  threads  remain  unabsorbed  for 
years,  and  the  absence  of  organisation  and  coagulation  in  the  interior 
ensure  the  retention  of  its  capillary  power. 

The  follo\ving  is  one  of  the  cases  described  by  Mr.  Handley  in  the 
paper  quoted  above  : 

The  patient,  a  woman  aged  56  years,  v/as  admitted  to  the  cancer  wards  of  the 
Middlesex  Hospital  on  January  18,  1908.  In  1894  a  portion  of  the  right  breast 
was  removed  at  the  Chichester  Hospital  for  carcinoma.  In  1896  recurrences  in 
the  breast  and  axilla  were  removed  at  St.  Marj^'s  Hospital.  In  1903  two  or  three 
small  recurrent  growths  were  removed  from  the  axilla.  In  1905  the  right  arm 
became  swollen  ;  it  slowl}"  became  paralysed,  and  has  been  the  seat,  during  the  past 
three  years,  of  excruciating  pain  which  frequently  kept  her  awake  at  night.  On 
admission  there  was  no  e\ndence  of  cancer  in  tlie  body  in  the  form  of  palpable 
tumours.  The  right  nipple  still  remained  intact  and  was  not  indrawn,  and  there 
was  no  lump  in  what  remained  of  the  right  breast.  The  chest  and  abdomen  were 
free  from  deposits.  The  growth  was  evidently  an  atrophic  scirrhus,  which  had  under- 
gone an  almost  complete  process  of  natural  cure.  The  right  arm  and  hand  below  the 
deltoid  were  greatly  swollen.  The  oedema  pitted  slightly  on  pressure,  though  it 
approached  the  solid  variety.  There  was  complete  paralysis  of  the  limb,  save 
that  the  third  and  fourth  fingers  could  be  moved  slightly.  The  hand  was  warm 
and  of  natural  colour.  Flexion  of  the  elbow  was  only  possible  through  15°  or 
rather  less. 

On  February  1,  under  chloroform,  a  number  of  silk  threads,  each  ruiuiing  up- 
wards from  the  wi'ist  to  the  loose  tissue  upon  the  chest-wall  just  below  the  axilla, 
were  buried  in  the  subcutaneous  tissue.  The  operation  produced  no  general  dis- 
turbance of  note.  On  the  next  day  it  was  obvious  that  the  bandages  were  loose 
and  tlie  strapping  on  her  fingers  was  in  the  same  condition  and  had  to  be  frequently 
replaced.  On  the  6th  it  was  noted  that  the  arm  and  hand  were  quite  flabby  and 
much  reduced  in  size.  The  skin  was  much  -WTinkled  and  luuig  on  the  fingers  in  folds. 
On  the  7th  the  patient  remarked  that  she  saw  her  knuckles  for  the  first  time  for 
years.  The  movements  of  the  fingers  were  beginning  to  return  and  she  was  able 
to  grasp  very  feebh'.  On  the  1 0th  the  forearm  and  hand  began  to  present  an 
almost  normal  ajipearance,  but  much  swelling  of  the  upper  arm  remained.  On  the 
24th  the  limb  was  continuing  to  diminish  in  size  though  less  rapidly  than  at  first. 
Unfortunately  measurements  of  the  limb  previous  to  the  operation  were  not  taken, 
so  that  no  accurate  record  remains  of  its  rapid  and  marked  subsidence  in  the  earliest 
days  after  the  operation.  However,  between  February  6  and  February  24  the 
circumference  at  the  wrist  diminished  from  7^  to  6^  ;  just  below  the  elbow  from 
10^  to  9|  ;  and  8|  inches  below  the  acromion  from  11  to  9f.  The  jiain  disappeared 
and  flexion  of  the  elbow  increased  from  15°  to  llO''.  The  movements  of  the  hand 
improved  so  that  the  patient  could  hold  a  pin  between  the  finger  and  thumb. 

Mr.  Handley  also  suggests  that  this  operation  will  be  found  of  use 
in  other  cases  of  lymphatic  obstruction,  such  as  elephantiasis.^ 

1  Proc.  Roy.  Soc.  Med.  Clin.  Sec,  February  1909. 


CHAPTER  IV 

AMPUTATIONS    OF    THE  FINGERS.     OPERATIONS  ON  THE 
HAND.     TENDON-GRAFTING  AND   TRANSPLANTATION 


Practical  anatomical  points.  I.  Positions  of  the  joints  (Fig.  13).  This 
has  to  be  renienibcred  :    (a)  in  front ;    (b)  behind. 

(a)  In  front.  Three  sets  of  creases  correspond  here,  though  not 
exactly  to  the  joints.  Of  these,  the  lowest  crease  is  just  above  the 
joint,  the  middle  is  opposite  to  the  inter-phalangeal  joint,  the  highest 
nearly  three-quarters  of  an  inch  below  the  metacarpo-phalangeal  joint. 

(6)  Behind.  It  is  to  be  remembered  (1)  that  in  each  case  it  is  the 
upper  bone  which  forms  the  prominence,  viz.  the  knuckle  is  formed 
by  the   head   of   the  metacarpal 

bone,    the   inter-phalangeal    pro-  ^'  __ 

minence  by  the  head  of  the  first 
phalanx,  and  the  distal  one  by 
the  head  of  the  second ;  (2)  that 
the  joint  in  each  case  lies  below 
the  prominence,  the  distal  joint 
being  one-twelfth  of  an  inch,  the 
inter-phalangeal  one-sixth  of  an 
inch,  and  the  metacarpo-phalan- 
geal joint  about  one-third  of  an 
inch  below.  1 

II.  Shape    of   the   joints.     In 
the  distal  and  the  inter-phalangeal 

the  joint  is  concave  from  side  to  side,  and  presents  a  concavity  towards 
the  tips  ;  in  the  metacarpo-phalangeal  joints,  on  the  other  hand,  the 
convexity  is  towards  the  finger-tips. 

III.  TheTheca.  This  fibrous  tunnel,  which  extends  downwards  to  the 
bases  of  the  distal  phalanges  and  upwards  to  the  palm,  is  lined  by  a 
synovial  sheath  and  transmits  the  flexor  tendons.  The  sheath  of  the 
little  finger  is  directly  continuous  with  the  palmar  bursa  which  encloses 
the  tendons  of  the  flexor  sublimis  and  the  flexor  profundus  digitorum  and 
extends  upwards  into  the  forearm.  The  sheath  of  the  thumb  also 
extends  into  the  forearm  and  usually  communicates  with  the  palmar 
bursa.  The  theca  gapes  widely  when  cut,  and  hence  there  is,  especially 
in  the  case  of  the  thumb  and  the  little  finger,  a  channel  along  which 
infection  can  easily  travel  to  the  palm  and  even  to  the  forearm.  Care 
should  thus  be  taken  to  keep  even  such  a  small  amputation  as  that 
of  a  finger  perfectly  aseptic.  The  flaps  of  an  amputation  through 
damaged  parts  should  not  be  too  closely  sutured ;  tension  should  be 
avoided  and  drainage  provided. 

1  The  terms  "  above  "  and  "  below  "  mean  nearer  to  and  farther  from  the  trunk. 

57 


Surface  markings  of  the  joints  of 
the  fingers. 


58  OPERATIONS  ON  THE  UPPER  EXTREMITY 

OPERATIONS  FOR  AMPUTATION  OF  THE  FINGERS 

As  the  rule  is  always  to  remove  as  little  as  possible,  the  actual  method 
adopted  will  always  depend  upon  the  aspect  of  the  finger  from  which 
undamaged  soft  parts  can  be  obtained.  The  following  amputations 
should  therefore  be  practised,  of  which  the  first  two  are  the  best : 

(1)  Long  palmar  flap  (Figs.  14,  16  and  20). 

(2)  Long  palmar  and  short  dorsal  flap  (Figs.  18  and  20). 

(3)  Two  lateral  flaps  (Figs.  17  and  20).  These  may  be  (a)  equal; 
(b)  unequal. 

(4)  One  long  lateral  flap. 

(5)  Two  equal  antero-posterior  flaps.  ^ 

Of  these,  the  palmar  flap  is  usually  the  one  made  use  of.  Though, 
as  the  hands  are  by  far  most  frequently  held  in  the  prone  position,  a 
dorsal  flap  falls  more  easily  into  place,  and  gives  a  more  concealed  scar 
a  palmar  flap  has  the  greater  advantages  of  a  scar  which  is  not  pressed 
upon  when  anything  is  held  in  the  hand,  of  possessing  finer  sensitiveness 

in  touch,  and  better  nutrition  ; 
furthermore,  this  flap  is  available 
even  in  the  last  phalanx,  where, 
from  the  presence  of  the  nail,  a 
dorsal  flap  is  not  obtainable 
(Fig.  14). 

Amputation  o£  a  Distal  Phalanx 
by  a  Palmar  Flap  (Fig.  14). 
First  Method.  The  hand,  to- 
gether with  the  sound  fingers, 
should  be  completely  covered  by 
a  sterilised  bandage.  The  hand 
then  being  well  pronated  and 
the  adjacent  fingers  well  flexed, 
the  surgeon,  having  placed  his  left  forefinger  just  below  and  behind 
the  joint,  and  flexed  the  phalanx  strongly  with  his  thumb  (a  step 
not  always  easy  with  infiltrated  tissues),  cuts-  with  a  slightly  semi-lunar 
sweep  and  drawing  the  blade  from  heel  to  toe,  straight  into  the  joint. 
To  effect  this  neatly,  the  convexity  of  the  sweep  should  pass  one- 
twelfth  of  an  inch  below  the  prominence  or  angle  produced  by  flexion, 
the  sweep  being  made  by  laying  on  the  whole  edge  of  the  knife,  while 
with  the  point,  as  this  incision  begins  and  ends,  the  lateral  ligaments 
are  partly  cut.  The  joint  being  thus  freely  opened,  the  knife  is  in- 
sinuated in  front  of  the  base  of  the  phalanx  (a  step  which  is  facilitated 
by  depressing  and  pulling  on  the  phalanx),  and  then,  being  kept  close 
to  and  parallel  with  the  bone,  cuts,  with  a  steady  sawing  movement,  a 
flap  well  rounded  at  its  extremity  about  two-thirds  in  length  of  the 
pulp  of  the  finger.^ 

Second  Method.  The  hand  being  supinated,  the  finger  to  be  operated 
on  extended,  and  the  others  flexed  out  of  the  way,  a  palmar  flap  is  cut 

^  These  will  produce  a  stump  with  an  exposed  scar. 

2  The  knife  in  all  these  finger  amputations  should  be  narrow,  short,  and  slender,  yet 
strong. 

3  If  the  flap  is  insufficient,  the  head  of  the  second  phalanx  must  be  removed.  In  this 
and  in  other  amputations  in  the  hand,  owing  to  the  soft  parts  cut  through  being  often 
infiltrated  and  fixed,  the  flaps  are  easily  made  too  short,  from  the  desire  of  the  surgeon 
to  leave  as  much  as  possible. 


AMPUTATION  OF  THE  FINGERS 


59 


by  transfixion,  the  knife  being  entered  just  below  the  palmar  crease, 
the  joint  being  then  opened  from  the  dorsum  as  before,  and  the  phalanx 
lastly  disarticulated.  To  cut  flaps  by  transfixion,  however,  is  not 
satisfactory  in  amputations  of  the  finger.  Sir  F.  Treves  sums  up  this 
question  in  the  following  words  :  "In  no  operation  upon  the  fingers  is  it 
well  to  cut  the  flaps  by  transfixion.  In  cutting  a  palmar  flap  by  this  means 
there  is  danger  of  slitting  up  the  digital  arteries.  The  flap,  moreover,  is 
apt  to  be  pointed  and  scanty,  and  to  contain  fragments  of  tendon." 

Third  Method.  If  the  surgeon  has  no  narrow  knife  by  him,  he  may 
modify  the  last  method  by  cutting  his  palmar  flap  first,  but  from  without 
inwards ;  he  then  opens  the  joint  from  the  dorsum,  and  disarticulates. 
As  a  rule  no  vessels  require  ligature.  Any  tendon  that  is  jagged  should 
be  cut  square. 

Difficulties  and  mistakes  in  amputation  of  a  Distal  Pfialanx.  (1)  The 
flap  may,  of  course,  be  made  too  short ;  it  is  often  made  too  pointed. 
I  would  take  this  opportunity  of  pointing  out  that  as  the  bones  of  the 
hand  are  large  in  relation  to  their 
soft  parts,  the  flap  or  flaps  should 
always  be  cut  sufficiently  long.  It 
is,  indeed,  a  golden  rule  in  all 
amputations  that  the  flaps  should  be 
of  sufficient  length  to  fall  together 
easily  over  the  end  of  the  bone  and 
to  come  together  without  the 
slightest  tension.  If  the  flaps  fit  at 
all  tightly  it  will  be  found  when  cica- 
trisation has  occurred,  that  the  scar  is 
adherent,  painful,  or  prone  to  ulcerate, 
or  the  bone  may  tend  to  make  its  way 
through  the  skin  when  pressure  is 
made  up  in  the  stump.  The  student 
must  then  in  this,  his  first  am  putation,  fix  upon  his  mind  a  rule  which 
must  be  followed  in  all  amputations,  large  or  small — to  measure  with 
the  eye  whether  the  flap  or  flaps  will  be  sufficient,  just  before  each  is 
finally  cut. 

(2)  If  the  phalanx  be  not  sufficiently  flexed,  or  if  the  site  of  the 
joint  has  not  first  been  marked  out  with  the  nail,  the  latter  mil  not  be 
readily  opened.  It  is  very  common  for  students,  forgetting  that  in 
the  case  of  each  joint  this  lies  below  the  corresponding  prominence 
(Fig.  13),  to  cut  above  the  level  of  the  joint  here,  their  knife  sawing  against 
the  neck  or  head  of  the  second  phalanx. 

(3)  It  is  often  difficult  to  pass  the  knife  readily  round  the  base  of  the 
phalanx,  especially  in  cases  wliere  the  blade  is  too  broad,  or  where,  as  in 
well-developed  hands,  the  base  of  the  phalanx  is  strongly  tuberculated. 

(4)  If  there  be  any  hitch  in  passing  the  knife  behind  the  phalanx,  the 
outline  of  the  flap  is  very  likely  to  be  jagged,  and  sloughing  may  then  ensue. 

Amputation  through,  or  disarticulation  of,  the  Second  Phalanx  (Figs.  16, 
17,  18).  This,  as  a  rule,  should  be  performed  through  the  phalanx,  and, 
whenever  this  is  possible,  at  or  beyond  its  centre,  so  as  to  leave  the  upper 
half  or  third  of  the  phalanx,  and  thus  ensure  the  preservation  of  some  at- 
tachment of  the  flexor  sublimis.  While  the  rule  not  to  amputate  a 
finger  at  the  joint  between  the  first  and  second  phalanges,  and  a  fortiori 
through  the  first  phalanx,  is  a  sound  one,  as  there  is  a  risk  of  leaving 


';4i^' 


Fig.  15.  a.  Flaps  after  amputation 
of  terminal  phalanx,  b.  Flaps  after 
amputation  through  second  jjhalanx. 
c.  Amputation  of  second  phalanx 
(Heath).  In  each  case  antero-posterior 
flaps  have  been  made.  In  b  the  flexor 
tendon,  and  in  c  both  flexor  and  ex- 
tensor tendons,  should  be  sutured  as 
directed  above,  having  been  first  cut 
long. 


60 


OPERATIONS  ON  THE  UPPER  EXTREMITY 


a  stump  stiff  and  incapable  of  flexion,  there  is  no  doubt  whatever  that, 
where  rapid  heahng  has  been  secured,  this  amputation  has  been  followed 
by  the  flexor  tendon  taking  on  a  fresh  and  sufficiently  firm  adhesion, 
and  so  leaving  a  longer  and,  withal,  a  mobile  stump. 

In  the  following  special  cases  the  whole  or  part  of  the  first  phalanx 
may  be  left,  and  in  all  of  them  the  severed  flexor  tendons,  pre\nously 
cut  long,  should  be  carefully  stitched  to  the  cut  theca  and  periosteum, 
or  into  the  flaps  before  these  are  adjusted.     Another  plan  is  to  suture 


Fig.  16. 


Amputations  of  the  fingers  and  the  thumb.     The  surface  marking  of  the 
superficial  pahnar  arch  is  also  shown. 


together  the  flexor  and  extensor  tendons  (cut  long  and  square)  over  the 
end  of  the  bone  (Waring). 

(1)  In  the  case  of  the  index  finger  the  proximal  phalanx  will  be  a  useful  opponent 
to  the  thumb,  as  in  holding  a  j)en.  (2)  In  the  case  of  the  little  finger,  leaving  the 
proximal  phalanx  will  give  greater  symmetry-  to  the  hand  when  this  is  fixed,  and  it 
may  on  this  account  be  left.  (3)  In  amputations  of  all  the  fingers  the  proximal 
phalanx  of  one  should,  if  possible,  always  be  left  to  oppose  to  the  thumb.  (4)  Where 
a  patient  insists  on  having  the  proximal  phalanx  left,  after  the  risk  of  stiffness  has 
been  explained  to  him.  Provided  that  the  divided  flexor  tendon  is  carefully  sutured 
to  the  theca  or  to  the  extensors,  the  more  the  stump  heals,  and  the  younger  the 
patient,  the  greater  will  be  the  movement  gained.^ 

1  Dr.  Tiffany,  of  Baltimore  (Trans.  Amer.Surg.  Assoc,  vol.  ii,  p.  826),  says  that  he 
has  been  in  the  liabit  "  for  a  number  of  years  "  of  passing  the  stitches  which  unite  the  skin 
through  the  tendons  and  their  sheaths  in  amputation  at  the  joint  between  the  first  and 
second  phalanges.  •'  I  have  never  failed,  as  far  as  I  can  remember,  to  secure  quite  as  good 
movement  as  if  Nature  had  originally  made  an  attachment  there  for  these  tendons." 


AMPUTATION  OF  THE  FINGERS  61 

Methods.  ( 1 )  By  a  long  palmar  or  dorsal  flap  (Figs.  17  and  18),  or  by 
dorso-palniar  flaps,  the  flaps  being  equal,  or  the  palmar  one  the  longer 
(Fig.  17). 

{I)  Bi/  Dorso-palmar  Flaps.  The  surgeon,  having  marked  with  his 
left  forefinger  and  thumb  the  spot  where  he  intends  to  divide  the  bone, 
cuts  between  these  points  a  short,  well-rounded  dorsal  flap  of  skin  ; 
he  then  sends  his  knife  across  below  the  bone,  making  it  enter  and 


Fig.  17.     Amputation  of  the  fingers  and  the  thumb. 

emerge  at  the  base  of  the  first  flap,  and  cuts  a  palmar  flap  about  two- 
thirds  of  an  inch  in  length,  and  not  pointed.  The  flaps  are  then  re- 
tracted, the  bone  cleared  with  a  circular  sweep  of  the  knife,  and  divided 
in  the  manner  given  below. 

While  long  palmar  and  short  dorsal  flaps  will  give  the  best  result, 
equal  flaps,  or  a  long  dorsal  flap,  may  be  employed  if  there  is  more 
extensive  damage  to  the  soft  parts  on  the  anterior  aspect  of  the  finger. 

(2)  By  Lateral  Flaps  (Figs.  16  and  17).  The  site  where  the  bone  is  to 
be  sawn  having  been  marked  by  the  left  forefinger  and  thumb  placed 
on  the  dorsal  and  palmar  aspects  of  the  finger  at  this  level,  the  surgeon, 
looking  over  the  finger,  enters  his  knife  in  the  centre  of  the  palmar 
aspect,  and  carries  it,  cutting  an  oval  flap,  about  two-thirds  of  an  inch 
in  length,  to  a  corresponding  point  on  the  centre  of  the  dorsum,  and 
then  from  this  point  down  again  over  the  side  of  the  finger  nearest  to 


62 


OPERATIONS  ON  THE  UPPER  EXTREMITY 


him,  to  the  point  where  the  knife  was  first  inserted.  The  flaps  being  • 
dissected  up  as  thick  as  possible,  and  the  remaining  soft  parts  severed 
with  a  circular  sweep,  the  bone  is  divided  with  the  saw  or  bone-forceps. 
If  the  situation  of  the  damaged  tissues  renders  it  desirable,  one  flap  can 
be  cut  longer  than  the  other.  In  using  the  bone-forceps  the  concave  sur- 
face is  always  to  be  turned  away  from  the  trunk ;  if  this  precaution  is  taken, 
and  the  bones  severed  c^uickly  with  a  sharp  instrument,  the  section  will  be 
clean  and  not  crushed.     But  a  fine  saw  is  nnich  the  better  instrument. 

Amputation  of  a  Finger,  e.g.  second  or  third  at  the  Metacarpo- 
phalangealJoint  (Figs.  17, 18  and  20).  This,  the  commonest  amputation 
in  the  hand,  being  required  for  severe  crushes,  tuberculous  disease,  and 
some  cases  of  whitlow,  should  be  often  practised.     Before  it  is  employed 


Fig.  18.  In  the  second  finger  amputation  through  the  second  phalanx  is  shown, 
the  bone  beng  divided  below  the  insertion  of  the  flexor  sublimis.  In  the  index 
finger  amputation  through  the  second  phalanx  by  short  dorsal  and  long  palmar 
flaps  is  figured.  The  flaps  for  amputation  of  the  index  finger  at  the  metacarpo- 
phalangeal joint  are  also  shown,  the  straight  part  of  the  incision  being  placed  rather 
to  the  radial  side  of  the  head  of  the  metacarpal  bone.  In  the  thumb  the  flaps  for 
amputation  at  the  carpo-metacarpal  are  indicated.  **  Show  where  the  radial  artery 
may  be  wounded  in  this  amputation.  Ligature  of  the  radial  artery  at  the  back  of 
the  wrist  is  also  represented.     {See  p.  124.) 

for  an  injury,  the  remarks  on  the  conservative  surgery  of  the  hand 
[see  p.  71)  should  be  consulted.  It  is  usually  performed  by  the  modified 
oval  method,  the  en  raquette  of  Malgaigne.  Lateral  flaps  may  also  be 
employed.  Other  methods,  to  be  used  according  to  the  extent  of  damage 
to  the  soft  parts,  are  described  below  (Fig.  20). 

The  hand  having  been  pronated,  the  radial  and  ulnar  arteries  con- 
trolled by  a  tourniquet,  an  Esmarch's  bandage,  or  the  fingers  of  an 
assistant  above  the  wrist,  some  sterilised  gauze  wrapped  round  the 
damaged  finger,  and  the  adjacent  ones  flexed  out  of  the  way  or  held 
aside  with  strips  of  sterilised  gauze,  the  point  of  the  knife  is  inserted 
three-quarters  of  an  inch  above  the  head  of  the  metacarpal  bone,  sunk 
down  to  the  bone  itself,  and  then  carried  down  in  the  middle  line  till 
it  gets  well  on  to  the  base  of  the  phalanx  ;  then  diverging  to  one  side, 
the  knife  is  carried  obhquely  well  below  the  web  ^  across  the  palmar 

>■  Cutting  into  the  web  will  lead  to  much  more  ha^.morrhage  and  it.may  be  difficult  to 
secure  the  vessels.  The  incision  should  pass  about  half  an  inch  below  the  web  otherwise 
there  will  be  difficulty  in  bringing  the  flaps  together  unless  the  head  of  the  metacarpal 
is  removed.  Even  then  there  is  likely  to  be  tension  on  the  sutures,  and  thus  alow  and 
painful  healing. 


AMPUTATION  OF  THE  FINGERS 


63 


aspect  of  the  first  phalanx  below  the  palm  and  then  around  the  other 
side  of  the  phalanx  (also  below  the  web)  so  as  to  join  the  straight  part 
of  the  incision  which  lies  over  the  head  of  the  metacarpal  bone. 

Lateral  Flaps  (Fig.  20).  In  practice,  especially  in  the  country,  where 
an  ana?sthetic  is  not  always  easily  available,  it  is  much  preferable, 
because  quicker,  to  make  two  separate  incisions,  each  beginning  three- 
quarters  of  an  inch  above  the  head  of  the  metacarpal  bone,  and  meeting 
again  on  the  centre  of  the  base  of  the  palmar  aspect  of  the  first  phalanx, 
well  below  the  palm,  instead  of  carrying  the  knife  continuously  round 
the  finger.  Thi^  method  is  not  only  quicker,^  but  it  does  not  leave, 
as  in  the  first  method,  a  small  tongue  of  tissue  on  the  palmar  aspect, 
which  is  a  little  difficult  to  adjust  satisfactorily,  and  behind  which 
discharges  may  collect. 

Sir  W.  Watson  Cheyue  and  Mr.  Burghard  ~  point  out  that  where  any 
such  projection  is  present,  as  in  a  working  man's  hand  with  a  very 
thick  palmar  skin,  the  removal  of  a  V-shaped  portion  here,  after  the 
completion  of  the  amputation,  will  cause  the  entire  disappearance  of 
the  projection. 

Whether  the  method  by  lateral  flaps  or  en  raquette  be  employed, 
the  knife  should  be  used  boldly,  the  extensor  tendon  severed  in  the 
first  incision  over  the  head  of  the  metacarpal  bone,  and  the  soft  parts 
at  the  sides  cut  to  the  bone.  Then,  the  finger 
being  now  extended,  one  Hp  of  the  cut  tissue 
is  taken  up  with  the  finger  and  thumb,  the 
flaps  are  dissected  up  as  thick  as  possible, 
tendons  cut  clean  and  square,  the  lateral  and 
anterior  ligaments  severed  with  the  point  of 
the  knife,  and  the  joint  opened  by  recollection 
of  its  site  well  below  the  projecting  knuckle 
{see  p.  57.  Fig.  13). 

Disarticulation  will  be  facilitated  by  twist- 
ing the  finger,  first  to  one  side,  and  then  to 
the  other,  so  as  to  render  tight  the  parts  which 
remain  to  be  cut.  On  no  account  should  the 
knife  needlessly  enter  the  palm.  This  vnW  only 
lead  to  troublesome  bleeding,  especially  in  in- 
flamed parts,  and  perhaps  to  the  spreading  of 
infective  inflammation.  A  caution  may  be 
given  here  which  applies  to  all  amputations, 
but  especially  to  those  performed  for  accidents., 
where  it  may  not  have  been  possible  to  secure 
absolute  sterihsation  of  the  parts  concerned. 
It  is  very  easy  for  the  tendons,  where  they 
are  drawTi  down  in  order  that  they  may  be 
cut  short  and  square,  to  carry  up  infection 
as  they  retract  into  their  sheaths.  At  this 
stage  especially  it  is  important  thoroughly  to 
irrigate  either  ^vith  sterihsed  saline  solution  or  with  some  weak  anti- 
septic lotion,  such  as  carbolic  1  in  40. 

Where  strength  has  to  be  considered  rather  than  appearance,  the 

'^  Because  it  avoids  the  hitch  usually  met  with  in  carrying  the  knife  around  the  base 
of  one  finger  between  two  others. 

2  Manual  oj Surgical  Treatment,  vol.  ii,  p.  .512. 


Fig.  19.  Amputation  of  the 
middle  finger  by  lateral  flaps 
(Heath).  The  neck  of  the 
bone  should  be  more  fully 
cleaned,  the  tendons  sepa- 
rated, and  the  bite  of  the 
forceps  pressed  more  securely 
round  the  neck  of  the  bone. 


64 


OPERATIONS  ON  THE  UPPER  EXTREMITY 


head  of  the  metacarpal  bone  should  be  left,  whatever  be  the  rank  in 
life  of  the  patient,  as  the  transverse  ligament  is  thus  less  interfered  with, 
the  hand  less  weakened,  and  the  palm  not  opened  up. 

But  where  appearance  is  the  most  important  point,  and  the  mutila- 
tion is  to  be  hidden  as  much  as  possible  by  the  approximation  of  the 
fingers,  the  head  of  the  bone  should  be  removed  by  a  narrow-bladed 
saw  or  by  bone-forceps  ^  (Fig.  19).  In  either  case  the  section  should 
be  made  obliquely  from  above  downwards  and  from  behind  forwards, 
so  as  to  remove  more  on  the  dorsal  than  the  palmar  aspect.  In  such 
cases,  after  a  little  practice,  it  is  not  necessary  to  perform  disarticulation, 

the  metacarpal  bone  being 
severed  after  the  flaps  have 
been  dissected  upwards  to  the 
proper  level. 

Here,  too,  care  must  be 
scrupulously  taken  not  to  in- 
terfere with  the  tissues  in  the 
palm. 

After  removal  of  the  finger 
and  the  Esmarch's  bandage, 
one  or  more  digital  vessels  lying 
rather  deeply  opposite  the  web 
of  the  finger  will  require  liga- 
ture.^ 

In  the  case  of  the  thumb, 
index  (Figs.  20  and  21),  or  little 
finger,  the  straight  part  of  the 
oval  incision  should  be  placed 
to  the  ulnar  side  of  the  meta- 
carpal bone,  rather  than  in  the 
dorsal  mid-line,  as  the  line  of  in- 
cision will  be  better  concealed. 
In  these  cases  the  saw  or  bone- 
forceps  should  be  applied  ob- 
liquely from  without  inwards 
and  from  within  outwards  re- 
spectively, so  as  to  leave  no 
projecting  bone  on  the  radial  or 
ulnar  aspect  of  the  hand,  and,  in 
the  case  of  the  index,  to  allow  of  the  thumb  being  readily  approximated 
to  the  second  finger.  It  may  be  worth  while  to  add  the  following  hints 
with  regard  to  the  after-treatment:  (1)  Not  to  bandage  the  adjacent 
fingers  too  closely  or  too  long  together,  otherwise  a  tendency  to  cross  at 
their  points  will  be  noticed  later  on.  (2)  In  this  and  all  other  dis- 
articulations where,  in  spite  of  copious  irrigation  with  sterile  saline  or 
other  solution,  a  co-existing  infective  condition  cannot  be  got  rid  of 
with  certainty,  the  cartilage  should  be  removed. 

Tedious  exfohation  is  otherwise  certain.  As  already  advised,  there 
should  be  no  close  suturing  in  these  cases,  and  boracic  fomentations  may 
be  employed  from  the  first.  In  this  and  many  other  amputations  of  the 
^  With  the  precaution  given  at  ii.  02.  A  saw,  avoiding  splintering,  is  preferable. 
-  Care  should  be  taken  to  seeure  these  vessels,  especially  where  they  are  enlarged  in 
any  iniiammatory  condition,  otherwise  profuse  bleeding  may  take  place  a  few  hours  after 
the  operation. 


Fig.  20.  Different  methods  of  amputating  the 
thumb  and  fingers  at  their  metacari)o-phalan- 
geal  joints.  In  the  case  of  the  thumb  a  long 
palmar  flap  has  been  made  ;  in  the  index  a  pal- 
mar and  external  flap  ;  in  the  middle  finger  a 
circular  incision  and  a  straight  dorsal  cut  (a 
modification  of  the  method  en  raquctte)  have 
been  employed  ;  the  ring  finger  has  been  re- 
moved by  two  lateral  flaps,  and  the  little  one  by 
an  internal  and  palmar  flap.     (Farabeuf.) 


AMPrTATIOX  OF  TIIK   FINCiERS  65 

hand,  peifonitecl  zinc,  which  can  be  easily  boiled,  is  the  best  material 
for  splints. 

Disarticulation  by  a  Circular  Incision  with  a  Straight  one  on  the 
Dorsum  ( Fi,u.  I'D).  This  method,  a  modilication  of  the  one  en  rnqncltc, 
is  pieferred  by  Farabeuf  as  simpler  and  sacrihcini^  less  skin.  The  hand 
being  completely  supinated,  and  the  other  fingers  bent  out  of  the  way, 
the  surgeon  cuts  across  the  root  of  the  finger  in  the  digito-palmar  fold, 
going  down  to  the  bone,  and  encroaching  as  far  as  possible  on  the  sides 
of  the  finger.  The  hand  being  pronated,  the  ends  of  the  circular  incision 
ai'c  prolonged  up  to  the  middle  line  of  the  dorsal  aspect  of  the  finger, 
where  a  straight  cut.  beginning  a  little  above  the  level  of  the  joint,  is 
drawn  to  and  perpendicular  to  the  first.  By  this  means  two  right- 
angled  flaps  are  marked  out.  These  are  raised  and  the  bone  disarticu- 
lated, by  the  steps  already  given. 

Amputation  by  a  Single  Flap.  Where,  owing  to  the  state  of  the  soft 
parts,  thismetiiod  is  re(juired.  Fig.  '10  indicates  how  it  may  be  employed. 

Amputation  of  a  Finger,  together  with  Removal  (complete  or  partial) 
of  its  Metacarpal  Bone.  This  operation  is  easily  performed  by  a  modifi- 
cation of  the  method  en  raquette  or  that  by  lateral  flaps  just  described. 


Fig.  21.    Amputation  of  little  finger  and  its  metacarpal 
by  the  oval  method. 

It  is  only  needful  to  prolong  the  dorsal  part  of  the  former  incision  or 
the  apex  of  the  latter  as  far  as  the  carpo- metacarpal  joint. 

Disarticulation,  w^hen  the  parts  are  much  swollen,  will  be  safely 
performed  here  by  carefully  prolonging  back  the  dorsal  incision  in  a  wound 
kept  bloodless  till  the  joint  is  felt  and  seen,  suitably  manipulating 
the  finger  so  as  to  put  the  structures  attached  to  the  metacarpal  bone 
on  the  stretch,  remembering  the  insertions  of  tendons  into  some  of 
these  bones,  severing  the  ligaments  of  the  articulations  with  careful 
touches  of  the  knife,  and  not  sinking  this  into  the  palm  for  fear  of 
wounding  the  palmar  synovial  sac  or  the  deep  palmar  arch.  Wherever 
possible,  the  extensor  tendons  should  be  drawn  aside  and  carefully 
preserved.  In  infected  cases,  the  greatest  care  must  be  taken,  e.g. 
irrigation  with  sterile  saline  solution  or  with  a  dilute  antiseptic  lotion. 

In  the  case  of  the  little  finger  (Fig.  21),  the  ulnar  border  should  be 
chosen  for  the  incision,  or,  if  the  dorsal  tissues  are  much  damaged,  a 
palmar  and  internal  flap  may  be  made.  In  clearing  the  metacarpal 
the  knife-point  must  be  kept  very  close  to  the  bone.  If  only  a 
portion  of  the  bone  needs  removal,  this  should  be  divided  with  a  ?aw 
and  not  ^\ith  bone-forceps. 

Farabeuf  gives  the  very  practical  hint  that  primary  union  should 

1  Manual  of  Surgical  Tnatment,  vol.  ii.  p.  514. 
SURGERY   I  t; 


66  OPERATIONS  ON  THE  UPPER  EXTREMITY 

be  secured  by  the  flaps  meeting  readily  without  tension.  Otherwise 
the  contraction  of  the  scar  will  drag  upon  the  next  finger,  and  cause 
it  to  stick  out  from  its  fellows  in  a  very  ugly  fashion. 

Where  a  metacarpal  bone  is  removed  for  sarcoma,  Sir  W.  Watson 
Cheyne  and  Mr.  Burghard  ^  advise  that  the  adjacent  bones  on  one  or 
both  sides  be  removed  as  well,  to  avoid  the  risk  of  lea\'ing  disease 
behind.  They  add  :  "  When  more  than  one  metacarpal  bone  is  removed, 
it  is  well  to  take  away  at  least  one  finger  in  order  to  preserve  the  full 
use  of  the  hand.  Unless  this  be  done,  the  fingers  are  apt  to  be  crowded 
together  as  the  wound  contracts,  and  considerable  interference  with  their 
usefulness  may  ensue."  " 

Amputation  of  two  or  three  contiguous  Fingers.  When  (a  very  rare 
contingency)  two  or  more  fingers  require  removal  at  the  same  level, 
i.e.  through  their  metacarpo-phalangeal  joints,  or  higher  up — the  modified 
racquet  or  lateral  flaps  may  again  be  employed,  the  apex  of  the  dorsal 
incision  starting  between  the  fingers  when  two,  and  over  the  central 
metacarpal  bone  when  three,  fingers  have  to  be  removed. 

AMPUTATION  OF  THE  THUMB 

Amputation  of  Phalanges  of  Thumb.  Very  little  need  be  said  about 
this  operation,  as  it  is  very  rarely  performed.  Owing  to  its  numerous 
muscles,  the  thumb  is  extremely  mobile,  and  thus  escapes  injury. 
Thanks  to  its  abundant  vascular  supply,  trimming  of  the  soft  parts 
after  an  injury  will  generally  leave  more  of  the  thumb  to  oppose  to 
the  fingers,  and  thus  is  to  be  preferred  to  any  set  operation.  In  cases 
of  necrosis  after  whitlow,  Mr.  Jacobson  has  twice  removed  both 
phalanges,  the  soft  parts  consolidating  usefully^  with  the  aid  of  the 
periosteum  that  was  left.  For  further  remarks  on  the  importance  of 
preserving  the  thumb,  see  Excision  of  the  Thumb,  p.  68,  and  Con- 
servative Surgery  of  the  Hand,  p.  70. 

Operation.  Amputation  of  the  phalanges  of  the  thumb  may  be 
performed,  in  the  case  of  the  distal  one,  by  a  long  palmar  flap,  as  in 
the  case  of  a  finger  (Figs.  14  and  20);  of  the  first  phalanx,  by  antero- 
posterior, lateral,  or  a  modification  of  the  circular  incision.  In  the  lattsr 
case,  a  short  longitudinal  incision  should  be  made  on  the  radial  rather  than 
upon  the  dorsal  aspect  as  in  this  way  less  damage  will  be  done  to  the 
tendons.  In  any  case  the  incisions  should  be  carried  well  on  to  the 
phalanx  to  ensure  sufficient  flaps  to  cover  the  head  of  the  metacarpal  bone, 
together  with  the  sesamoid  bones,  which  should  never  be  removed. 

The  line  of  the  metacarpo-phalangeal  joint  is  very  nearly  transverse, 
and  lies  just  in  front  of  the  knuckle. 

After  amputation  of,  or  through,  the  phalanges,  the  severed  end  of 
the  long  flexor,  pre\aously  cut  long,  should  be  carefully  stretched  into 
the  angle  of  the  flaps  and  to  the  extensor,  and  also,  if  possible,  into  the 
theca  and  periosteum  as  well. 

Amputation  of  the  Thumb  at  the  Carpo-metacarpal  Joint  (Figs.  16 
and  22).  Indications.  This  operation  is  rarely  called  for  on  the  living 
subject.'^  Gunshot  injuries,  some  growths,  especially  chondromata  of 
the  phalanges  and  metacarpal  bone,  epithelioma  of  a  scar,  and  melanotic 
sarcoma  occasionally  call  for  it. 

^  This  is  strongly  indicated  in  those  eases  where  it  is  especially  important  to  leave  the 
thumb  long  for  holding  a  pen  or  any  delicate  instrument. 
*  It  is  not  infrequently  used  as  an  examination  test. 


AMPUTATION  OF  THE  THUMB 


67 


Operation.  The  position  of  the  joint  between  the  trapezium  and 
metacarpal  bone,  its  shape,  with  two  saddle-like  articular  surfaces 
fitting  into  each  other  by  mutual  coaptation,  and  the  position  of  the 
radial  artery  passing  over  the  back  of  the  styloid  process  of  the  radius 
just  above  this  joint  (Figs.  18  and  (i.'i),  and  again,  when  perforating  the 
first  interosseous  space,  lying  close  to  the  metacarpal  bone,  must  be 
remembered. 

The  operation  is  usually  performed  by  a  modification  of  the  method 
en  raquette.  An  Esmarch's  bandage,  or  tourniquet,  having  been  applied 
above  the  wrist,  the  hand  held  midway  between  pronation  and  supina- 
tion, and  the  thumb  held  over-extended  so  as  to  relax  the  parts,  the 
surgeon  inserts  the  point  of  a  strong  narrow  scalpel  just  above  the 
joint.  This  lies  a  full  finger's  breadth  below 
the  tip  of  the  styloid  process.  Its  position  can 
usually  be  made  out  by  tracing  up  the  meta- 
carpal bone  with  one  finger  along  its  inner  and 
the  thumb  along  its  outer  margin,  the  .thumb 
being  alternately  abducted  and  adducted.  The 
knife,  entering  the  narrow  interval  between  the 
tendons  of  the  extensor  ossis  metacarpi  and  primi 
internodii,  should  avoid  la  "  tahatiere  anatomique  " 
and  the  radial  artery.  Where  there  is  much 
swelling  comparison  must  be  made  with  the 
sound  thumb.  The  incision  is  then  carried  along 
the  dorsum  of  the  bone  as  far  as  the  base  of  the 
first  phalanx,  where  it  passes  (in  the  case  of  the 
left  thumb)  obliquely  to  the  ulnar  side  below 
the  web,  and  then  around  the  palmar  aspect  of 
the  phalanx,  along  the  radial  side,  to  join  the 
dorsal  incision  again.  Taking  up  first  one  edge 
of  the  incision  and  then  the  other,  the  surgeon 
dissects  up  the  soft  parts  from  the  bone,  keeping 
the  knife-point  close  to  this,  especially  on  the 
inner  side,  where  it  is  in  close  proximity  to  the 
radial  artery.  The  extensor  tendons  and  the 
short  muscles  of  the  thumb  being  severed,  the 
joint  between  the  trapezium  and  the  metacarpal 
bone  is  felt  for  and  opened  from  behind,  the 
whole  thumb  being  strongly  flexed  into  the  palm  ; 

the  thumb  is  now  removed  by  putting  the  remaining  tissues  on  the 
stretch  by  twisting  the  metacarpal  bone  in  different  directions. 

Amputation  of  the  Thumb  at  the  Carpo  metacarpal  Joint  by  Transfixion 

(Fig.  22).  The  hand  being  held  as  before,  and  the  parts  relaxed  by  sHghtly  adducting 
the  thumb,  an  incision  is  made  (in  the  case  of  the  left  thumb)  from  the  base  of  the 
metacarpal  bone  rather  to  its  palmar  aspect,  along  its  dorsum,  and  then  obliquely 
to  the  ulnar  side  of  the  base  of  the  first  phalanx  ;  the  knife,  a  long  narrow  bistoury, 
is  then  pushed  from  this  point,  at  the  junction  of  the  web  with  the  thumb,  through 
the  thenar  eminence  to  the  point  where  the  incision  started,  over  the  carpo-meta- 
carpal  joint.  By  cutting  outwards,  along  the  line  indicated  in  Fig.  22,  a  flap  is  formed 
of  the  tissues  in  the  ball  of  the  thumb,  the  knife  being  kept  close  to  the  bone  at 
first,  but  directed  more  superficially  afterwards,  as  it  comes  out  through  the  skin 
over  the  sesamoid  bones  and  base  of  the  first  phalanx,  to  prevent  its  being  locked 
here.  This  flap  being  held  back,  the  metacarpal  bone  is  dissected  out  by  keeping  the 
knife  close  to  it,  the  joint  opened,  and  the  thumb  removed  as  before. 

On  the  right  side  it  is  better  to  cut  the  palmar  flap  by  transflxion  first,  making 


Fig.  22. 


68  OPERATIONS  ON  THE  UPPER  EXTREMITY 

the  knife  enter  and  emerge  just  as  desci-ibed  above.  The  blade  of  the  knife  is  then 
drawn  from  the  base  of  the  first  phalanx  obliquely  across  the  dorsum  of  the  meta- 
carpal bone,  from  one  extremity  of  the  transfixion  incision  to  the  other.  The 
operation  is  completed  as  before. 

Whatever  method  is  employed  the  radial  artery  should  not  be  seen  ;  only  its 
digital  branches  should  require  ligature. 

In  practice,  total  removal  of  the  thumb  is  one  of  the  rarest  amputa- 
tions. Part  of  the  metacarpal  bone  should  always  be  left  if  possible. 
Even  if  stiff,  it  will  be  most  useful  when  the  fingers  are  opposed  to 
it.  The  long  flexor  should  always  be  sutured  to  the  theca  or  otherwise 
secured. 

PARTIAL  EXCISION  OF  THE  THUMB 

Removal  of  Phalanges.  Owing  to  the  exceeding  value  of  the  thumb, 
a  phalanx  should  always  be  preserved  if  possible  not  only  in  whitlow 
necrosis,  but  in  the  case  of  the  first  or  proximal  phalanx  when  it  is  the 
seat  of  an  enchondroma.  By  this,  not  only  is  appearance  saved  by  less 
shortening,  but  the  use  of  the  long  flexor,  in  particular,  is  preserved. 

Mr.  Royes  Bell  ^  published  a  case  in  which  he  excised  the  proximal  phalanx  in  a 
woman,  aged  19,  for  a  huge  enchondroma  of  sixteen  years'  growth,  the  joints  being 
movable.  The  phalanx  was  excised  by  two  semi-lunar  incisions  over  the  tumour,  the 
knife  being  kept  close  to  the  bone,  and  the  joints  opened.  No  tendons  were  cut. 
Eighteen  months  later  the  condition  of  the  thumb  was  excellent,  both  for  all  general 
movements  and  for  writing. 

In  1897  Mr.  Jacobson  performed  a  simUar  operation  on  a  patient  aged  33.  The 
first  phalanx  of  the  right  thumb  was  removed,  by  a  single  dorsal  incision,  for  an 
enchondroma  of  twelve  years  standing,  and  the  base  of  the  distal  one  resected  for  a 
similar  but  much  smaller  growth.  The  long  flexor  was  stitched  to  the  portion  of  the 
distal  phalanx  left.  Healing  was  complete  in  three  weeks  ;  active  and  passive 
movements  were  then  assiduously  carried  out.  When  the  patient  was  last  seen  six 
months  after  the  operation,  the  thumb  was  much  shortened  and  also  somewhat 
weaker  than  its  fellow,  but  it  was  steadily  gaining  in  strength  and  usefulness,  and  its 
movements  were  almost  completely  restored. 

Removal  of  Metacarpal  Bone.  This  should  always  be  excised,  wherever 
possible,  in  preference  to  sacrificing  a  part  of  such  incalculable  value 
as  the  thumb. 

A  straight  incision,  which  reaches  one-fourth  of  an  inch  beyond 
each  extremity  of  the  bone,  ha\dng  been  made  along  the  dorsum,  the 
tendons  are  drawn  aside  ;  the  distal  end  and  joint  are  next  cleared 
and  opened,  when  the  bone  can  be  used  as  a  lever  whilst  it  is  freed  from 
the  soft  parts  on  the  palmar  aspect  and  then  disarticulated.  Removal 
of  this,  as  with  the  other  metacarpals,  is  sometimes  facilitated  by  dividing 
the  bone  in  the  centre  and  then  removing  it  in  two  pieces.  In  young 
subjects,  the  epiphysis,  if  healthy,  should  be  left.  If  possible,  the 
periosteum  should  always  be  preserved.  The  position  of  the  radial 
artery,  both  on  the  ulnar  side  of  the  metacarpal  bone  and  above  the 
carpo-metacarpal  joint,  must  be  borne  in  mind. 

Excision  of  the  Phalanges  and  Joints  of  the  Fingers.  Only  excision 
of  joints  need  be  alluded  to  here,  as,  save  in  the  case  of  removal  of  the 
distal  phalanx  (or  the  last  two  in  the  case  of  the  index)  for  necrosis, 
excision  of  a  phalanx  leaves  a  very  useless  finger. 

Excision  of  an  ititerphalangeal  joint  may  be  required  in  some  very 
rare  cases  of  "  snapping  "  or  "  clasp-knife  "  finger,  where  the  trouble 
is  believed  to  be  due  to  irregularity  of  the  joint  surfaces.  Also  in  those 
1  Lancet,  1872,  vol.  ii.  p.  846. 


DISLOCATION   OF    Tlir.  TIIUMH  GO 

cases  ol  c()u<,'ciiital  contraction  ol  tlie  linj^er,  where  the  lateral  ligaments 
are  much  shortened.  At  p.  SS  it  is  pointed  out  that,  in  some  cases 
of  needles  deeply  situated  in  the  palm,  a  dorsal  incision  and  partial 
removal  of  a  metacarpal  bone  affords  the  best  way  of  fretting  at  the 
foreign  l)()d\-. 

Reduction  of  Dislocations  of  Thumb  and  Finger  at  the  Metacarpo- 
phalangeal Joint.  Excision  of  the  Metacarpo-phalangeal  Joint.  The 
difficulty  often  met  with  in  reducing  a  metacarpo-phalangeal  dislocation 
in  the  case  of  the  thumb  has  long  been  recognised.  Mr.  Battle  has 
shown  with  instructive  cases  ^  that  like  difficulty,  due  to  similar  causes, 
may,  though  more  rarely,  be  met  with  in  the  case  of  a  finger.  es])ecially 
the  index.  Other  papers  by  the  late  Mr.  Davies-Colley  and  Mr.  Symonds  ^ 
and  Mr.  Jordan  Lloyd '^  will  repay  perusal.  Any,  or  several,  of  the 
following  factors  may  be  the  cause  of  the  above  difficulty  :  ( 1 )  The 
buttonhole-like  slit  with  which  the  two  heads  of  the  flexor  brevis  and 
their  sesamoid  bones  now,  in  their  altered  relations,  embrace  the  head 
of  the  metacarpal  bone  ;  (2)  the  lateral  ligaments  ;  (3)  the  interposition 
of  the  torn  anterior  or  glenoid  ligament,  between  the  base  of  the  phalanx 
and  the  head  of  the  metacarpal  bone  ;  (4)  the  contraction  of  the  numerous 
muscles  around  the  dislocated  joint ;  (5)  the  shortness  of  the  leverage 
afforded  by  the  dislocated  bones  ;  (6)  the  tendon  of  the  flexor  longus 
pollicis  may  be  displaced  and  form  a  tense  band  to  the  inner  side  of 
the  joint,  winding  round  the  neck  of  the  metacarpal.  The  chief  cause, 
however,  is  the  displacement  of  the  glenoid  or  palmar  ligament  of  the 
carpo- metacarpal  joint.  This  structure,  which  is  a  thick -plate  of  fibre- 
cartilage,  occupies  the  interval  between  the  lateral  ligaments  with 
which  it  is  continuous  on  the  palmar  aspect  of  the  joint.  It  is  intimately 
connected  with  the  sesamoid  bones,  and,  while  firmly  united  to  the 
phalanx,  is  but  loosely  attached  to  the  metacarpal.  When  dislocation 
backwards  occurs  as  the  result  of  violent  hyper-extension  of  the  joint 
the  displaced  phalanx  tears  through  the  weak  attachment,  carrying 
the  ligament  backwards  with  it  over  the  head  of  the  metacarpal  bone. 

Remembering  then  that  the  anterior  and  lateral  ligaments — forming 
one  continuous  structure — aie  the  chief  impediments  to  reduction,  mani- 
pulation should  be  tried  first  and  always  with  an  anaesthetic.  In  the 
case  of  a  finger,  the  displaced  phalanx  is  well  tilted  back  on  to  the 
dorsum  of  the  metacarpal,  in  order  to  bring  the  glenoid  ligament  and 
other  structures  already  mentioned  well  in  front  of  the  anterior  margin 
of  the  articular  surface  of  the  phalanx  before  flexion  is  employed.  This, 
with  firm  pressure  of  the  thumbs  against  the  base  of  the  displaced 
phalanx,  generallv  causes  it  to  slip  into  place.  In  the  case  of  the  thumb 
reduction  should  be  tried  on  the  same  lines,  the  whole  thumb  being 
first  adducted  towards  the  palm.  The  displaced  phalanges  may,  if 
necessary,  be  grasped  }>y  special  forceps  to  give  greater  leverage.  Should 
manipulation  fail,  as  it  very  likely  will,  one  of  the  following  operations 
should  be  employed  : 

(I)  Tenotomy.  A  tenotome  is  introduced  on  the  dorsal  aspect  to  one 
side  of  the  mid-line  so  as  to  avoid  the  extensor  tendon.  It  should  be 
carried  down  to  the  base  of  the  phalanx  and  then  be  made  to  cut  upwards 
along  the  neck  of  the  metacarpal.  By  this  means  the  glenoid  ligament 
will  be  split  longitudinally.     A  repetition  of  the  manipulations  will  then 

1  Lancet,  1888,  vol.  ii.  pp.  1222,  1271. 

2  IbicJ.  vol.  i,  p.  522.  ^  Lancet,  1892,  vol.  i,  p.  469. 


70  OPERATIONS  ON  THE  UPPER  EXTREMITY 

generally  be  successful.  Occasionally  the  tenotomy  knife  is  introduced 
on  each  side  of  the  extensor  tendons  and,  the  phalanges  being  extended, 
the  structures  between  the  bones  are  divided  transversely.  In  this 
way  the  short  flexor  is  cut  and  unnecessary  damage  may  be  done.  Should 
the  simpler  procedure  fail,  it  is  better  to  perform  an  open  operation. 

(2)  By  a  Palmar  Incision.  A  median  incision  two  inches  in  length 
is  made  over  the  anterior  aspect  of  the  joint  through  which  the  head 
of  the  metacarpal  is  freely  exposed.  If  the  tendon  of  the  long  flexor 
has  slipped  to  the  inner  side  of  the  metacarpal  it  may  be  replaced  by 
means  of  a  strabismus  hook  ;  the  tendons  of  the  flexor  brevis  may  be 
hooked  aside,  and  the  torn  glenoid  ligament  may  be  drawn  from  between 
the  articular  surfaces  by  suitable  hooks  or  forceps.  Aftei  extension  the  head 
of  the  bone  can  then  be  replaced.  If  possible  a  few  catgut  stitches  should 
be  used  to  close  the  tear  in  the  capsule  ;  the  wound  is  then  closed  and 
the  thumb  put  up  on  a  perforated  zinc  or  a  moulded  splint. 

(3)  By  a  Dorsal  Incision.  The  dislocation  is  exposed  by  an  incision 
to  the  radial  side  of  the  dorsum  of  the  joint.  The  glenoid  ligament  can 
then  be  replaced  and  any  tense  band  be  divided.  The  want  of  room 
and  the  close  connection  of  the  extensor  tendons  with  the  capsule  always 
render  this  small  operation  one  of  some  difficulty.  The  palmar  incision 
should,  as  a  rule,  be  employed. 

(4)  Excision  of  the  Metacarpo- phalangeal  Joint.  This  is  especially  in- 
dicated when  the  dislocation  has  remained  unreduced  for  a  long  time. 
The  head  of  the  metacarpal  should  be  exposed  through  a  palmar  incision, 
as  described  above.  The  soft  parts  are  freely  retracted,  and  the  end 
of  the  displaced  metacarpal  ha\'ing  been  cleared  by  keeping  the  knife- 
point closely  applied  to  it,  sufficient  is  then  removed  in  situ  by  a  narrow 
saw,  which  is  preferable  to  bone-forceps.  Free  resection  of  the  one 
bone  will  probably  suffice,  if  sufficiently  free  ;  merely  paring  off  the 
articular  cartilage  is  likely  to  lead  to  a  stiff  joint.  Only  if,  owing  to  the 
amount  of  matting,  or  previous  inflammation,  there  be  additional  risk 
of  ankylosis,  should  the  base  of  the  first  phalanx  be  removed  as  well. 
C'are  must  be  taken,  before  this  is  done,  to  detach  carefully,  as  com- 
pletely as  possible,  the  tendons  inserted  into  it,  together  with  the 
periosteum,  and  since  two  freshly  sawn  surfaces  are  left  additional 
precautions  must  be  taken  against  ankylosis.  Any  tendon  accidentally 
cut  should  be  sutured.  The  patient  must  be  prepared  for  some  shorten- 
ing, especially  if  the  epiphysis  of  the  phalanx  has  been  removed. 

CONSERVATIVE  SURGERY  OF  THE  HAND 

While  each  case  requires  individual  consideration,  it  is  hoped  that 
the  following  hints  may  be  of  ser\'ice  to  the  surgeon  when  called  upon, 
suddenly,  to  form  what  is  a  very  important  decision. 

(1)  The  question  of  trying  to  unite  a  totally  separated  part  is  alluded 
to  at  p.  78.  The  question  of  palmar  haemorrhage  is  considered  at 
p.  88  ;  and  the  treatment  of  injuries  to  tendons  and  nerves  will  be 
found  under  these  headings  respectively. 

(2)  After  injury,  except  in  rare  cases,  where  the  combined  com- 
minution of  bone,  injury  to  tendons,  and  stripping  of?  of  skin  is  extreme, 
no  set  amputation  is  to  be  performed.  In  the  case  of  a  part  of  such 
incalculable  value,  and  so  well  supplied  with  blood  as  the  hand,  the 
surgeon  should  remember  Verneuil's  words  and  not  "  approach  these 
cases   with   the   bistoury."     He   is   to   render   the   part   as   aseptic  as 


CONSERVATIVE  SURGERY  OF  THE  HAND  71 

possible,  and  then  to  wait  and  watch  what  Nature  will  do  towards 
the  uUinude  restoration  of  usejulness.  This,  of  course,  entails  risks  of 
suppuration,  sloughing,  and  even  worse  ones,  such  as  tetanus.  Assiduous 
attention  to  the  advice  at  p.  73  alone  justifies  running  these  risks. 

Speaking  generally,  these  cases,  in  which  the  decision  has  to  be 
made  between  too  conservative  surgery  and  in  removing  too  much, 
fall  into  two  groups. 

A.  Injuries  limited  to  the  Fingers.  Here  conservative  surgery  is  less 
rigidly  indicated  than  in  complicated  and  extensive  injuries  to  the 
hand.  \i  the  injury  to  the  finger,  especially  the  third  or  fourth,  be 
such  that  useful  function  will  be  lost,  it  will  be  wiser  to  amputate  it, 
and  not  hold  out  any  hopes  of  usefulness,  which  will  only,  after  prolonged 
and  tedious  treatment,  prove  illusive.  If  it  be  the  index  which  is  most 
damaged,  the  surgeon  will  remember  that  a  freely  movable  middle 
finger  will  steadily  improve  in  sharing  with  the  thumb  the  loss  of  the 
index.  And  if  the  head  of  the  metacarpal  bone  has  been  removed, 
a  new  interdigital  space  will  gradually  be  developed,  which  may  be 
very  useful  for  a  working  man. 

B.  Complimted  and  extensive  injuries  to  the  Hand.  Here  the  difficulty 
of  estimating  the  extent  of  the  damage,  the  power  of  ultimate  recovery 
in  a  part  like  the  hand,  and  the  amount  of  loss  of  function,  together 
with  the  hopelessness  of  any  really  useful  artificial  substitute,  should 
make  conservative  surgery  the  rule,  and  the  surgeon  should  wait  and 
see  how  much  antiseptic  baths  and  dressings,  together  with  the  other 
aids  given  below,  will  save  from  destruction. 

(3)  Later  Amputation.  But  while  it  is  a  cardinal  principle  to  preserve 
every  inch  of  the  hand,  a  single  finger  or  a  thumb  alone  being  far  more 
useful  than  the  most  elaborate  artificial  limb  that  can  be  made,  and 
while  to  gain  this  end  it  is  frequently  advisable  to  trim  up  an  injured 
part  and  to  remove  bone  in  preference  to  doing  any  set  amputation, 
it  must  always  be  remembered  that  a  part  may  he  capable  of  being  saved, 
and  yet  ultimately  be  useless  unless  it  be  at  least  partially  movable.  Again, 
atrophy  of  a  part,  at  first  promising  in  usefulness,  may  set  in  some 
time  after  the  injury,  brought  largely  by  trophic  disturbances.  In  either 
of  these  cases  a  rigid  cicatricially  contracted  claw,  or  a  pointed,  sensitive, 
and  shrunken  part  may  call,  later  on,  for  amputation. 

(4)  Amongst  the  very  exceptional  cases  ivhich  call  for  primary  amputa- 
tion are  those  where  (1)  one  or  more  fingers  are  mangled  and  pulped 
out  of  all  shape  or  recognition  ;  (2)  where  all  the  tendons  are  torn 
through,  especially  if  this  has  happened  at  more  than  one  place,  as  in 
the  fingers  and  in  the  palm  also,  and  where,  with  these  injuries,  there 
is  much  opening  of  the  joints  as  well  as  fracture  of  the  bones  and  ripping 
off  of  the  skin  ;  (3)  where  the  fingers  are  extensively  split  longitudinally  ; 
(4)  another  condition,  which  surgeons  in  large  manufacturing  centres 
are  certain  to  meet  with,  requires  grave  consideration,  i.e.  where  a 
hand  is  flayed,  owing  to  its  having  been  caught  between  rollers  which 
hold,  but  do  not  crush  ;  here,  as  the  patient  draws  back,  the  skin  is 
stripped  off,  like  a  glove,  from  the  WTist.  If,  in  addition,  bones  are 
crushed,  the  palmar  thecae  opened,  amputation,  leaving  part  of  one 
finger,  if  the  thumb  is  intact,  or  through  the  wrist- joint,  should  be 
performed  at  once  ;  and  Billroth  '  advises  this  step  where  the  skin  is 
completely  stripped  off  without  other  injury,  fingers  entirely  deprived 

^  Led.  on  Surg.  Pathology  and  Therapeutics.  Syd.  Soc.  Trans.,  vol.  i,  p.  207. 


72  OPERATIONS  ON  THE  UPPER  EXTREMITY 

of  their  skin  almost  invariably  becoming  gangrenous,  and  the  result 
being  "  under  the  most  favourable  circumstances,  nothing  more  than 
an  unwieldy  cicatrised  stump." 

The  following  case  ^  is  a  good  instance  of  the  above  : 

"  The  hand  of  a  little  boy  was  caught  in  the  rolling  machine  of  a  bakery,  and 
the  skin  divided  at  the  wrist  just  as  cleanly  as  if  it  had  been  done  by  intention,  and 
an  entire  glove  of  the  skin  taken  off.  Wlien  I  saw  it.  it  was  held  on  by  the  tips  of 
the  fingers  only.  There  was  no  injury  other  than  that  described.  I  felt  satisfied 
that  amputation  was  proper  ;  but  the  patient  iasisted  that  he  was  willing  to  take 
the  risk  if  amputation  was  not  performed,  and  I  replaced  the  flap,  and  stitched  it  in 
several  places,  believing  that  it  w'ould  slough.  It  did  slough,  and  he  lost  his  fingers 
up  to  the  knuckles,  and  the  only  part  that  was  saved  was  a  small  portion  of  the 
thumb,  and  the  metacarpal  portion  of  the  hand.  This,  of  course,  was  a  cicatricial 
surface,  which  I  covered  with  grafts,  and  it  finally  healed.  The  boy  can  hold  a  pen 
in  a  little  groove  by  the  side  of  the  thumb,  and  it  is  probable  that  the  remnant  of 
the  hand  will  finallj^  become  useful." 

The  explanation  of  the  certainty  with  which  the  stripped-ofi  skin 
dies  in  these  cases,  and  the  uselessness  of  the  most  careful  stitching, 
lies  in  the  fact  that  not  only  have  the  vessels  passing  from  the  deep 
parts  to  the  skin  been  torn  through,  but  the  skin  itself  has  been  submitted 
to  an  enormous  strain  and  dragging.  In  such  cases  where  it  is  clear 
the  glove-like  skin  must  go,  but  the  deeper  parts  are  uninjured,  an 
attempt  should  be  made  by  skin-grafting,  after  Thiersch's  method 
{see  p.  42),  or  by  pedunculated  flaps  (see  p.  7-4),  to  pro^^de  a  covering 
and  prevent  the  sloughing  of  the  deeper  parts. 

(5)  Skin-grafting  is  especially  to  be  made  use  of  where,  after  an 
injury  to  the  hand,  it  may  be  possible  to  save  one  or  two  fingers  only, 
or.  particularly,  the  thumb  and  index  finger,  by  taking  skin,  if  possible, 
or  a  pedunculated  flap,  from  the  damaged  hand,  the  opposite  arm.  or  the 
abdo.iien.  In  slighter  cases  the  large  grafts  taken  by  Thiersch's  method 
iq.v.)  from  the  arm  will  be  employed.  Dr.  Schreiber-  advises  skin- 
grafting  in  smaller  injuries.  Thus,  if  the  skin  be  torn  away  from  the 
dorsum  of  a  finger,  over-extension  will  follow  when  the  wound  is  healed 
unless  it  is  grafted.  On  the  other  hand,  if  it  be  the  pulp  that  is  torn 
away,  successfid  grafting  will  give  a  rounded,  sensitive,  fleshy  end, 
instead  of  a  thin,  sensitive,  pointed  one.  The  surgeon  must,  of  course, 
prepare  his  patient  for  disappointment.  The  grafts  may  die.  and  the 
injured  part  be  reduced  to  a  claw,  active  movement  largely  disappearing. 
Skin-grafting  may  also  be  made  use  of  later  on  if  one  or  more  fingers 
become  contracted,  and  division  of  the  cicatrix  leaves  a  gaping  wound. 
The  above  remarks  refer  to  skin-grafting  for  small  areas  on  the  fingers, 
and  the  back  of  the  hand  only.  The  case  of  the  palm  and  the  employ- 
ment of  pedunculated  flaps  is  referred  to  later  [see  p.  74). 

In  some  cases  the  method  of  desossement  of  French  surgeons  will 

be  useful  in  supplementing  or  replacing  skin-grafting.     Supposing  that 

in  a  case  of  severe  laceration,  in  which  it  is  determined  to  try  and  save 

the  hand,   one  finger  requires  amputation,   by  turning  out  the  bone. 

removing  the  nail  and  tendons,  some  of  the  soft  parts  thus  left  may  be 

utilised  in  filling    up  any  large  gap    below.     The  incision,  eti  raquette, 

is  made  along  the  dorsum  or  palmar  aspect  according  as  it  is  desired 

that  the  soft  parts  of  the  finger  should  fall  into  place  along  the  back 

or  front  of  the  hand. 

^  Dr.  Gregory,  of  St.  Louis,  U.S.  Trans.  Amtr.  Surg.  Assoc,  vol.  2,  p.  232. 
2  Munch.  Med.  Woch.,  Aug.  19,  1892. 


(ONSEHVATIVE  SURGERY  OF  THE  HAND  73 

Mr.  C.  B.  Keetley,  wliose  iiigeniiity  is  well  known,  made  use  of  the 
soft  parts  in  a  different  way.^ 

A  young  woiuiui  liad  all  the  (ingers  of  the  right  hand  ciiishcd  and  torn,  and  on 
the  ])alinar  surface  burnt,  by  the  hot  I'oller  of  a  machine-rnangle.  "Nearly  every 
inter-phalangeal  joint  was  open  on  the  palmar  as|)oet.  All  the  flexor  tendons  of 
the  middle  and  ring  fingers  were  destroyed.  But  their  dorsal  tendons  were  intact. 
1  therefore  amputated  tlie  ring  finger,  jireserving  all  its  dorsal  soft  struetures.  These 
being  then  brought  round  and  fixed  to  the  previously  refreshed  ])alinar  surface  of 
the  phalanges  and  joints  of  the  middle  finger,  the  extensors  of  the  ring  finger  assumed 
the  duties  of  Hexors  of  the  middle  finger.  The  results,  both  as  regards  appearance 
and  function,  were  surprisingly  good." 

(("))  Injury  to  Joints.  Where  the  tendons  are  uninjured,  or  can  be 
sutured,  where  there  is  no  extensive  comminution  of  bone  or  great 
injury  to  the  skin,  the  finger  will,  of  course,  be  saved.  If  expectant 
treatment  is  adopted,  even  if  the  parts  heal  quickly,  the  surgeon  will 
l)e  fortunate  if  he  manages  to  preserve  for  his  patient  half  the  natural 
iaiiii;e  of  movement  of  the  joints  affected.  And,  to  do  this,  splints — • 
of  perforated  zinc,  not  of  wood  alone — will  have  to  be  frequently  changed, 
the  part  being  put  up  for  a  short  time,  flexed,  then  extended,  massage 
assiduously  employed,  &c. 

Probably  excision  of  a  joint  which  has  been  freely  opened  will  restore 
better  movement  if  the  patient  is  brave  and  persevering.  It  should 
certainly  be  tried — and  removal  of  the  bones  carried  out  sufficiently 
widely  to  prevent  ankylosis — in  the  case  of  the  joints  of  the  thumb 
{see  p.  68). 

(7)  Injury  to  Tendons.     This  is  fully  considered  at  p.  93. 

(8)  To  sum  up  the  chief  points  :  Primary  amputations,  especially 
what  may  be  called  formal  operations,  are  only  to  be  made  use  of  under 
the  very  rarest  circumstances  ;  any  surgeon  who  makes  use  of  them 
will  almost  always  find  that  he  has  overstepped  what  was  absolutely 
needful.  The  part  should  be  thoroughly  cleansed  (with  the  aid  of  an 
anaesthetic)  by  means  of  turpentine  and  soap,  with  a  sterilised  nail-brush 
and  lotion,  these  solutions,  if  necessary,  being  used  continuously  in  an 
arm-bath. 

A  word  of  warning  may  not  be  out  of  place  here.  In  his  desire  to 
obtain  asepsis  the  surgeon  should  remember  possible  effects  of  over- 
strong,  irritating  chemicals,  such  as  formalin,  carbolic  acid,  &c.  The 
vitality  of  the  soft  parts  is  much  lowered,  and  in  the  case  of  the  fingers, 
they  are,  on  three  aspects,  thin  and  easily  compressed  against  closely 
adjacent  bones.  The  hopelessly  damaged  soft  parts  should  be  trimmed 
and  drainage  provided.  It  is  only  by  great  care  here  that  the  surgeon 
is  justified  in  submitting  his  patient,  during  the  attempt  to  save  a 
mangled  part,  to  the  danger  of  infection,  gangrene,  tetanus,  &c.  If 
there  is  any  doubt  as  to  the  completeness  of  the  cleansing,  the  part 
should  be  kept  in  an  arm-bath  with  a  weak  aseptic  lotion  constantly 
renewed.  But  it  is  always  advisable  to  get  the  wound  sweet  and  safe 
under  a  boracic  acid  fomentation  and  at  rest  as  soon  as  possible.  If 
any  part  must  be  amputated,  a  flap  of  skin  or  tendon  that  may  be 
useful  is  to  be  transferred  to  the  parts  that  are  being  saved.  So,  too, 
later  on,  if  a  surface  is  left,  which  by  cicatrising  slowly  will  lead  to 
distortion,  or  if  tendons  exposed  have  fibrillated  and  died,  an  attempt 
must  be  made  to  cover  the  one  by  flaps  taken  close  by  or  from  a  distance, 
and   replace   the   other   by   distance-sutures   {see   p.    100).     Secondary 

1  Lancet,  March  4.  1905. 


74 


OPERATIONS  ON  THE  UPPER  EXTREMITY 


operations  will  also  include  removal  of  any  painful  stumps,  especially 
those  which  interfere  with  the  approximation  of  the  thumb  to  another 
finger. 

Fig.  23  is  an  excellent  instance  of  what  may  be  effected  by  conserva- 
tive surgery  of  the  hand.     It  represents  the  remains  of  a  hand,  consisting 

of  the  thumb,  stump  of  the 
index,  and  of  the  Httle  finger, 
and  also  shows  of  how  much 
flexion  the  shortened  index  is 
still  capable.^ 

Value  of  Pedunculated 
Flaps  in  Injuries  of  the  Hand. 
This  method,  which  we  owe 
to  Dr.  Fenger,  is  described 
in  a  lucid  article  by  Dr. 
Schroeder,  of  Chicago.  It  is 
pointed  out  that  Thiersch's 
method  does  not  give  either 
the  elasticity  or  resistance 
which  are  especially  needed  in 
the  palm  ;  the  resulting  scar 
is  also  prone  to  break  down. 
It  may,  however,  be  usefully 
employed  on  the  dorsum. 

Dr.  Schroeder's  patient  was  aged  30,  the  right  hand,  contracted  into  a  fist,  had 
been  left  untreated  since  a  burn  in  infancy.  Its  functions  were  ahnost  entirely  lost 
(Fig.  24).  The  hand  and  right  liip  were  most  carefully  prepared  for  two  days.  The 
operations  were  six  in  number. 

First  Operation.  The  cicatricial  tissue  was  dissected  off  the  palm,  fingers,  and 
thumb.  This  left  a  wound  extending  from  the  carpo-metacarpal  Joints  to  the  distal 
phalanges  (Fig.  25).  The  deformity  of  the  thumb  was  corrected,  but  the  new  position 
was  maintained  with  difficulty.  The  first  finger  was  still  flexed  by  the  shortened 
anterior  ligament  of  the  first  interphalangeal  joint,  which  was  ruptured  in  extending 
the  finger.  The  hand  was  now  placed  upon  the  hip  and  incisions  made  in  the  skin 
as  guides.  The  upper  flap  was  made  wide  enough  to  cover  the  denuded  space  above 
the  first  row  of  digital  furrows,  having  an  anterior  and  posterior  pedicle,  the  distal 
end  of  the  thumb  passing  out  through  the  posterior  pedicle  (Fig.  26).     The  anterior 


Fig.  28. 


Fig.  24. 


flap  passed  over  to  the  crest  of  the  ilium.  The  hand  was  now  placed  under  this  flap,  the 
fingers  separated,  and  incisions  made  opposite  the  middle  of  the  distal  phalanx  of 
each  as  guides.  The  hand  was  again  removed  and  the  pockets  made,  one  for  each 
finger,  leaving  attachments  between  the  fingers  for  nourishment  and  better  immo- 
bilisation of  the  fingers. 

^  The  figure  is  taken  from  a  paper  on  Railway  Injuries  by  Dr.  Thomson,  of  Kentucky. 
Trans.  Amer.  Surg.  Assoc,  vol.  ii,  p.  190. 


CONSKin'A'I'IVE  SI  KGERY  OF  THE  HAND  75 

The  hand  was  now  plated  in  position  and  the  upper  and  lower  Haps  united,  as 
well  as  the  lower  border  of  the  lower  Hap  to  the  fingers,  and  the  upper  border  of  the 


Fig.  25. 

upper  flap  to  the  edge  of  the  skin  of  the  wrist.      There  are  several  important  pre- 
cautions to  be  taken  in  this  step,  namely  : 

(1)  Xot  more  than  a  quarter  of  an  inch  of  subcutaneous  tissue  must  be  taken, 
because  a  thicker  flap  is  clumsy  and  more  difficult  to  unite  to  the  skin  of  the  hand. 


Fig.  26. 


However,  if  more  is  taken  it  will  be  absorbed  in  time.     Some  subcutaneous  tissue 
must  be  attached,  or  the  vitality  of  the  flap  is  endangered.     (2)  There  must  be  no 


70 


OPERATIONS  ON  THE  ITPPER  EXTREMITY 


tension  on  the  jjedieles.     (3)  The  edges  of  the  skin  of  the  hand  must  he  luiderniined 
for  at  least  a  quarter  of  an  inch,  so  as  to  allow  of  easy  approximation. 

Sterile  gauze  was  ])laced  at  the  back  of  the  hand,  and  gauze  drains  hehind  the 


Fig.  27. 


fingers.  A  large  dressing  was  placed  over  the  hand  and  retained  by  adhesive  straps. 
A  plaster  case  was  next  applied,  extending  from  the  shoulder  to  the  glut«o-femoral 
fold.     At  the  end  of  three  days  a  trap-door  was  (Fig.  27)  cut  in  the  case  and  the 


Fig.  28. 


dressings  changed.     Boric  acid  solution  was  the  strongest  antiseptic  used  in  these 
dressings.     The  wound  was  dressed  every  third  day. 

Second  Operation.     This,  performed  on  the  eighth  day,  consisted  in  dividing  the 
inner  pedicle  to  where  the  thumb  protruded.     Part  of  this  pedicle  was  united  to  its 


CONSERVATn  K  SUlUiKHV  OK  TIIK  HAND  77 

former  place.  The  flaj)  was  united  to  the  thumb  (Kig.  2.S).  A  new  case  was  applied 
because  of  the  broken  condition  of  the  old  one.      Dressing  as  before. 

Third  Opcrnt'KW.  On  the  sixteenth  day  the  icruainder  of  the  ])osterior  flap 
was  divided  and  the  ila|)  stitched  to  tiic  radial  side  of  hand  and  index  finger.  The 
flap  was  now  nourished  from  the  anterior  pedicle  and  interdigital  septa  and  the  new 
adhesion  formed. 

Fourth  Operation.  On  the  1  wenty -second  day  the  inner  ])edicle  was  divided  and 
stitched  to  the  ulnar  sidl^  of  the  i)alm  and  little  linger.  The  interdigital  septa 
were  divided,  and  the  hand  thus  liberated.  At  this  time  the  granulating  wound  on 
the  hip  was  curetted,  ])artly  closed  l)y  undermining  the  skin  around  it,  and  then 
grafted. 

Fifth  Operation.  On  the  twenty-seventh  day  the  bridges  of  tlap  between  the 
index  and  second  and  between  the  little  and  ring  fingers  were  divided  and  sutured 
to  their  respective  edges  of  the  finger. 

!^i.rth  Operation.  On  the  thirty-second  day  the  bi-idge  between  the  second  and 
ring  flnger  was  divided,  and  the  parts  sutured  as  before. 


Fig.  29. 


Whenever  an  edge  of  flap  was  united  to  the  edge  of  normal  skin,  it  was  necessary 
to  dissect  back  the  skin,  freshen  the  edges  and  bevel  those  of  the  flap  below,  so  that 
good  coaptation  would  be  possible  and  primary  union  assured.  Dr.  Schroeder 
with  great  candour  states  that  it  was  not  possible  in  any  of  his  cases  to  avoid  infection 
absolutely,  but  by  frequent  dressings  and  proper  drainage  this  did  not  interfere 
with  a  good  result.  In  this  case  the  joint  opened  in  the  index  finger  became  anky- 
losed.  The  usefulness  of  the  hand  was  very  much  improved,  the  patient,  three 
months  after  the  operation  (Fig.  29),  was  able  to  partially  flex  and  extend  the  fingers. 
Three  other  cases  are  given.  In  one,  also  resulting  from  a  burn,  a  useful  hand  was 
obtained.  The  remaining  two  were  due  to  injury.  In  one,  where  the  hand  had  been 
caught  between  rollers,  the  greater  part  of  the  skin  on  the  palm  and  dorsum  were  torn 
away  and  the  flexor  tendons  freely  exposed  in  the  palm.  A  single  flap  was  taken  from 
the  hip  and  its  free  edge  united  to  the  radial  side  of  the  thumb  and  upper  and  lower 
edge  of  the  palm.  A  most  satisfactory  result  followed.  In  the  last  case,  after  an 
attempt  to  save  a  very  badly  crushed  hand  had  failed,  the  fingers  and  most  of  the 
skin  on  the  palm  and  dorsum  ched  ;  the  stump  was  grafted  from  the  hip.  After 
several  weeks  the  pedicle  was  lengthened,  cut  low  down,  and  the  flap  turned  up  on 
the  dorsum  and  sutured.  The  result  was  good,  giving  the  patient  a  stump  against 
which  the  thumb  could  be  pressed. 


78  OPERATIONS  ON  THE  UPPER  EXTREMITY 

REUNION  OF  SEVERED  DIGITS 

The  question  wiW  sometimes  arise  as  to  the  advisabiUtv  of  attempting 
to  reunite  severed  portions  of  thumb  or  fingers.'  Many  such  successful 
cases  have  occurred,  and  the  surgeon  may  well  make  the  attempt,  when 
the  parts  are  cleanly  severed,  through  a  phalanx,  especially  the  distal 
one,  and  when  the  patient  is  young  and  healthy  ;  when  the  cut  has 
passed  through  a  joint,  not  through  a  phalanx,  the  outlook  is  far  less 
promising.     The  following  are  instances  of  the  paits  severed  : 

The  first,  second,  and  third  fingers  cut  off  above  a  diagonal  hne  beginning  in  the 
middle  phalanx  of  the  index  finger  and  ending  in  the  last  phalanx  of  the  third  finger 
near  the  root  of  the  nail.  The  parts  had  been  l^ing  in  the  snow  for  some  time  and 
were  kept  for  two  or  three  hours  before  being  applied.  In  other  cases  the  part  has 
been  severed  longitudinally,  containing  in  it  a  portion  of  bone  split  off.  The  time 
between  the  injury  and  the  treatment  has  varied  from  twenty  minutes  to  tliree  or 
four  hours,  and  the  severed  part  has  been  picked  out  of  sawdust,  brought  up  in 
dirty  paper,  whilst  in  a  third  the  patient  was  sent  back  to  find  it  in  the  field  in 
which  he  had  been  reaping. 

When  there  is  the  least  shred  of  soft  parts  left  holding  on  the 
severed  bit,-  even  a  bad  compound  fracture  of  the  finger  with  severe 
laceration  of  the  soft  parts  may  be  saved. 

The  age  and  condition  of  the  patient,  the  time  which  has  elapsed 
since  the  injury,  the  part  aft'ected,  i.e.  whether  the  index  finger  or  the 
thumb,  must  all  be  considered.  And.  in  any  case,  the  patient  should 
be  warned  that,  though  the  attempt  may  succeed,  the  parts  unite,  and 
sensation  be  restored,  the  result  may  be  a  stiff  and,  therefore,  com- 
paratively useless  member  ;  indeed,  on  this  account,  amputation  may 
eventually  be  required. 

If  it  be  decided  to  make  the  attempt,  the  part  should  be  carefully 
cleansed  with  soap  and  water,  antiseptics  being  used  with  caution  ; 
it  is  then  united  exactly  with  a  few  salmon-gut  or  horsehair  sutures, 
enveloped  in  aseptic  wool,  and  kept  in  situ  ^^^th  carefully  adjusted 
splints  of  perforated  zinc.  The  dressings  should  not  be  disturbed  for 
at  least  three  days  if  possible. 

SUPERNUMERARY  DIGITS  (POLYDACTYLISM) 

This  congenital  deformity  is  sufficiently  common  and  important  to 
require  a  brief  notice.  The  condition  is  usually  symmetrical,  and  there 
may  be  one  or  several  additional  digits.  The  chief  point  of  importance, 
from  a  practical  point  of  view,  is  the  mode  of  j  miction  of  the  super- 
numerary digits.  This,  consisting  of  two  or  three  phalanges,  may  be 
joined  by  mere  fibrous  tissue  ;  in  other  cases  there  may  be  a  complete 
articulation  between  it  and  the  side  of  an  adjacent  metacarpal  bone, 
or  the  carpus,  a  metacarpal  bone  being  usually  present,  in  addition  to 
the  phalanges,  in  the  latter  case.  Lastly,  the  allied  condition  of 
supernumerary  phalanx  may  be  present  in  cases  where  the  terminal 
phalanx  of  a  thumb  or  finger  is  bifid. 

Treatment.  This  consists  of  amputation,  as  early  as  possible,  with 
strict  aseptic  precautions,  so  as  to  secure  primary  union  and  a  perfect 
scar  in  a  part  where  a  deformity  is  so  noticeable,  and  also  to  prevent 
the  risks  of  infection  when  a  joint  is  opened.  In  each  case  the  finger 
is  removed  by  an  elliptical  incision,  the  flaps  being  cut  so  as  to  meet 
exactly  ;    where  the  union  is  fibrous,  this  is  all  that  is  required.     But 


COXSKRVATIVP:  surgery  of  the  hand  79 

where  an  articular  surface  is  present,  this  must  be  exposed  after  dis- 
articulation of  the  finger,  and  sufficient  of  the  joint  chiselled  or  cut 
away  with  strong  scissors  so  as  to  leave  the  surface  of  the  bone  plane 
and  uniform  ;  otherwise  growth  will  continue  at  this  spot  up  to  adult 
age,  and  a  very  unsightly  deformity  may  be  produced.  When  the 
articulation  is  with  the  carpus,  additional  care  is  required  in  carrying 
out  the  above  steps. 

In  the  case  of  a  bifid  phalanx  the  treatment  involves  more  trouble 
on  the  part  of  both  surgeon  and  patient  or  the  friends,  if  the  result  is 
to  be  satisfactory.  That  portion  of  the  phalanx  which  is  the  largest, 
which  diverges  least  from  the  straight  line,  and  which  carries  the  best- 
developed  nail  (if  these  three  points  coincide)  is  to  be  preserved,  and  the 
other  one  removed.  In  carrying  out  this  step,  if  the  phalanx  be  not 
completely  bifid,  it  should  be  spilt  down  through  its  base  with  a  chisel, 
bone-forceps,  or  strong  scissors,  and  the  part  to  be  removed  taken 
away.  Any  ligaments — i.e.  the  lateral  on  the  opposite  side — or  struc- 
tures which  will  prevent  the  part  left  from  being  brought  into  the  straight 
line  should  be  divided.  As  soon  as  the  wound  is  healed,  careful  move- 
ments of  the  joints  and  bringing  the  phalanx  into  the  straight  fine  must  be 
practised  every  few  days,  and  a  metal  splint  worn  with  a  collar  round  the 
wrist,  \\ith  a  lateral  prolongation  coming  up  along  the  affected  finger 
or  thumb  on  the  side  away  from  that  to  which  the  phalanx  projects, 
this  prolongation  admitting  of  being  bent  outwards  to  any  needful 
extent  ;  by  this  means  the  phalanx,  which  is  at  fault,  can  be  drawn 
straight.  But  persevering  daily  treatment  for  four  or  six  months  will 
be  required. 

WEBBED  FINGERS  (SYNDACTYLISM) 

(Figs.  30,  31,  and  32) 

These  should  always  be  remedied  in  early  childhood  ;  if  left  un- 
touched, the  fingers  may  be  useful,  but  the  annoyance  of  the  deformity 
will  be  serious.  The  surgeon  should  not  yield  to  pressure  put  on  him 
to  operate  in  early  infancy.  Simple  di\"ision  of  the  web — a  trifling 
operation — is  out  of  the  question  ovsing  to  the  inevitable  recurrence 
of  the  deformity.  On  the  other  hand,  especially  if  extensive  dissections 
are  made  in  raising  flaps,  the  loss  of  blood  ^411  be  considerable,  and  not 
without  risk  both  as  to  the  \ntality  of  the  flaps  and  of  the  infant  itself. 
Xo  operation  should  be  undertaken  before  the  child  is  at  least  three 
years  old  ;  in  cases  where  the  union  is  very  close,  it  is  preferable  to 
wait  till  the  age  of  four.  Where  several  fingers  are  united,  quite  a 
month  should  elapse  between  the  operations  on  the  first  and  second 
pairs. 

The  treatment  will  depend  upon  the  condition  and  extent  of  the 
web.  In  the  slighter  cases  there  is  merely  an  increase  downwards  for 
some  distance  of  the  normal  web  ;  there  is  then  an  objectionable  deformity 
rather  than  any  actual  disability.  In  the  more  serious  cases  the  fingers 
may  be  joined  down  to  the  terminal  phalanx.  The  web  may  then  be 
lax  and  free  (Fig.  30).  or  close  and  thick  (Fig.  32),  or  two  fingers  may  be 
more  or  less  completely  joined  by  bony  union  of  phalanges. 

(1)  The  simpler  methods,  \'iz.  wearing  a  piece  of  thick  silver  wire 
or  fine  drainage  tubing  through  a  hole  made  through  the  base  of  the 
web  where  the  cleft  should  begin  ("  ear-ring  "  perforation),  may  first 


80 


OPERATIONS  ON  THE  UPPER  EXTREMITY 


Fig.  30.     Agnew's  operation  for  webbed  fingers.     The 

flap   is  dorsal,   large,    and  single.    (Keen   and   White  : 

American  Text-hook  of  Surgery.) 


be  tried.  The  tubing,  which  has  the  advantage  of  interfering  less  with 
the  movements  of  the  hand,  may  be  attached  to  a  band  round  the  wrist ; 
the  wire  may  be  twisted  in  a  loop  round  an  adjacent  finger. 

When  the  perforation 
is  soundly  cicatrised — 
i.e.  in  about  three  or 
four  weeks  —  the  web 
should  be  slit  up,  each 
half  split,  dissected  up 
for  a  little  way,  and  the 
edges  of  the  two  flaps 
thus  formed  united  with 
a  few  points  of  sterilised 
horsehair.  The  greatest 
care  must  be  taken  to 
secure  primary  union,  for 
otherwise  granulation  and 
cicatrisation  will  inevit- 
ably lead  to  contraction 
and  displacement  of  the 
finger.  The  fingers  should  be  kept  apart  by  a  layer  of  gauze  through- 
out the  healing.  This  method  has  the  disadvantage  of  being  tedious, 
and  the  formation  of  epidermis  round  the  foreign  body  is  liable  to  be 
incomplete. 

(2)  If  the  above  fail,  one  of  the  following  plastic  operations  should 
be  made  use  of  : 

Agnew's  or  Norton's  ^  (Figs.  30  and  31).  These  can  only  be  carried 
out  in  cases  where  the  web  is  ample.  In  Norton's  operation  (Fig.  31), 
small  triangular  flaps  are  raised  on  the  dorsal  and  palmar  aspects  of 
the  base  of  the  web  which  is  cut  then  through  and  the  flaps  very  care- 
fully stitched  together  without  tension. 
The  object  is  to  ensure  rapid  union  in  the 
upper  end  of  the  cleft,  and  thus  no  re- 
development of  the  web.  Agnew's  opera- 
tion employs  a  single  larger  flap  (Fig.  30) 
raised  from  the  dorsum.  The  flap  should 
be  thick  enough  to  avoid  risk  of  slough- 
ing, and  somewhat  narrow  to  avoid 
bulging.  To  prevent  tension  it  should  be 
sufiiciently  long,  its  base  being  at  the  level 
of  the  metacarpo-phalangeal  joints,  and  its 
apex,  which  should  be  rounded,  almost 
reaching  to  the  base  of  the  second  pha- 
langes. The  apex  is  sutured  to  the  palmar 
edge  of  the  cleft,  and  its  sides  to  the  skin 
at  the  edge  of  the  wound.  Any  re- 
dundant tissue  between  the  knuckles 
that  prevents  their  coming  together 
should  be  cut  away.  The  remaining  web 
is  then  split  and  treated  as  above 
described.     The  line  of  the  natural  web  should  be  carefully  preserved. 


Fig.  31.       Norton's  operation   for 

webbed     fingers.      The    flaps     are 

small  and  double. 


i  On  the  Continent  this  operation  goes  by  the  name  of  Morel -Lavallee. 


CONSERVATIVE  SURGERY  OF  THE  HAND 


81 


Didot's  (Fig.  32).  This  operation  was  introduced  for  those  cases 
in  which  the  web  is  very  narrow.  Two  narrow  longitudinal  flaps  are 
dissected  up  as  thick  as  possible  from  the  palmar  and  dorsal  aspects 
of  the  afTected  fingers  by  two  incisions,  one  along  the  middle  line  of  the 
dorsum  of  one  finger  and  another  along  the  mid-line  of  the  palmar 
surface  of  the  other,  from  a  point  opposite  to  the  extremity  of  the  web 
to  the  knuckle.  By  short  transverse  incisions  at  each  end  of  the  vertical 
ones  (Fig.  32),  the  two  flaps  are  marked  out.  These  are  most  carefully 
raised  {see  below),  and  each  flap  is  then  folded  round  to  cover  the  raw 
surface  of  the  finger  to  which  it  is  attached,  and  secured  with  a  few 
interrupted  sutures  of  fine  silkworm-gut  or  horsehair. 

Didot's,  like  many  French  operations,  is  most  ingenious  and,  on 
paper,  it  looks  an  excellent  one.  But,  in  practice,  the  following  objec- 
tions will  present  themselves:  (1)  It 
is  a  severe  operation,  especially  in 
little  children.  (2)  It  is  not  easy  to 
raise  satisfactory  flaps  in  parts  so  small 
and  with  skin  so  little  developed.  Thus, 
if  the  flaps  are  too  thick  it  is  easy  to 
injure  the  extensor  tendons  or  digital 
nerves  or  vessels  ;  on  the  other  hand,  if 
the  flaps  are  too  thin  they  slough,  and 
infection  then  readily  occurs.  (3)  The 
flaps  are  nearly  always  insufficient  to 
cover  the  denuded  surfaces  unless  they 
are  submitted  to  such  tension  as  may 
lead  to  sloughing.  Thus  in  part  the 
wounds  must  heal  by  granulation,  which 
may  lead  to  harmful  contracting  scars, 
or  by  the  aid  of  skin-grafting,  which  is 
liable  to  be  rendered  futile  by  the  rest- 
lessness of  the  patient.  (4)  Consider- 
able difficulty  will  be  met  with  in  fitting 
neatly  the    quadrangular    edges    of  the 

flaps  at  the  roots  of  the  fingers  so  as  satisfactorily  to  re-establish  the 
normal  web. 

For  the  above  reasons  the  method  of  operating  by  a  triangular  flap 
is  preferable  (Figs.  30  and  31)  wherever  the  web  is  loose  enough  to 
render  this  feasible. 

Mr.  Bidwell,  in  one  case,^  combined  the  methods  of  a  flap  from  the 
web  with  one  from  the  dorsum  of  one  finger  and  skin-grafting. 

In  those  rare  cases  where  the  union  is  bony,  the  choice  lies  between 
(a)  lea\dng  things  as  they  are  or  (6)  remo\dng  the  bone  of  one  of  the 
united  fingers  after  exposing  this  adequately  by  two  rectangular  flaps, 
dorsal  and  palmar.  Separation  of  the  fingers  is  not  practicable,  for 
there  is  no  possibility  of  obtaining  skin  flaps  to  cover  the  raw  surface. 
Such  an  attempt  is  almost  certain  to  result  in  two  deformed  and  useless 
fingers,  which  will  probably  require  amputation. 

After  all  operations  on  webbed  fingers,  especially  the  one  introduced 
by  Didot,  there  is  more  or  less  tendency  for  the  fingers  to  become  stiffly 
flexed  or  extended,  according  as  any  excess  of  scar  has  formed  on  the 
palmar  oj-  dorsal  surface.     Thus  it  is  very  common  for  the  finger  which 

1  Lancet,  June  29,  1895. 
SURGERY   I  6 


Fig.  32.     Didot's  operation  for 
webbed  fingers.     (Reeves.) 


82         OPERATIONS  ON  THE  UPPER  EXTREMITY 

has  the  dorsal  flap,  and  in  which  the  cicatrix  lies  along  the  palmar 
surface,  to  become  flexed.  This  tendency  must  be  met  by  persevering 
use  of  a  splint,  one  similar  to  that  mentioned  at  p.  J^3  being  applied 
to  the  dorsal  or  palmar  surface  of  the  finger  as  required.  At  first  it 
must  be  worn  day  and  night,  and  then  removed  for  varying  periods 
in  the  day  to  admit  of  active  and  passive  movements  being  assiduously 
practised.  It  -^ill  require  to  be  worn  at  night  for  many  months.  In  a 
few  cases  of  this  deformity  a  pedunculated  flap  taken  from  the  dorsum 
will  provide  the  most  extensive  and  mobile  skin  in  the  position  of  the 
web. 

CONTRACTED    PALMAR    FASCIA    (DUPUYTREN  S    CONTRACTION) 
AND  OTHER  CONTRACTIONS  OF  THE  FINGERS 

(Figs.  33,  34) 

Dupuytren's  contraction  of  the  palmar  fascia  is  usually  met  %\ith 
in  middle-aged  men.  Though  it  often  appears  to  be  due  to  continued 
slight  irritation  or  injury,  such,  for  example,  as  is  caused  by  the  frequent 
use  of  some  tool  or  instrument,  it  is  undoubtedly  in  many  cases  associated 
with  a  tendency  to  gout.  The  palmar  fascia  is  triangular  in  shape  ;  the 
apex  is  attached  to  the  anterior  annular  ligament,  while  below  it  ter- 
minates in  four  processes  to  the  four  inner  fingers.  Each  digital  process 
consists  of  a  central  portion  which  joins  the  theca  and  two  lateral 
processes  which  are  attached  to  the  skin  of  the  web,  the  capsule  of  the 
metacarpo-phalangeal  joint,  and  the  side  of  the  first  phalanx.  The 
contraction  takes  place  especially  in  the  processes  going  to  the  two 
inner  fingers.  Commencing  about  the  transverse  palmar  creases,  it 
steadily  and  progressively  cripples  the  hand  by  drawing  down  the 
fingers,  causing  flexion,  first  at  the  metacarpo-phalangeal  and  later 
at  the  first  interphalangeal  joints  (Fig.  33). 

Operation.  This  may  be  either  subcutaneous,  by  multiple  punctures, 
or  open,  the  latter  being  effected  either  by  multiple  transverse  cuts 
through  an  open  longitudinal  incision  or  by  excision  of  the  contracted 
fascia. 

The  Subcutaneous  Method.  The  best  is  Adams'  operation,  in  which 
the  contracted  bands  are  divided  by  multiple  punctures  from  the  surface 
downwards.  The  skin  must  first  be  carefully  prepared  and  cleansed. 
If  thought  desirable,  local  anaesthesia  may  be  employed.  Finding  some 
spot  where  adhesion  of  the  skin  to  the  fascia  has  not  yet  taken  place, 
the  surgeon,  avoiding  the  site  of  the  vessels,  passes  a  fine  small  tenotomy 
knife  between  the  skin  and  fascia,  and  divides  the  band  from  above 
downwards,  taking  care  not  to  dip  the  point  too  freely.  If  too  much 
straightening  is  attempted  at  once,  the  punctures  "svill  gape  A^idely 
and  readily  tear,  especially  where  the  skin  and  fascia  are  adherent. 
In  cases  of  contraction  of  two  fingers,  a  number  of  punctures — e.g.  five 
to  nine— may  be  required.  It  is  usually  easy,  by  operating  on  the 
pahnar  bands,  to  rectify  the  contraction  at  the  metacarpo-phalangeal 
joint.  The  straightening  of  the  contraction  between  the  first  and 
second  phalanges  is  much  more  difficult.  The  digital  prolongations 
of  the  fascia  may  be  divided  by  punctures  in  the  web  between  the 
fingers,  extreme  care  being  taken  to  avoid  the  digital  vessels  and  nerves  by 
not  depressing  the  point,  and  by  keeping  to  the  middle  fine.  But  when 
the  surgeon  finds  some  difficulty  in  correcting  this  contraction  thoroughly, 


DUFUYTREN'S  CONTRACTION 


83 


he  will  act  most  wisely  by  correcting  the  remaining  contraction  gradually 
by  the  use  of  Adams'  finger-splint  with  rack-and-pinion  movements 
opposite  the  metacarpo-phalangeal  and  intorphalangeal  joints.^ 

The  splints,  which  should  be  constructed  of  metal  to  combine  light- 
ness with  rigidity,  should  accurately  ht  the  palm,  and  the  length  and 
breadth  of  each  linger.  They  are  secured  by  broad  strips  of  soft  leather. 
At  intervals  during  the  clay  the  splint  should  be  removed,  and  the  hands 
well  soaked  in  hot  water,  scrubbed  in  this  with  a  nail-brush,  and  the 
patient  assiduously  practise  placing  the  affected  finger-tips  on  a  table, 
and  then  making  pressure  on  the  dorsal  surface  of  the  fingers  with  those 
of  the  other  hand.     The  skin  should  be  most  carefully  cleansed,   and 


Fig.  33. 

an  aseptic  dressing  applied  for  three  or  four  days,  when  the  punctures 
will  be  practically  healed.  The  splint  should  be  worn  day  and  night  at 
first,  carefully  padded  at  all  pressure  points.  Some  weeks  will  be 
required  to  correct  the  interphalangeal  contraction,  and  in  advanced 
cases  relapses  can  only  be  prevented  by  the  persevering  use  of  the 
splint.  In  any  occupation  which  entails  much  grasping,  gloves  padded 
on  the  palmar  surface  should  be  worn.  If  the  surgeon  attempts  to 
straighten  completely  an  advanced  case  of  phalangeal  as  well  as  of  meta- 
carpo-phalangeal contraction,  he  runs  the  risk  (1)  of  dividing  a  digital 
nerve,  which  may  lead  to  most  intolerable  pain ;  (2)  of  damaging  the 
tendons,  for  these  bands  are  often  in  close  relation  with  the  theca  ;  and 
(3)  of  injuring  the  vessels  and  thus  producing  slight  gangrene  of  the 
finger-tips. 

^  Other  splints  will  be  found  figured  by  Mr.  Adams  {Lancet,  1891,  vol.  ii,  p.  166).  If  the 
skin  has  been  much  strained  or  interfered  with,  the  straightening  should  be  deferred 
for  a  few  days. 


84         OPERATIONS  ON  THE  UPPER  EXTREMITY 

The  threefold  association  of  the  palmar^  fascia  with  the  theca,  the 
skin  of  the  web,  and  the  superficial  transverse  ligament  is,  as  the  result 
of  the  disease,  rendered  more  intimate  than  ever. 

To  guard  against  a  relapse  the  patient  should,  regularly  and  methodi- 
cally, practise  active  and  passive  movements  of  the  joints,  wear  the 
splint  at  night  for  a  considerable  time,  and  if  any  persistent  or  recurrent 
bands  threaten  to  be  troublesome,  treat  these  by  rubbing  in  oleate  of 
mercury  ointment.  Should  the  patient  be  the  subject  of  gout  or  addicted 
to  alcohol  he  should  be  warned  and  treated  accordingly.  Figs.  33  and 
341  represent  a  right  hand  crippled  by  Dupuytren's  contraction  before 
and  five  years  after  operation.  The  man  was  a  patient  of  Dr.  J.  E.  B. 
Burroughs,  of  Lee,  and  was  operated  on  in  1883,  the  contraction 
of  the  metacarpo-phalangeal  joints  being  straightened  at  once  after 
numerous  punctures  made  in  the  manner  described  above,  while  that 
at  the  interphalangeal  joints  was  remedied  chiefly  by  the  presevering 
use  of  Adams'  splint  already  described.  In  1890  the  fingers  could  be 
completely  extended,  were  perfectly  mobile,  and  free  from  the  shghtest 
tendency  to  contraction.  It  will  be  seen  from  Fig.  33b  that  some 
thickening,  puckering,  and  corrugation  of  the  palmar  skin  and  fascia 
still  persists,  but  this  had  now  no  power  of  producing  contraction,  the 
patient,  a  relieving  officer,  being  able  to  write,  &c.,  without  any  hin- 
drance whatever.  But  to  show  the  importance  of  persevering  in  the  after- 
treatment  mentioned  above,  when,  after  another  four  years,  the  patient 
was  again  seen  in  1894,  there  was  some  recurrence  of  the  flexion  of  the 
interphalangeal  joints.  The  above  advice,  which  had  been  insisted  upon, 
had  been  entirely  neglected.  And  this  is  very  often  the  case,  owing 
to  patients  thinking  that  the  operation,  of  itself,  will  accomplish  every- 
thing, and  that  no  responsibility  in  the  after-treatment  rests  with  them. 

Operation  by  Multiple  Transverse  Cuts  through  an  Open  Longitudinal 
Incision.  This  method  has  been  advocated  by  Goyrand,  Kocher,  and 
in  this  country  by  Mr.  Hardie,  of  Manchester,  and  Mr.  Keetley.  It  has 
been  recommended  on  the  ground  that  mere  subcutaneous  division  of 
the  contracted  fascia  cannot  be  sufficient  if  the  thickened,  puckered, 
hardened  skin  is  left  alone,  and  also  that  intimate  adhesion  of  the  altered 
skin  to  the  fascia  is  so  general  that  it  is  difficult,  if  not  impossible,  to  get 
the  knife  between  the  two  at  a  sufficient  number  of  spots  for  adequate 
straightening  by  the  subcutaneous  method.  Keetley,  who  advocates 
this  operation,  thus  describes  the  steps.  "  The  limb  having  been  elevated 
and  an  Esmarch's  bandage  applied,  the  hand  and  forearm,  carefully 
sterilised,  are  held  extended  and  supinated  on  a  sterilised  towel  on  a 
mall  table  beside  the  operating  table,  with  the  fingers  as  much  extended 
and  separated  as  possible.  A  longitudinal  incision  is  made  through 
the  skin  and  into  the  contracted  fascia.  If  the  finger  is  much  contracted, 
this  incision  can  only  be  completed  by  degrees,  as  the  division  of  the 
bands  gradually  permits  the  unfolding  of  the  fingers.  The  extent  and 
degree  of  the  contracted  fascia  are  now  easily  seen,  and  it  should  be 
divided  transversely  and  completely  in  many  "places  until  all  resistance 
is  removed,  and  nothing  but  shortening  of  the  ligaments  and  structures 
around  the  joints  remains.  This  should  be  left  to  be  overcome  by  after- 
treatment.     Here  and  there  the  skin  itself  may  have  to  be  freed  by  a 

1  The  asterisks  in  Fig.  34  show  spots  where  the  tenotomy  knife  might  be  introduced 
in  contraction  of  the  palmar  fascia  slip  going  to  the  ring  finger.  The  contracted  band 
thus  isolated  by  the  punctures  gradually  atrophies. 


DUPUYTREN'S  CONTllACTION  85 

touch  of  the  knife.  The  skin  incision  is  closed  by  silkworni-^ut  sutures 
placed  close  to  the  edges  of  the  wound.  If  the  above  directions  are 
strictly  followed,  merely  a  linear  cicatrix  will  remain,  such  as  contrasts 
favourably  with  what  has  been  reportcnl  as  the  ultimate  state  of  things 
aftei'  excision  of  the  conti'acted  fascia." 

Excision  of  the  Contracted  Bands  oJ  Fascia,  (a)  Bij  Rectanyular  Flaps. 
The  skin  having  been,  for  two  days  at  least,  softened  by  the  frequent 
use  of  soft  soap  and  hot  water  and  the  inunction  of  lanoline,  and  care- 
fully sterilised,  a  longitudinal  incision  is  made  over  the  contracted  band 
from  its  upper  to  its  lower  limit,  and  then  small  transverse  incisions 
are  made  at  each  end  of  this,  so  that  two  small  rectangular  flaps  may 
be  dissected  up.  A  twofold  difficulty  at  once  presents  itself  :  the 
skin  is  usually  so  adherent  in  places  that  the  satisfactory  making  of  these 
flaps  is  by  no  means  easy,  a  difficulty  much  increased  by  the  flexed 
position  of  the  finger.  A  hard  band  of  horny  adherent  skin  may  be 
removed  by  a  narrow  elliptical  incision.  The  contracted  fascia,  when 
exposed,  is  dissected  out,  and  the  flaps  united  with  silkworm  gut  or 
horsehair.  The  second  difficulty  is  now  met  with  owing  to  the  con- 
traction and  adhesion  of  the  skin  which  has  to  be  united.  Where  union 
is  impossible,  skin-grafting  ^  ought  to  be  employed  ;  any  surface  left 
to  granulate  means  more  or  less  recurrence  of  the  trouble. 

(b)  Bij  a  Y-shaped  incisioyi  (Fig.  34).  The  base  of  the  V  is  opposite 
to,  a  little  above,  and  overlapping  the  root  of  the  affected  finger  ;  the 
apex  is  situated  in  a  line  with  the  centre  of  the  same  finger,  in  the  palm, 
about  on  a  level  with  the  transverse  crease.  Two  diverging  incisions 
join  these  points,  and  are  carried  down  through  the  skin  and  fascia. 
The  latter  may  be  divided  completely  or  removed  entirely  when  the 
finger  can  be  straightened.  This  leaves  a  gaping  triangular  wound  in 
the  palm  with  its  apex  upwards.  Theoretically  this  should  be  united 
by  careful  stitching  in  the  form  of  a  Y.  But  the  contracted  state  of 
the  skin  almost  always  prevents  accurate  stitching,  and  leads  to  some 
gaping  of  the  wound,  and  a  raw  surface  which  may  require  grafting. 

For  the  severest  cases  Sir  W.  Watson  Cheyne  and  Mr.  Burghard^  re- 
commend a  combination  of  the  subcutaneous  method  and  the  V-shaped 
incision.  "  In  very  advanced  cases,  where  the  fingers  are  tightly  bound 
down  to  the  palm,  removal  of  the  fascia  by  dissection  cannot  be  per- 
formed, because  it  is  impossible,  on  account  of  the  contraction  of  the 
fingers,  to  get  proper  access  to  the  palm  so  as  to  make  the  requisite 
incisions.  Under  these  circumstances  the  best  treatment  is  to  divide  the 
fascia  in  the  first  instance,  and  to  get  the  finger  as  straight  as  possible  by 
this  means.  As  a  rule,  however,  division  of  the  fascia  will  not  allow  the 
finger  to  come  quite  straight,  because  the  skin  itself  is  contracted,  and 
therefore  the  result  is  incomplete.  The  operation  by  the  V-shaped 
incision  may  be  very  usefully  combined  with  tenotomy  so  as  to  compel 
the  straightening  of  the  fingers.  The  two  operations  should,  however, 
be  done  at  different  times.     The  result  of  the  tenotomy  is  to  endanger 

I  Skin-grafting  has  been  somewhat  hghtly  recommended  in  these  cases  as  too  certain 
to  complete  the  healing.  The  following  cautions  may  be  emphasised:  (a)  Any 
unhealed  surface  remaining  after  an  open  operation  for  contracted  palmar  fascia  is  far 
from  being  an  ideal  one  for  skin-grafting,  like  the  smooth,  level,  regular  surface  of  a  large 
ulcer  :  (6)  When  the  surface  to  be  grafted  is  of  any  extent,  and  the  hand  one  much  em- 
ployed in  manual  labour,  the  grafts  may  not  afford  a  permanent  protection.  Plastic 
operations  are  out  of  question  in  these  patients,  both  from  a  local  and  a  more  general 
point  of  view.  2  Manual  of  Surgical  Treatment,  vol.  i,  p.  291. 


86 


OPERATIONS  ON  THE  UPPER  EXTREMITY 


the  vitality  of  the  skin  at  various  points  ;  this,  however,  very  rarely 
sloughs,  unless  too  great  a  pressure  be  brought  to  bear  upon  it.  Hence 
a  sufficient  time  must  be  allowed  to  elapse  between  the  tenotomy  and 
the  open  operation  to  allow  these  damaged  portions  of  skin  to  recover, 
and  during  this  time  the  fingers  should  be  kept  somewhat  extended 
on  a  splint ;  three  weeks'  interval  is  usually  enough."  Before  per- 
forming any  operation  the  surgeon  should  remember  that  there  is  a 
considerable  likelihood  of  subsequent  cicatricial  contraction.  Another 
possible  troublesome  sequela  is  pain  and  tenderness  in  the  region  of  the 


Fig.  34. 


scar.  Total  removal  of  the  contracted  fascia  necessarily  takes  away 
its  capacity  for  protecting  the  underlying  nerves. 

In  less  severe  cases,  where  the  metacarpo-phalangeal  joint  is  not 
flexed  to  more  than  a  right  angle,  the  method  of  multiple  subcutaneous 
punctures  should  be  adopted.  Nowadays,  with  all  the  advantages 
of  modern  surgery,  there  is  no  excuse  for  the  patients  not  coming  for 
treatment  early.  In  those  cases,  and  these  ought  to  be  exceptional, 
where  the  induration  is  more  widespread  and  denser,  a  longitudinal 
incision  and  multiple  transverse  section  of  the  bands,  or  their  total 
removal,  should  be  employed.  The  treatment  of  the  most  severe  cases 
has  been  described  above.  In  answer  to  the  objection  that  the  simpler 
method  is  liable  to  be  followed  by  relapses,  this  must  be  admitted,  but 
a  relapse  may  also  follow  other  and  more  radical  steps.  And  where 
relapses  do  follow,  they  are  fiequently  due  to  the  patients  either  not 
being  duly  warned,  or  to  their  neglecting  the  warning  that  the  treat- 
ment may  require  repetition,  and  that,  in  any  case,  it  demands 
imperatively  that  much  of  the  responsibility  for  success  lies  with  them 
in  the  after-treatment.  This  entails  patience,  assiduous  attention  to 
the  employment  of_  splints  and  the  needful  manipulations  for  many 
months,  and  the  giving  up  of  alcohol.  Where  these  essentials  are 
attended  to,  relapses  will  be  comparatively  infrequent. 

Those  who  prefer  the  more  recently  advocated  methods  must  remem- 


DUPUYTREN'S  CONTRACTION  87 

ber  the  following  points,  viz.  the  age  and  vitality  of  many  of  these 
patients  ;  the  need  of  thorough  sterilisation  of  the  skin — not  an  easy 
matter  when  the  contraction  of  the  fingers  renders  access  to  all  the 
hollows  and  inequalities  difficult ;  the  oozing  and  possible  need  of  a 
drain  ;  the  fact  that  tlie  puckered  state  of  the  skin  always  makes  accurate 
stitching  difficult,  loading  to  a  "raw  surface  and  the  need  of  grafting, 
of  the  objections  to  which  mention  has  already  been  made,  a  need 
which  is  increased  by  the  tendency  of  the  sutures  which  it  has  been 
possible  to  insert  to  cut  their  way  out  owing  to  the  necessary  tension 
in  places  and  the  diminished  vitality  of  the  skin.  Lastly,  there  is  the 
swelling  of  the  hand  which  may  occur,  especially  in  gouty  patients,  and 
which  interferes  greatly  with  the  use  of  splints. 

CONGENITAL  AND  OTHER  CONTRACTIONS  AND  DEFORMITIES 

OF  THE  FINGERS 

In  addition  to  Dupuytren's  contraction,  there  is  a  somewhat  similar  congenital 
deformity,  occurring  chiefly  in  girls,  in  which  one  tinger,  usually  the  little  one,  is 
flexed  at  the  first  interphalangeal  joint  ;  there  may  also  be  flexion  of  the  second  inter- 
phalangeal  joint,  but  the  first  phalanx  is  hyper-extended  on  the  metacarpal — an 
important  difi'erence  from  Dupuytren's  contraction.  The  condition  may  be  bilateral. 
The  mischief  appears  to  lie  in  a  contraction  of  the  central  slip  of  the  prolongation 
of  the  fascia  to  the  finger  ;  the  fascia  of  the  palm  and  the  lateral  shps  are  not  affected. 
There  is  seldom  any  real  interference  with  the  usefulness  of  the  hand,  advice  being 
sought  on  account  of  the  deformity.  Palliative  treatment  can  only  be  of  avail  in 
early  life,  when  the  small  size  of  the  parts  renders  it  difficult  to  carry  it  out.  If 
operation  be  undertaken,  the  open  method  with  multiple  transverse  incisions  can 
be  easily  made  use  of  as  the  skin  is  not  affected,  and  the  band  is  median,  so  that  the 
digital  vessels  and  nerves  are  not  endangered.  If  the  above  be  insufficient  the 
lateral  ligaments  of  the  flexed  joint  must  be  divided,  and  tendon-lengthening  may  be 
needful  ;  in  the  most  confirmed  cases,  where  ankylosis  is  present,  the  question  of 
excision  or  amputation  will  arise. 

Severe  Contraction  due  to  Injury.  Here  such  steps  as  tendon-lengthening 
(p.  99)  combined  with  a  plastic  operation  may  occasionally  be  employed  with 
Ijenefit. 

Snap  or  Trigger  Finger.  In  this  curious  condition  full  extension,  more 
rarely  flexion,  of  one  finger  is  prevented  and  can  only  be  attained  with  the  help 
of  the  other  hand,  the  finger  being  now  suddenly  flexed  or  extended  with  a  snap 
like  the  closing  of  a  blade  of  a  pocket-knife.  Some  pain  and  tenderness  are  usually 
experienced  near  the  metacarpo-phalangeal  articulation.  The  pathology  is  un- 
certain. In  some  cases  a  thickened  synovial  fringe  has  been  found,  in  others  a 
small  ganglion  is  jaresent,  while  a  large  sesamoid  bone  is  sometimes  the  cause  of  the 
trouble.  The  articular 'surfaces  may  show  the  changes  characteristic  of  osteo- 
arthritis. The  treatment  is  to  explore  and  if  possible  to  remove  any  cause  which 
may  be  found. 

Mallet  Finger.  In  this  deformity  the  terminal  phalanx  is  slightly  flexed  and 
cannot  be  extended.  It  is  usually  the  result  of  an  injury  which  has  either  stretched 
the  extensor  aponeurosis,  or  torn  the  central  slip  from  its  insertion.  If  a  splint  is  not 
successful  a  median  longitudinal  incision  must  be  made,  the  extensor  tendon  is 
identified  and  the  proximal  end  stitched  to  the  periosteum. 

NEEDLES  IN  THE  HAND 

Those  who  are  aware  of  the  difficulties  which  may  accompany 
exploration  here,  and  the  unsatisfactory  results  which  sometimes  follow 
on  this  step,  will  be  familiar  with  the  need  of  having  two  skiagrams, 
one  taken  laterally  and  one  antero-posteriorly.  While  on  this  sub- 
ject two  hints  may  be  given :  one  is  that  the  needle  fragments  may 
be  sometimes  multiple  here  as  in  the  foot,  the  other,  that  skiagraphy 
is  especially  useful  in  doubtful  cases,  e.g.  where  a  patient  evidently 
neurotic  complains   of  a  hand  being  numb,  useless,   or  painful,   when 


88  OPERATIONS  ON  THE  UPPER  EXTREMITY 

there  is  some  doubt  as  to  the  presence  of  the  needle,  or  when  one 
needle  fragment  has  been  successfully  removed.  With  regard  to  the 
operation  itself,  the  use  of  a  tourniquet  or  Esmarch's  bandage  is 
advisable.  In  spite  of  careful  localisation  by  X-rays,  considerable 
difficulty  may  be  experienced  in  finding  the  needle ;  this  may  be 
due  to  its  displacement  by  manipulations  in  the  early  stages  of  the 
operation,  or  to  the  small  size  or  deep  situation  of  the  fragment. 
The  wound  should  therefore  be  kept  as  free  from  blood  as  possible  by 
gentle  sponging,  the  greatest  care  being  taken  that  the  incision  is  made 
exactly  over  the  situation  of  the  needle.  In  the  most  difficult  cases  it 
may  be  desirable  to  make  a  further  skiagraphic  examination  in  the 
course  of  the  operation.  In  some  cases  the  electro-magnet,  which  is 
employed  for  extracting  fragments  of  steel  from  the  eye,  may,  if 
available,  be  used  ;  though  occasionally  successful,  this  often  fails  as 
the  magnet,  though  of  great  power,  is  unable  to  draw  the  needle  through 
muscular  fibres,  especially  when  the  direction  of  the  former  is  at  right 
angles  with  the  latter. 

Where  the  needle  fragment  lies  very  deeply  in  the  palm,  especially 
if  a  good  deal  of  cicatricial  tissue  be  present  from  previous  operations, 
the  needle  may  be  removed  from  the  dorsum  by  partial  excision  of  a 
metacarpal  bone. 

A  middle-aged  woman,  \^  ho  had  been  operated  upon  three  times  for  the  removal 
of  a  needle  from  the  palm,  was  admitttd  under  Mr.  Jacobson  in  October  1903; 
it  was  clear  from  the  scars  and  contracted  state  of  some  of  the  fingers  that  an 
aseptic  result  had  not  always  been  secured.  Mr.  Shenton  demonstrated  the  presence 
of  a  needle  fragment  lying  deeply  on  the  palmar  aspect  of  the  fifth  metacarpal  bone, 
a  little  above  its  base.  The  central  portion  of  the  metacarpal  was  removed,  thus 
securing  access  through  normal  tissues.  A  rusty  black  needle  fragment  was  at  once 
seen  embedded  in  the  interossei.  The  wound,  dressed  at  first  with  fomentations 
and  kept  well  elevated,  healed  quickly,  and  the  patient  was  again  able  to  use  her 
needle. 

It  must  always  be  remembered  that  when  the  needle  is  deeply  placed, 
there  is  a  danger  that  some  important  structure,  such  as  a  nerve,  tendon, 
or  artery,  may  be  injured  in  the  operation  for  its  removal.  Suppura- 
tion, too,  will  be  attended  with  serious  results.  For  these  reasons, 
especially  in  elderly  patients,  or  those  whose  general  condition  renders 
an  ansesthetic  undesirable,  it  may  -be  advisable  to  wait  and  see  whether 
the  presence  of  the  needle  causes  any  severe  symptoms. 

PALMAR   HEMORRHAGE 

There  are  four  arterial  arches  concerned  in  the  arterial  supply  of  the  hand,  viz. 
(a)  the  superficial  palmar  arch,  formed  chiefly  by  the  ulnar  artery,  but  completed 
by  a  branch  from  the  radial,  usually  the  superficialis  \ol;e.  (6)  The  deep  palmar 
arch  formed  by  the  radial  and  completed  by  the  deep  branch  of  the  ulnar  artery. 
(c)  The  anterior  and  posterior  carpal  arches,  formed  by  the  anterior  and  posterior 
branches  of  the  radial  and  ulnar.  The  comes  nervi  mediani  artery  is  occasionally 
enlarged  at  the  exj^ense  of  the  radial  or  ulnar  ;  it  then  usually  joins  the  superficial 
palmar  arch  and  takes  an  important  part  in  the  blood-supply  of  the  hand.  The 
superficial  palmar  arch  is  situated  beneath  the  palmar  fascia  but  is  superficial  to 
the  flexor  tendons  and  the  branches  of  the  median  nerve  ;  it  can  be  marked  out 
by  a  line  commencing  just  external  to  the  pisiform  bone,  and  then  curving  down- 
wards and  outwards  across  the  middle  third  of  the  j^alm  opposite  the  upjier  end  of 
the  cleft  between  the  thumb  and  index  finger  (Fig.  16)  The  deep  palmar  arch  is 
situated  about  half  an  inch  above  this  ;  it  rests  against  the  metacarpals  and  interossei 
beneath  the  flexor  tendons. 

Treatment.  This  will  vary  accordingly  as  the  case  is  seen  early  or  later,  and 
will  also  depend  upon  the  septic  or  aseptic  nature  of  the  wound. 


PALMAR  H.1:M0RRHAGE  89 

A.  Early  Cases.  The  bleeding  '  may  be  always  temporarily  controlled  by 
pressure  or  by  the  use  of  a  tourniquet.  The  woiuid  will  often  be  small,  or  even 
a  mere  puncture.  The  most  desirable  metliod  is,  aftt-r  tiie  skin  has  been  cleansed 
as  thoroughly  as  possible,  to  open  uj)  the  wound  and  secure  both  ends  of  the  injured 
vessel.  This  is  far  ])referabl(^  to  ligature  of  the  brachial,  or  of  the  ulnar  (jr  radial 
arteries,  for  the  bleeding  may  come  from  a  small  branch  such  as  the  su[)erHcialis 
vohr*  and  not  from  one  of  the  palmar  arches.  Another  method  is  by  the  applica- 
tion of  a  graduated  compress  wliieh  may  be  tried  if  the  wouiul  be  a  small  ])uncture 
and  the  bleeding  not  severe.  Tlu>  bracliial  having  been  controlled  by  a  tourniquet 
and  the  wound  cleansed,  a  compress — consisting  of  sterilised  gauze  or  lint,  cut  in 
pieces  increasing  in  size  from  a  threepenny  bit  to  half  a  crown — is  prepared,  together 
with  strapping,  sterilised  i)ads  and  bandages.  The  fingers  are  now  bandaged, 
the  compress  is  placed  in  jjosition,  covered  by  the  sterilised  pads  and  secured  by 
careful  bandaging.  If  tlie  above  precaution  be  omitted,  so  much  and  so  i)aiiiful 
oedema  of  the  lingers  will  take  place  as  to  inevitably  necu-ssitate  early  removal  of 
the  compress  ancl  probable  recurrence  of  the  ha-morrhage.  The  arm  should  be 
kept  at  rest  on  a  splint,  or  better  still,  the  elbow  should  be  fully  flexed  and  the  arm 
loosely  bound  to  the  side.  The  patient,  if  restless,  should  at  first  be  kept  under  the 
influence  of  moi  pliia.     The  compress  should  not  be  disturbed  for  three  or  four  days. 

B.  Later  Cases.  If  pressure  has  been  tried  but  has  not  been  successful,  the 
wound,  owing  to  the  difficulty  in  rendering  the  skin  of  the  ])alm  aseptic,  is  likely  to 
be  infected  ;  the  hand  will  then  be  red,  brawny,  painful,  and  suppurating.  If 
ha>morrhage  still  continues  after  the  tension  has  been  relieved  by  carefully  made 
incisions  it  will  be  best  to  tie  the  brachial  artery  at  once  in  the  middle  of  the  arm 
(p.  171)  rather  than  to  ligature  the  radial  and  ulnar  in  the  lower  third  of  the  fore- 
arm (pp.  127,  13  )),  and  for  these  reasons  : 

(1)  Ligature  of  the  brachial  will  be  performed  through  healthy  and  uninflamed 
parts. 

(2)  While  the  anastomoses  round  the  elbow  are  so  free  and  so  reliable  as  to 
prevent  any  risk  of  gangrene  after  ligature  of  the  main  vessel,  ligature  of  the  radial 
and  ulnar  is  rendered  uncertain  owing  to  (a)  the  anastomoses  between  the  two 
palmar  arches  ;  (6)  the  anastomoses  between  these  and  the  carpal  arches  ;  (c)  the 
blood  brought  by  the  comes  nervi  mediani  artery,  which  will  not  be  stopped  by 
ligature  of  the  radial  and  ulnar  ;  (d)  the  fact  that  if  inflammation  has  set  in, 
dilatation  of  the  arteries  will  have  taken  place. 

After  early  ligature  of  the  injured  vessel  the  wound  may  be  infected,  and  secondary 
haemorrhage  occur.  Under  these  circumstances  an  attempt  again  to  secure  the 
bleeding  vessel  in  situ  is  likely  to  fail.     Ligature  of  the  brachial  will  then  be  indicated. 

PALMAR  ANEURYSM 

The  rarity  of  this  disease  in  arteries  so  small  in  size  as  those  of  the  forearm  and 
hand  is  well  known.  Aneurysm  when  present  in  the  palm  is  usually  the  result  of 
injury,  or  much  more  rarely  it  is  embolic  in  nature  and  co-exists  with  serious  disease 
of  the  heart. 

In  a  third  class  of  case  the  aneurysm  is  an  instance  of  localised  subacute  end 
arteritis  deformans,^  and  arises  without  any  known  cause.  Here  other  arteries 
—e.g.  the  cerebral — are  very  probably  also  affected.  The  inner  part  of  the  super- 
ficial palmar  arch  is  that  chiefly  affected. 

Operatiun.  If  other  treatmcxit  has  failed,  if  the  aneurysm  continues  to  increase, 
to  cause  troublesome  throbbing,  and  numbness  of  the  fingers  supplied  by  the  ulnar 
nerve,  it  is  best  treated  by  excision  after  ligature  of  the  uhiar  artery  above  and 
below.  The  skin  having  been  thoroughly  cleansed,  and  an  Esmarch's  bandage 
applied  above,  a  longitudinal  incision,  two  or  three  inches  long,  is  made  over  the 
swelling,  dividing  the  skin,  palmaris  brevis,  and  jjalmar  fascia.  Any  tendons  and 
the  ulnar  nerve  are  carefully  drawn  aside.  The  ulnar  artery  is  then  tied  with 
steriHsed  silk  or  catgut  above  and  below  the  swelling.  The  sac  is  next  snipped  away 
with  scissors,  and,  if  needful,  the  deep  branch  of  the  ulnar  artery  is  tied  also.     The 

1  The  wound  sometimes  does  not  bleed  when  examined.  If  there  is  a  history  of 
much  bleeding  and  if  the  depth  of  the  wound  make  it  probable  that  an  artery  is  injured, 
pressure  should  he  applied. 

2  An  instructive  case,  treated  successfully  by  incision  of  the  sac  with  interesting 
remarks  on  the  pathology  and  treatment  of  this  disease,  is  recorded  by  Dr.  J.  Criffiths,  of 
Cambridge,  Brit.  Med.  Journ.,  1897,  vol.  ii,  p.  646. 


90 


OPERATIONS  ON  THE  UPPER  EXTREMITY 


palmar  fascia  should  be  united  -with  a  few  buried  sutures  of  fine  sterilised  catgut,  and 
the  skin  incision  closed  with  sterilised  salmon-gut. 

jMovements  of  the  thumb  and  index  finger  should  be  carefully  commenced  in  two 
or  three  days,  but  the  other  fingers  should  be  kept  quiet  for  the  first  week.  The 
wound  should  have  healed  in  ten  days. 

While  the  above  course  is  certainly  the  best,  cases  which  have  been  recorded  ^ 
show  that  ligature  of  the  ulnar,  or  of  the  ulnar  and  radial,  will  be  suifieient  in  palmar 
aneurysm,  if,  for  any  reason,  the  surgeon  prefer  to  adopt  this  course. 


COMPOUND  PALMAR  GANGLION 

TUBERCULOUS    TENO-SYNOVITIS 

Tuberculous  teno-syuovitis  occurs  in  two  forms  :  (1)  AVhere  the 
distended  sheath  contains  numerous  "  rice-grain  "  or  "  melon-seed  " 
bodies  ;  (2)  the  f ungating  form,  in  which  masses  of  tuberculous  granula- 
tion tissue  exist  in  and  project  from  the  lining  membrane.  Some  cases 
where  there  is  a  chronic  serous  effusion  into  the  tendon-sheath  are  also 
tuberculous  in  origin.  Tuberculous  disease  may  affect  any  tendon- 
sheath,  but  one  of  the  most  frequent  and  important  sites  for  this  disease 
is  the  sheath  of  the  flexor  tendons  or  palmar  bursa. 

Practical  Points.  (1)  There  is  the  risk  of  spreading  infection  if  the 
wound  be  not  kept  carefully  aseptic.     (2)  Recurrence  is  very  frequent, 

from  the  fact  that  it  is  difficult  to  remove  all 
the  "  melon-seed  "  bodies  which  are  often  pre- 
sent in  great  abundance,  or  all  the  diseased 
synovial  membrane.  (3)  A  compound  palmar 
ganglion  is  very  often  tuberculous.  In  these 
cases  the  disease  is  very  likely  eventually  to 
extend  to  the  carpus.  The  arrangement  of 
the  syno\dal  sheaths  of  the  fingers  is  shown  in 
Fig.  35. 

Treatment.  A  radical  operation  is  strongly 
advised  for  compound  palmar  ganglion  owing 
to  the  frequency  with  which  this  disease  is 
tuberculous,  and  its  consequent  dangers  from 
its  surroundings.  But  as,  in  a  few  cases,  this 
disease  may  be  of  a  chronic  inflammatory 
nature,  and  as  the  surgeon  may  not  always 
be  able  to  avail  himself  of  the  skilled  assist- 
ance, &c.,  which  is  an  absolute  sine  qua  non  for  the  radical  operation,  a 
simpler  operation  will  be  first  described.  It  is  not  recommended,  and  any 
one  employing  it  must  remember  that  if  he  fails  to  cure  the  disease,  he 
will  have  rendered  subsequent  needful  steps  much  more  difficult. 

A.  The  parts  ha\nng  been  rendered  sterile,  an  incision  should  be 
made  an  inch  above  the  anterior  annular  ligament,  avoiding  the  median 
nerve,  and  going  down  into  the  ganglion,  the  opening  ^  into  which  is 
not  to  be  a  mere  button-hole,  but  must  be  kept  free  and  dilated.  The 
edges  of  the  free  opening  into  the  ganglion  being  held  apart  by  tissue 
forceps,  all  the  "  melon-seed "  bodies  must  be  removed,  partly  by 
pressure,  partly  by  the  use  of  the  curette,  which  should  explore  all  the 

^  A.  Caddy,  of  Calcutta  {Lancet,  1896,  vol.  ii.  p.  603).  The  aneurysm  was  traumatic, 
and  the  patient  33.  The  radial  and  ulnar  were  tied.  W.  Robertson,  of  Glasgow  {Brit. 
Med.  Joiirn.,  1897.  vol.  ii.  p.  1637).  Here  there  had  been  no  wound,  but  the  palm  had  been 
repeatedly  knocked  in  starting  some  engine-gear.  The  patient  was  18.  The  ulnar 
artery  alone  was  tied. 


Fig.  3.5. 


COMPOUND  PALMAR  GANGLION  91 

cavities  into  which  these  ganglia  are  sometimes  divided.  The  question 
of  providing  a  second  opening  below  the  annular  ligament  will  now 
arise.  When  the  ganglion  is  large,  and  when  the  "  melon-seed  "  bodies 
are  numerous,  a  second  op(Mnng  should  certainly  be  made.  This  may 
be  done  by  passing  a  director  or  dressing- forceps  from  the  upper  opening 
under  the  annular  ligament,  and  cutting  down  upon  it  through  the 
palmar  fascia,  care  being  taken  to  avoid  the  superficial  arch.  This 
opening  having  been  enlarged  with  the  help  of  the  dressing- forceps, 
the  curette  is  again  applied,  if  needful,  and  when,  either  by  this  means 
or  by  rubbing  between  the  openings  a  strip  of  sterilised  gauze,  all  the 
"  melon-seed  "  bodies  are  detached  and  removed,  the  cavity  is  washed 
out  with  a  sterile  saline  solution  and  then,  by  pressure,  and  the  applica- 
tion of  sterilised  pads,  dried  as  thoroughly  as  possible. 

A  small  rubber  drainage  tube  may  be  inserted  for  a  few  days  between 
the  upper  two  of  the  interrupted  silkworm-gut  sutures  which  close  the 
wound  above  the  wrist.  The  hand  and  forearm  may  be  conveniently 
put  up  with  the  fingers  flexed,  as  on  a  Carr's  splint.  Passive  move 
ments  of  the  fingers  should  be  started  at  the  end  of  a  week. 

B.  A  more  radical  operation  should  be  performed  in  practically 
every  case,  owing  to  the  probable  tuberculous  nature  of  the  trouble 
and  the  risk  of  the  infection  extending  to  the  carpus.  It  should  cer- 
tainly be  performed  when  there  is  reason  to  suspect  tuberculous  mischief, 
or  when  the  disease  recurs.  The  ganglion  having  been  opened  by  the 
steps  given  above,  but  with  much  freer  incisions,  its  walls  will  certainly 
be  found  to  be  thick  and  velvety,  perhaps  showing  vascular  fringes 
over  the  tendons.  In  such  cases  each  of  the  tendons  must  be  separately 
hooked  up  and  cleaned  with  curved,  blunt-pointed  scissors  and  dissecting 
forceps,  the  diseased  tissue  being  removed  in  as  large  continuous  pieces 
as  possible.  To  eradicate  the  whole  of  the  tuberculous  synovial  mem- 
brane it  will  be  needful  to  divide  the  anterior  annular  ligament,  the 
position  of  the  median  nerve  being  first  carefully  noted.  The  four  cases 
given  below,  in  which  this  step  was  taken,  show  that  no  weakening 
of  the  hand  need  be  feared.  The  incision  must  be  boldly  made  from 
about  one  and  a  half  inches  above  the  annular  ligament  down  through 
this  structure  to  a  point  just  above  the  level  of  the  superficial  palmar 
arch.  Otherwise  there  is  danger  that,  by  insufficient  exposure  of  the 
parts,  persistence  of  the  tuberculous  mischief,  and,  ultimately  disease 
of  the  carpus,  may  ensue.  When  by  the  use  of  a  blunt  hook,  dissecting 
forceps,  and  blunt-pointed  scissors,  each  individual  tendon  has  been 
cleaned  as  thoroughly  as  possible,  the  surgeon  examines  for  the  presence 
of  bone  disease,  flushes  out  the  cavity  with  hot  sterile  saline  solution, 
followed  by  rubbing  in  of  sterilised  iodoform  emulsion.  During  the 
operation  every  bleeding-point  must  be  secured  and  ligatured.  The  use 
of  forci-pressure  is  less  advisable  owing  to  the  risk  of  damage  to  the 
tendons  ;  general  oozing  is  checked  by  the  hot  saline  solution.  The 
annular  ligament  is  then  united  with  buried  sutures  of  catgut  and  the 
dressings  are,  when  the  wound  has  been  closed,  applied  so  as  to  exert  a 
uniform  pressure. 

Two  more  points  need  reference.  First,  as  to  the  use  of  a  tourniquet. 
This  is  not  of  material  importance.  The  after  oozing,  always 
free,    will   be  especially    so    if    this,    or    an   Esmarch's   bandage,    be 

1  If  on  cutting  into  the  ganglion  its  wall  is  found  to  be  thick,  velvety ]^and  vascular 
this  operation  is  certain  to  fail. 


92  OPERATIONS  OX  THE  UPPER  EXTREMITY 

employed.  Drainage  should  be  pro\'ided  by  inserting  a  small  tube 
between  two  of  the  silk:«-orm-gut  sutures  which  are  left  untied  at 
the  upper  end  of  the  wound.  The  tube  may  be  removed  and  the 
wound  closed  after  two  or  three  days.  Another  and  more  important 
point  is  one  which  has  not  received  adequate  attention,  and  that  is 
the  condition  of  the  sheath  of  the  flexor  longus  pollicis.  There  are 
usually  two  synovial  sheaths  beneath  the  annular  hgament,  one  for 
the  flexor  tendons  of  the  fingers  and  the  median  nerve,  the  other  for 
the  long  flexor  of  the  thumb.  The  latter,  which  may  communicate 
with  the  former,  extends  continuously  from  above  the  annular  ligament 
to  the  base  of  the  ungual  phalanx  of  the  thumb.  It  is  not  always  involved 
in  tuberculous  syno\-itis  of  the  palmar  bursa.  Thus  in  two  of  the  cases 
mentioned  below  it  had  escaped.  In  two.  fulness  in  the  thenar  eminence 
and  thickening  along  the  tendon  below  gave  evidence  of  more  extensive 
tuberculosis.  In  order  to  avoid  di\-iding  the  short  muscles  of  the  thumb, 
the  .sheath  was  laid  open  along  the  phalanges,  the  thickened  tuberculous 
membrane  there  was  removed,  and  then,  by  means  of  a  curette  and  strips 
of  sterilised  gauze  soaked  in  iodoform  emulsion,  passed  by  means  of 
sinus-forceps  from  the  opening  over  the  thumb  below  to  that  above  the 
annular  hgament,  the  diseased  synovial  tissue  was  curetted  and  rubbed 
away  as  far  as  possible  from  that  part  of  the  sheath  which  lies  beneath 
the  muscles  of  the  thenar  eminence.  As  soon  as  the  wounds  were 
healed  collodion  dressings  were  employed,  and  over  these,  uniform 
pressure  with  strapping,  apphed  especially  firmly  over  the  thumb. 
The  cure  was  complete  when  the  patients  left  the  hospital,  and  remained 
so  {vide  infra)  during  the  six  months  which  had  elapsed  since  the  oper- 
ation. After  this  operation  passive  movements  of  the  fingers  must  be 
begun  as  early  as  possible  to  guard  against  matting  together  of  the 
tendons.  The  constitutional  and  general  treatment  of  tuberculosis  must 
also  be  carefully  carried  out. 

In  the  following  four  cases  Mr.  Jacobson  di\^ded  the  anterior 
annular  hgament.  "  The  first,  in  1896,  was  a  woman,  set.  53.  who 
earned  her  living  by  working  at  fancy  embroidery.  Dr.  Holland 
\\  right,  whose  patient  the  woman  was.  sent  her  to  me  in  June 
1904  to  show  the  result.  This  was  perfect;.  The  patient  had  followed 
her  employment  all  the  time,  but  there  was  some  e\'idence  of  phthLsis 
in  the  left  lung.  The  second  case  was  a  woman,  set.  i'l.  Though 
very  numerous  '  melon-seed '  bodies  and  much  thickening  of  the 
synoA-ial  membrane  was  present,  this  was  the  only  case  in  which  tubercle 
bacilli  could  not  be  found.  When  I  last  saw  this  patient,  one  and  a  half 
years  after  the  operation,  the  hand  was  as  good  as  its  fellow.  The 
third  and  fourth  patients  were  sent  to  me  by  Dr.  Jones,  of  Alton,  almost 
coincidently,  in  1903.  In  both  the  sheath  of  the  flexor  longus  pollicis  was 
markedly  involved.  Both  were  young  patients,  one  a  grocer's  assistant ; 
the  other,  a  barmaid,  had  been  operated  upon  before  by  a  single  incision 
above  the  wrist.  This  fact,  the  disease  persisting,  greatly  increased  the 
difficulty  of  the  operation.  In  answer  to  my  inquiries,  the  man  wrote 
to  me  as  follows  about  six  months  after  the  operation  :  '  My  hand  is 
quite  strong,  much  stronger  than  when  I  first  felt  anything  of  it.  The 
top  joint  of  the  thumb  is  still  stiff,  and  I  can't  close  the  hand  quite  as 
well  as  the  other.  Otherwise  it  feels  perfectly  well.'  With  regard 
to  the  fourth  case,  that  of  the  barmaid,  Dr.  Jones  \\Tote  about  six  months 
after   the  operation  :    '  As  far  as  I  can  see.  the  result  is  as  perfect  as 


UNION  OF  DIVIDED  TENDONS  93 

possible.     8he  has  regained  all  movements  of  the  fingers,  the  grip  of 
the  hand  is  a  little  weaker  than  on  the  sound  side.' 

'■  The  above  cases  prove  that,  with  skilled  assistance,  there  need  be 
no  hesitation  about  division  of  the  annular  ligament.  With  regard  to 
my  treatment  of  the  flexor  sheath  of  the  thumb,  six  months  is  insufficient 
to  prove  anything.  At  all  events,  the  example  is  worth  following.  If 
the  method  prove  incomplete,  I  should  not  hesitate  to  divide  the  muscle 
and  lay  open  the  whole  of  the  sheath.  A  sound  hand,  at  the  expense 
of  a  less  mobile  thumb,  would  certainly  be  preferable  to  persistent 
tuberculosis,  matted  tendons,  and  invaded  wrist- joint  with  sinuses, 
and  secondary  tuberculosis  in  the  lungs  or  elsewhere.  Should  tuber- 
culous teno-synovitis  occur  in  the  extensor  sheaths  at  the  back  of  the 
■wrist  it  must  be  treated  on  the  same  lines,  i.e.  the  sheath  must  be 
thoroughly  opened  up,  the  diseased  synovial  membrane  clipped  or  scraped 
away,  any  pockets  thoroughly  curetted,  and  any  bony  focus  completely 
scraped  out." 

Treatment  of  a  simple  ganglion.  These  small  cy.sts,  which  most  commonly 
occur  ill  connection  with  the  tendon  sheaths  at  the  back  of  the  \VTi.st,  are  variously 
regarded  as  due  to  local  tenO'-synoWtis,  colloid  degeneration  of  the  synovial  mem- 
brane, or  hernial  jjrotrusions  of  the  tendon  sheath,  or  in  some  cases  from  the  .synovial 
membrane  of  the  carpal  joints.  Should  simpler  methods,  such  as  the  application  of 
iodine,  pressure,  or  incision  with  the  injection  of  a  few  drops  of  pure  carbolic  fail, 
the  ganglion  should  be  excised. 

OPERATIONS  FOR  UNION  OF  DIVIDED  TENDONS. 
TENORRAPHY.     TENOPLASTY 

As  in  the  case  of  divided  nerves,  the  union  of  divided  tendons  may  be 
primary  or  secondary,  according  as  the  surgeon  sees  the  case  at  once 
or  after  an  interval.  This  injury  is  especially  frequent  and  of  great 
importance  in  the  tendons  of  the  hand  and  v\Tist. 

Preliminary  consideratio7is.  (1)  The  diagnosis  usually  presents  no 
difficulties.  There  wall  be  entire  loss  of  the  movement  produced  by 
the  injured  tendon.  Loss  of  power  may  result  from  injury  to  a  motor 
nerve,  but  in  this  case  there  will  probably  be  some  anaesthesia,  and 
electrical  stimulation  of  the  muscle  wd\  produce  the  lost  movement. 
(2)  When  a  tendon  is  di\'ided  there  will  certainly  be  some  retraction  of 
the  proximal  end  owing  to  the  tonic  contraction  of  the  muscle.  Mr.  A.  H. 
Tubbv  ^  points  out  that  in  the  case  of  the  extensor  tendons  of  the  fingers, 
there  wall  be  but  little  retraction  if  they  are  divided  at  the  back  of  the 
hand  or  fingers  owing  to  the  connection  between  the  various  tendons, 
their  aponeurotic  expansions,  and  their  close  attachment  to  their  sheaths. 
If  the  extensors  of  the  thumb  are  di\aded  at  the  back  of  the  wrist  there 
is  but  little  retraction  ;  if,  however,  they  are  divided  at  the  back  of  the 
metacarpal  the  upper  end  may  retract  as  much  as  three  inches.  In 
the  case  of  the  flexor  tendons  there  is  but  slight  retraction,  owing  to  the 
presence  of  the  vinculse  if  they  are  divided  over  the  phalanges  ;  there 
is  also  but  little  separation  if  the  injury  occurs  in  the  palm,  but  if  they 
are  divided  above  the  wrist  great  retraction  of  the  upper  end  is  to  be 
expected.  (3)  It  is  necessary  to  insist  upon  the  importance  of  immediate 
suture.  If  the  injury  to  the  tendon  has  at  first  been  overlooked  the 
difficulty  in  finding  the  separated  ends  and  bringing  them  together  is 
much  increased  owing  to  obliteration  of  the  sheath  and  matting  of  the 

1  Deformities,  1912,  p.  769. 


94  OPERATIONS  ON  THE  UPPER  EXTREMITY 

tendon  to  surrounding  structures.  Here,  too,  it  may  be  pointed  out 
that  adhesions  of  the  flexor  tendons  to  each  other  or  to  a  cicatrix  will 
certainly  prevent  full  extension  of  the  fingers.  (4)  In  all  these  opera- 
tions careful  aseptic  precautions  must  be  taken.  A  tendon  has  a  poor 
blood-supply  and,  if  the  wound  becomes  infected,  sloughing  is  very 
likely  to  occur. 

For  the  sake  of  convenience,  operations  for  the  union  of  divided 
tendons  may  be  classed  under  the  following  heads  : 

A.  Cases  where  both  ends  can  be  found  and  where  they  can  be  easily 
adjusted.  If  the  injury  is  recent  a  longitudinal  incision  enlarging  the 
original  wound  will  usually  be  best,  but  in  some  cases — e.g.  where  the 
injury  is  old-standing  and  the  tendons  are  matted  together — a  flap 
may  be  preferable.  Any  bruised,  torn,  sloughy,  or  scarred  tendon 
tissue  is  removed  as  cleanly  and  charily  as  possible  with  a  sharp  knife 
or  scissors.  There  is  no  difficulty  in  finding  the  distal  or  fixed  end  of 
the  tendon.  Should  the  proximal  end  have  retracted,  it  may  be  sought 
for  by  one  of  the  methods  described  on  p.  97.  The  best  msterial  for 
sutures  is  fine  catgut,  which  wiU  resist  absorption  for  twenty  days  ; 
sterilised  silk  may  also  be  employed,  while  Cheyne  and  Burghard' 
recommend  the  use  of  very  fine  fishing  gut.  Small  non- cutting  curved 
needles  should  be  used  ;  needles  with,  a  cutting  edge  are  very  likely 
to  tear  through  the  damaged  tendon. 

Methods  of  inserting  the  sutures.  (1)  When  the  tendon  is  round,  and 
either  of  medium  or  large  size,  the  suture  may  be  passed  from  before 
backwards  through  one  tendon  end,  and  then  from  behind  forwards 
through  the  other,  and  the  ends  are  knotted  on  the  superficial  surface 
of  the  tendon.  Large  tendons  may  be  secured  with  two  lateral  or 
with  one  central  and  two  lateral  sutures,  smaller  tendons  with  one 
median  suture  only.  As  the  suture  is  tightened  the  ends  must  be 
kept  in  exact  apposition,  and  not  allowed  to  override  one  another. 
In  this  method  and  in  the  others  which  follow,  care  must  be  taken  not 
1.0  insert  the  sutures  too  near  to  the  tendon  ends.  There  is  a  tendency 
for  the  sutures  to  separate  and  cut  through  the  parallel  fasciculi ;  this 
will  certainly  happen  if  there  is  any  tension  or  if  muscular  contraction 
throws  any  strain  on  the  stitches.  This  splitting  is  very  likely  to  take 
place  in  the  thin  flat  extensor  tendons. 

(2)  Under  these  circumstances,  where  the  tendon  is  flat,  there  is  a 
strong  tendency  for  the  suture  to  cut  its  way  out  if  inserted  in  the 
ordinary  manner  ;  one  of  the  following  methods,  viz.  Wolfler's,  Le  Fort's, 
Le  Dentu's,  which  are  made  plain  in  Figs.  36  and  37,  will  be  found 
preferable. 

(3)  Where  the  tendon  is  round  and  small,  too  small  for  the  methods 
of  Wolfler  or  Le  Dentu,  and  where,  owing  to  the  size  of  the  tendon  and 
the  tension,  a  suture  inserted  in  the  ordinary  way  will  cut  out,  Schwartz's 
method  may  be  tried  (Fig.  37).  A  circular  ligature  is  tightly  tied  round 
each  tendon  end  a  short  distance  from  the  cut  surface  ;  two  longitudinal 
sutures  are  then  passed  above  and  below  these  Hgatures,  and  thus 
prevented  from  slipping,  serve  to  draw  the  ends  together.  An  objection 
to  this  method  is  that  the  circular,  ligatures  endanger  the  nutrition  of 
the  tendon  ends. 

(4)  Cheyne  and  Burghard  ^  advise  the  following  method,  which  avoids 
the  above    drawback   to   Schwartz's,  while   it   meets  the  tendency   of 

Loc.  infra  ciL,  p.  228.  ^  Manual  of  Surgical  Treatment,  vol.  ii.  p.  9.3. 


TTNION  OF  DIVIDED  TENDONS 


95 


Fig.  36. — Wolfler's  transverse 
tendon-suturo  {Wien.  Med. 
Woch.,  1888,  5. 1).  When  the 
ends  touch,  the  inventor  calls 


oidimiiily  applied  interrupted  sutures  to  cut  out  too  quickly  :  "  The  best 
plan  is  to  pass  the  needle  across  from  front  to  back  through  the  whole 
thickness  of  the  tendon  quite  to  one  edge  of  it  and  close  to  the  line  of 
division,  and  then  to  tic  the  thread  over  the 
small  piece  of  tendon  included  in  the  loop. 
Although  the  piece  of  tendon  below  the  ligature 
may  possibly  die,  a  secure  hold  is  thus  ob- 
tained, which  may  be  pulled  on  firmly  without 
fear  of  the  thread  cutting  its  way  out.  The 
same  procedure  should  be  adopted  also  on  the 
opposite  side  of  the  tendon,  and  both  the  upper 
and  lower  ends  should  be  prepared  in  this  way, 
care  being  taken  that  the  stitches  are  inserted 
at  exactly  corresponding  points  in  the  two 
ends,  so  that  the  tendon  is  not  twisted  when 
they  are  tied  together.  The  ends  of  the  cor- 
responding threads  on  either  side  of  the  (divi- 
sion are  then  tied  sufficiently  closely  to  bring  hV^method  "  direct  transverse 

the  two  cut  surfaces  into  apposition.      It  is  well    tendon"  suture,  and  gives  it 

to  put  in  one  or  two  stitches  in  the  centre  to   ^L^rdTcanlrbobS^ghuo" 

remforce  the  lateral  ones  ;     these  will  prevent    gether,  and  the  threads  are  tied 

the  cut  surfaces  from  being  displaced  laterally  and  left  to  form  guides  for  the 
or  curled  up,  and  as  they  do  not  bear  any  strain,  '^'"'^°Sng  bridge^"'  '°"' 
they  may  be  inserted  in  the  usual  manner." 

When  the  divided  tendons  have  been  united  and  all  haemorrhage  and 
oozing  have  been  checked,  the  wound  is  carefully  sutured.  If  the  wound 
when  first  seen  is  dirty,  or  if  after-collection  of  blood  or  serum  is  thought 
possible,  a  small  drainage  tube  should  be  inserted.  The  dressings  should 
be  applied  in  sufficient  quantity  and  uniformly  so  as  to  exert  even  pres- 
sure.    If  possible  they  should  remain  unchanged  for  seven  or  ten  days. 

The  limb  must  be  ar- 
ranged on  a  splint  in 
such  a  position  that  no 
undue  tension  falls  upon 
the  united  tendons,  while 
at  the  same  time  the  com- 
fort of  the  patient  is 
attended  to.  Moulded 
splints  of  poro-plastic  or 
gutta-percha  are  best,  or 
a  perforated  zinc  trough, 
which  is  readily  cut,  fairly 
easily  bent  and  moulded 
to  any  degree  of  flexion, 
and  which  can  be  boiled, 
will  be  found  useful  in  the 
common  cases  of  tendons 
injured  about  the  wrist 
where  the  elbow,  wrist, 
and  fingers  must  be  kept  flexed.  If  wooden  splints  be  employed, 
a  Carr's  splint  is  comfortable,  but  must  be  reinforced  by  an  angular 
spfint  to  maintain  flexion  of  the  elbow.  Wooden  splints  are,  however,  much 
less  efficient,  in  that  they  fail  to  secure  the  needed  amount  of  flexion, 


A.  B. 

Fig.  37.   A.  Le  Dentu's  method  of  tendon-suture. 

B.  That  of  Wolfler. 

C.  E.  Schwartz's  method. 

(Le  Dentu  and  Delbet,  Traite.  de  Chir.,  t.  iii,  p.  825.) 


96         OPERATIONS  OX  THE  UPPER  EXTREMITY 

or  the  power  of  modifying  this  later  on.  The  patients  comfort  will  be 
greatly  promoted  by  remo\ing  the  splint  every  two  or  three  days  and 
altering  the  angles  slightly.  Restlessness,  while  recovering  from  the 
anfesthetic,  must  be  prevented,  for  contraction  of  the  muscle  may  cause 
the  sutures  to  tear  through  and  the  ends  of  the  tendon  to  again  separate  ; 
if  the  sutures  do  not  hold,  the  parts  will  tend  to  heal  in  one  contracted 
mass.  Most  careful  attention  will  be  needed  afterwards  in  the  employ- 
ment of  warily  begun,  and  perseveringly  continued,  passive  and  active 
movements.  In  commencing  movements  the  surgeon  has.  on  one 
hand,  to  prevent  the  formation  of  adhesions  ;  on  the  other,  he  must 
remember  the  risk  of  breaking  down  the  recently  formed  union.  The 
date  must  vary  with  each  case,  but,  as  a  rule,  in  the  case  of  the  tendons 
of  the  fingers,  passive  movement  may  be  begmi.  very  gently  so  as  not 
to  strain  the  union,  about  the  sixth  day.  and  gradually  increased.  From 
the  fourteenth  to  the  twenty-first  day  will  usually  be  early  enough  for 
the  commencement  of  active  movements.  Soft  adhesions  will  certainly 
have  formed,  but  if  the  sutures  have  been  so  placed  as  to  secure  a  firm 
hold,  and  if  the  wound  has  run  an  aseptic  course,  there  is  little  risk  of 
the  union  being  broken  down. 

In  cases  of  secondary  tendon-suture,  as  in  that  of  nerves,  the  result 
may  be  disappointing  for  some  months  ;  but  if  the  tension  was  not 
extreme,  and  if  the  wound  heals  by  primary-  union,  the  final  result  will 
probably  be  satisfactory,  if  the  patient  does  his  best  to  help  the  surgeon. 
This  opportunity  may  be  taken  to  point  out  that,  in  the  treatment  of 
incised  wound  of  the  hand  or  foot,  the  condition  of  the  tendons  should 
be  cleared  up  as  well  as  that  of  the  vessels.  Too  often  attention  is 
directed  solely  to  arresting  the  urgent  haemorrhage,  especially  if  the 
situation  of  the  womid  does  not  exactly  correspond  to  the  course  of  a 
tendon.  The  wound  heals  quickly,  and  then  attention  is  drawn  to  the 
I0.SS  of  power.     The  following  is  a  good  instance  : 

In  August,  1888,  H.  P.,  aet.  31,  was  seen  with  constant  flexion  of,  and  in- 
ability to  extend,  the  last  two  phalanges  of  the  thumb.  A  few  months  before 
he  had  been  treated  for  .severe  hsemorrhage  from  an  incised  wound  of  the  dorsum  over 
the  first  phalanx  and  metacarpal  of  the  right  thumb.  Bj'  dissection  the  extertsor 
secundi  intemodii  was  fomid  to  have  been  divided,  the  upper  end  coming  into  Anew 
on  following  up  the  sheath. 

The  extensor  brevis  had  been  only  partially  divided  for  three-quarters  of  its 
width.  When  trimmed  the  two  ends  of  the  extensor  secimdi  were  separated  by  an 
interval  of  an  inch  on  complete  extension  of  the  thumb.  By  the  use  of  a  stout 
suture,  and  by  pushing  down  the  upper  end  of  the  tendon,  the  ends  were  brought 
to  within  a  quarter  of  an  inch  of  one  another  ;  two  fine  sutures  then  brought  the 
ends  into  good  but  not  exact  apposition.  On  hyper-extending  the  thumb  the  V- 
shaped  notch  in  the  partially  divided  extensor  primi  was  obliterated,  so  no  sutures 
were  used  here,  the  edges  of  the  notch  being  merely  refreshed.  A  splint  was  applied 
on  the  palmar  aspect,  so  as  to  keep  the  thumb  hj^^er-extended.  When  seen  two 
months  later,  the  piatient  had  recovered  complete  power  of  exten.sion. 

B.  Cases  where  only  one  end  can  be  found.  The  distal  or  fixed  end 
of  the  tendon  can  nearly  always  be  found.  The  difficulty  of  finding 
the  upper  retracted  end  of  one  of  the  flexor  tendons  may  often  be  extreme. 
Should  it  not  come  into  \-iew  on  sHtting  up  the  sheath  for  a  short  distance 
one  of  the  following  methods  may  be  tried  :  (a)  The  muscular  belly 
may  be  pressed  down  by  manipulation  with  the  fingers,  or  an  Esmarch's 
bandage  may  be  appHed  commencing  at  the  elbow  and  passing  down 
wards  towards  the  wrist,  (b)  M.  Felizet  ad\ises,  if  'sHtting  up  the  sheath 
and   methodically  pressing   down   the   muscular   belly   are   insufficient, 


UNION  OF  DIVIDED  TENDONS 


97 


Fig.    38.       Buttonhole  method    of  tendon-anastomosis. 
Method  of  MM.  Tillaux  and  Duplay.    (Duplay  and  Reclus, 
Traite  de  Chir.,  t.  i,  p.  825.) 


that  the  upper  end  may  be  made  to  emerge  into  view,  and  further 
disturbance  of  the  parts  avoided,  by  extending  the  adjacent  fingers. 
By  this  step,  what  M.  Felizet  terms  the  Uttlc  fibro-serous  vincula,  which 
tie  together  adjoining  tendons,  are  drawn  upon  and  pull  down  the 
upper  end  of  the  severed  tendon  into  view,  (c)  When  the  slitting  up 
of  the  sheath  would  have  to  be  very  extensive,  and  might  involve  danger 
to  important  structures,  Cheyne  and  Burghard  advise  that  a  second 
incision  be  made  over  the  tendon  well  above  the  wound,  and  the  sheath 
opened  ;  from  this  incision  the  tendon  is  pushed  down  by  means  of  sinus 
forceps  until  the  divided  end  appears  in  the  original  wound,  {d)  In  cases 
where  difficulty  is  experienced  in  finding  the  distal  end,  e.g.  in  secondary 
operations  for  divided  tendons  at  the  wrist  where  the  proximal  end  is 
likely  to  be  fixed  by  adhesions,  the  same  writers  advise  as  follows  :  "  A 
better  plan  than  di- 
viding the  aimular  liga- 
ment is  to  cut  into  the 
palm  and  expose  the 
tendon  well  on  the  dis- 
tal side  of  the  division  ; 
then,  by  pushing  a 
probe  up  the  sheath, 
the  point  at  which  ad- 
hesion has  taken  place 
may  be  found,  and  an 
attempt  made  by  for- 
cing the  probe  upwards 

through  the  adhesions,  to  make  it  protrude  into  the  wound,  and  form  a 
guide  along  which  the  tissues  can  be  turned  aside  until  the  end  is 
reached."  (e)  The  only  alternative  to  these  methods  is  to  make  a 
prolonged  dissection  upwards,  dividing  the  sheath,  the  annular 
ligament,  and  the  muscles,  but  taking  the  greatest  care  not  to 
damage  vessels  or  nerves,  until  the  proximal  end  is  found  and  freed.  If, 
after  careful  search,  it  is  still  impossible  to  find  the  upper  end,  the 
lower  end  may  be  attached  to  a  neighbouring  tendon  by  tendon- 
anastomosis.  This  may  be  eft'ected  by  one  of  the  three  follo^^^ng 
methods  :  (a)  Bv  fixing  the  severed  end  in  a  button-hoJe  made  by  splitting 
an  adjacent  tendon  longitudinally  (Fig.  38).  (h)  Anastomosis  by  bifurca- 
tion or  splitting  of  an  adjacent  tendon.  Schwartz  describes  a  case 
where  the  proximal  ends  of  two  of  the  extensors  of  the  thumb  divided 
at  the  back  of  the  metacarpal  could  not  be  found.  The  tendon  of  the 
extensor  carpi  radialis  longior  was  split  longitudinally ;  the  outer 
division  was  separated  below  and  sutured  between  the  peripheral  ends 
of  the  divided  extensors  of  the  thumb  (Fig.  39).  The  following  case^ 
is  a  good  example  of  this  method,  and  of  one  means  of  employing  sutures 
so  as  to  prevent  tension  : 

An  oblique  cut  with  a  bread- knife  divided  the  common  extensor  of  the  index  and 
middle  finger,  and  the  extensor  indicis,  the  central  end  of  the  latter  retracting  so  far 
that  it  could  not  be  reached,  unless  by  slitting  up  its  sheath.  The  ends  of  the  common 
extensor  were  united  by  fine  silk  sutures.  The  peripheral  end  of  the  extensor  indicis 
was  attached  to  both  ends  of  the  sutured  tendon  from  the  extensor  communis  to  the 
index  finger.  The  strongly  stretched  extensor  tendons  of  the  second  and  third 
fingers  were  now  fixed  (to  prevent  retraction  by  muscular  action)  by  sutiu:es  past 
2  cm.  higher  up,  through  skin  and  tendon  sheath,  and  tied  over  a  strip  of  gauze. 

1  Fillenbaum,  Wien.  Med.  Wocli.,  Nos.  29  and  30,  1885. 
SURGERY  I  7 


98 


OPERATIONS  ON  THE  UPPER  EXTREMITY 


These  were  removed  on  the  fifth  day.  Passive  moveraeut  was  begun  on  the  sixteenth 
day.     Six  months  later  the  man  had  perfect  use  of  his  lingers. 

The  back  of  the  hand  is  the  most  favourable  situation  for  the 
anastomosis  of  tendons,  as  they  are  here  united  by  fibrous  expansions. 

Thus  a  neighbouring  tendon  can  be  relied 
upon  to  render  active  the  peripheral  end  of 
another  tendon  whose  central  end  cannot  be 
found.  Furthermore,  it  is  on  the  back  of 
the  hand,  and  especially  near  the  knuckles, 
that  operations  on  tendons  give  the  best 
results.  Retraction  is  less  here  than  else- 
where, owing  to  the  presence  of  connecting 
bands  and  expansions  to  the  joint  capsules ; 
there  is  less  bleeding  ;  the  skin  is  thinner, 
and  its  greater  mobility  renders  less  harm- 
ful the  formation  of  any  adhesions.  But 
while  tendon  anastomosis  is  especially  applic- 
able to  the  extensors,  the  following  case,  in 
w^hich  Mr.  F.  T.  PauP  joined  the  tendon  of 
the  flexor  longus  pollicis  to  the  index  tendon 
of  the  flexor  profundus,  shows  that  it  may 
also  be  employed  in  the  case  of  the  flexors. 

A  boy,  fet.  7,  had  sustained  a  severe  cut  across 
the  ball  of  the  right  thumb.     There  was  no  power 
over  the  last   joint,  and  consequently  no  power  of 
holding  anything — e.g.  a  pen  in  the  usual  way.     An 
incision  over  the  flexor  longus  revealed  the  distal 
end  of  the   tendon  in   good   condition   and   firmly 
attached  to  the  scar.     The  central  end  was  sought 
for,  but  though  the  incision  was  ])rolonged  an  inch 
above  the   annular   ligament   could  not  be  found. 
Under  these  circumstances  it  was  decided  to  form 
Fig.  39.      Tendon-anastomosis    an  anastomosis   between   the  terminal  end   of  the 
by  splitting  or  bifurcation  of  an    cut  flexor  and  the  side  of  the  index   tendon  of  the 
adjacent  one.     Method  of  M.  E.    flexor  profundus  ;  a  step  which,  if  successful,  would 
Schwartz.   (Dentu  and  Delbet.)    give  the  patient  power  of  flexing  the  thumb  and  fore- 
finger together,  and  thus  of  holding  articles  between 
them.     The  free  end  of  the  thumb  tendon  was  inserted  into  a  notch  made  in  the 
side  of  the  index  tendon,  where  it  was  fixed  by  two  or  three  sutures.     A  year 
later  it  was  found  that  not  only  had  the  boy  the  combined  power  of  grasp  hoped 
for,  but  that,  under  training  by  a  skilled  pianist,  he  was  obtaining  independent 
movement  of  the  thunjb  and  forefinger.     The  fact  that,  while  the  boy  had  only 
one  muscle  between  the  two  digits,  he  could  yet  fle.x  them  sei)arately,  was  entirely 
due  to  the  training  of  the  extensors.     Thus,  if  told  to  bend  the  thumb  alone,  he 
would  fix  the  forefinger  by  its  extensor,  and  then  flex  the  thumb,  or  the  reverse. 

C.  Cases  where  both  ends  can  be  found,  but  it  is  impossible  to  adjust 

them.  This  difficulty  is  usually  met  with  in  some  cases  of  secondary 
tendon  suture,  or  after  the  removal  of  a  growth  which  has  become 
adherent  to  a  tendon.     The  following  methods  are  available  : 

(1)  Tendon  Lengthening,  (a)  Method  of  Trnka  {Fig.  44).  This  may 
be  tried  in  the  case  of  large  tendons.  The  longitudinal  incision  must 
not  be  carried  too  near  the  end  of  the  tendon,  and  to  prevent  the  dis- 
placed slip  becoming  detached  by  any  tension  that  it  may  be  called 
upon  to  bear  it  should  be  secured  above  as  well  as  below  by  several 
fine  sutures  (Fig.  44a). 

^  Liverpool  Med.  Chir.Journ.,  1895,  p.  500. 


UNION  OF  DlVinEO  TKNDONS 


99 


Fi(i.40.  Tendon- 
lengthening  hy 
Czerny's  method. 
( D  e  n  t  u  an  d 
Delbet.) 


(b)  Method  of  Czermi  (Fif^.  41)).  CziMiiy,  in  a  case  in  which  one  of 
the  extensors  of  the  tliunil)  had  been  diviih'd,  filled  up  the  gap  by 
sphtting  the  ptM-ij)li(M'al  end  to  the  i'e(juii'ed  extent  and  reversing  it, 
suturing  the  lower  end  of  the  dis])Iaced  slip  to  the  divided 
central  end.  If  this  method  be  employed,  a  circular 
suture  should  be  inserted  at  the  angle  where  the  slip  is 
turned  down  so  as  to  prevent  its  being  torn  away.  Should 
this  happen,  the  separated  portion  of  the  tendon  is  almost 
certain  to  slough.  A  transverse  incision  is  made  between 
one  or  two  inches  above  the  free  end  of  the  proximal  part 
of  the  tendon,  according  to  the  size  of  the  gap  to  be  filled. 
The  incision  only  goes  across  half  of  the  tendon,  and  from 
this  point  the  latter  is  split  vertically  downwards  as  far 
as  a  point  from  a  (juarter  to  half  an  inch  from  the  cut 
end.  The  flap  is  then  turned  down,  care  being  taken 
that  it  is  not  detached,  and  to  meet  any  future  tension 
at  the  angle  sutures  are  passed  and  securely  tied  as 
described  above.  If  necessary  a  similar  flap  may  be 
turned  up  from  the  distal  portion  of  the  tendon.  Under 
these  circumstances  the  two  flaps  should  be  cut  long  enough  to  overlap,  so 
that  sutures  can  be  placed  between  their  contiguous  sides.  Here,  as  in 
all  cases  when  newly  united  tendons  are  submitted  to  some  tension, 
the  parts  must  be  kept  fully  relaxed  for  a  sufficient  time,  active  and 
passive  movements  begun  very  gently,  and  increased  very  gradually. 
Where  many  tendons — e.(j.  the  flexors  of  the  wrist — have  been  lengthened, 
it  may  be  wise  to  defer  active  movement  for  a  fortnight. 

In  the  method  of  Hibbs  (Fig.  45)  a  longitudinal  slip  is  turned  down  as 
in  Czerny's  method  ;  further  lengthening  is  then  obtained  by  splitting 
this  slip  in  a  similar  fashion,  the  transverse  incision  being  made  on  the 
opposite  side  of  the  tendon  to  the  first,  and  the  longitudinal  incision 
extending  upwards  towards  the  first  transverse  cut  (Fig.  45).  The 
angles  require  careful  strengthening  by  sutures. 

(c)  The  tendon  may  be  lengthened  by  some  method  requiring  a 
second  transverse  division  of  the  tendon.  Some  other  method  should, 
if  possible,  be  adopted,  for  there  is  a  strong  tendency  for  the  separated 
portion  to  slough.     When  the  tendon  is  thick  and  rounded,  Anderson's 

method  may  be  em- 
ployed. The  gap  that 
remains  between  the  two 
ends  of  the  tendon  hav- 
ing  been  carefully 
measured,  each  tendon  is 
split  accurately  in  the 
middle  line,  care  being 
taken  not  to  bring  the 
split  too  near  to  the  end 
of  the  tendon.     At  the 

two  ends  of  the  above  incision  section  of  the  opposite  halves  of  the 

tendon  is  made,  as  in  Fig.  41. 

(d)  Tendon  lengthening  by  zig-zag  incisions  (Fig.  42).  Poncet  has 
shown  that  this  method  may  be  successfully  employed  in  cases  where, 
owing  to  the  tension,  the  sutures  threaten  to  cut  through. 

In  the  first  case,  that  of  a  boy  whose  tendo  achillis  had  just  been  severed, 


s^ 


-4 4- 


.^s^' 


Fit;.  41.   One  method  of  tendon-lengthening,    a.  Tendon 

split  longitudinally,     b.  Section  completed  by  incisions 

at   ends  of  fissure,     c.  Divided  tendon    elongated  and 

sutured.     (Anderson.) 


100        OPERATIONS  ON  THE  UPPER  EXTREMITY 


zag 


M.  Poncet.  in  order  to  diminish  the  tension  so  as  to  allow  the  ends  to  come  together 

made,  on  the  upper  portion  of  the  tendon,  two  cuts  in  zigzag  fashion,  each  passing 

a  little  more  than  half  across  the  width  of  the  tendon.     Marked 

elongation  of  the  tendon  followed,  and  the  ends  were  then  easily 

sutured  without  tension.     The  boy  was  allowed  to  walk  on  the 

twenty-eigh.th  day,  and  left   the  hospital   about  seven   weeks 

after  the  injury,  walking  being  almost  perfect. 

While  this  method  is  especially  applicable  to  the 
tendo  achillis  owing  to  its  size.  M.  Poncet  has  also  used  it 
in  the  case  of  the  extensor  indicis.  The  incisions  should 
always  pass  through  at  least  half  the  width  of  the  ten- 
don ;  there  is  no  risk  of  the  tendon  sloughing  if  all  pre- 
cautions are  taken  to  avoid  infection  of  the  wound. 

(e)  Tendon  lengthening  hij  means  of  osteotomy.  M. 
Poncet  has  also  made  use  of  the  following  ingenious 
method  for  uniting  a  severed  tendo  achillis  (Fig.  43)  : 

Forty  days  after  the  injury  (by  an  axe)  the  wound  was  healed, 
but  the  ends  of  the  tendon  were  3  cm.  apart,  and  the  lameness 
was  very  disabling.  A  U-shaped  flap  having  been  turned  up- 
wards from  the  back  of  the  heel,  a  slice  of  the  os  calcis.  con- 
taining the  insertionof  the  tendon,  was  detached  vertically  by  a 
saw  ;  when  quite  loose  it  was  glided  upwards,  and  the  lower  part 
of  it  fixed  to  the  upper  part  of  the  sawn  surface  with  an  ivory 
peg.  The  ends  of  the  tendon  could  now  be  brought  into  close 
apposition  without  undue  tension.     The  result  was  perfect. 

(2)  Distance  sutures,  (a)  Distance  sutures  alone.  In 
some  cases,  where  the  ends  of  the  tendons  could  not  be  Fig.  42.  Tendon- 
adjusted,  the  widely  separated  lengthening  by  zig- 
ends  have  been  joined  by  suture 
loops  which  have  appeared  to 
diminish  muscular  tension,  and  to  help  in  directing 
the  process  of  repair.  Cat-gut  and  fine  silver  wire 
have  been  employed,  but  mercurialised  silk  {see 
footnote,  p.  106)  is  recommended  by  Mr.  Tubby  as 
the  most  satisfactory  material. 

Distance  sutures  seem  to  have  been  employed 
in  this  country  as  long  ago  as  1899.  by  Mr.  Gost- 
ling.  of  Worcester.^  in  a  case  of  injury  to  the  ex- 
tensors of  the  thumb. 

Eleven  weeks  before,  while  the  j^atient  was  pruning,  his 
knife  inflicted  a  wound,  the  scar  of  Avhich,  an  inch  in  length, 
was  found  an  inch  above  the  ba.se  of  the  metacarpal  of  the 
left  thumb.  Just  below  this  scar  the  di.stal  ends  of  the  ex- 
teiasor  primi  internodii  and  extensor  ossis  metacarpi  poUicis 
could  be  easily  felt,  but  the  proximal  ends 
could  only  be  indistinctly  made  out,  five 
inches  off.  on  the  back  of  the  forearm.  The 
left  hand  was  seriously  crippled,  the  thumb 
being  flexed  and  adducted  into  the  palm. 
An  incision  exposed  the  distal  ends  at  once, 
but  the  synovicil  sheath  was  blocked  for 
three-quarters  of  an  inch  bj^  scar  tissue. 
This  was  cut  through  and  the  sheath  slit 
up  until  the  proximal  ends  of  the  tendons 
w^ere  found.  All  four  ends  were  smoothly 
rounded  off.  and  no  adhesions  had  formed.  As  the  ends  were  five  inches  apart  it 
was  impossible  to  bring  them  nearer  together  than  three-quarters  of  an  inch.     The 

^  Lancet,  vol.  ii,  1890,  p.,767. 


incisions. 
(Poncet.) 


Fig.    43.     Suture  of    tendo    achillis    by 

partial   detachment  and  sliding  upward 

of    the    OS     calcis.       Poncet's     method. 

(Duplay  and  Reclus.) 


TENDON  GRAFTING 


101 


ends  having  been  pared,  the  corresponding  ends  were  nniled  hy  two  catgut  sutures. 
The  wound  healed  l)v  primary  union,  and  six  montiis  later  all  the  movements  of 
the  tiuiml>  were  perfect. 

M.  (iliick.  who  has  employed  the  method  of  distance  sutures  with 
marked   success   in   several    cases,    used    it   in   one    instance    not   for 

filling  up  a  gap    in    a  tendon,   but   for    re- 
placing an  end  which  was  lost.^ 

A  boy  had  the  tendons  of  the  exterusor  indicis 
and  the  extensor  communis  divided  as  the  result 
of  an  injury.  The  central  ends  were  tied  witli 
loops  of  silk  which  were  carried  to  their  points  of 
insertion  and  fixed  by  means  of  a  steel  needle.  The 
first  trial  failed,  the  sutures  tearing  out.  A  second 
ojieration  succeeded.  When  the  needle  was  removed, 
at  t  he  end  of  four  weeks,  both  t  he  middle  and  terminal 
phalanges  could  be  extended. 

In  another  case  in  which  the  two  ends  of 
tiie  flexor  tendons  of  the  middle  finger  were 
widely  separated  after  an  injury,  M.  Gliick^ 
was  able  to  remedy  a  gap  of  10  cm.  by  the 
substitution  of   threads   of   silk  and  catgut. 
Healing  by  first  intention  and  perfect  restora- 
tion of  movement  followed.     It  was  thought 
that  in  this  case  a  gradual  substitution  of  the 
catgut  by  connective  tissue  took  place.       In 
other  cases  the  foreign  body  employed  remains  long  encysted  in  a  sheath 
of  connective  tissue.     In  all  these  operations  strict  asepsis  is,  of  course, 
essential. 

(3)  Tendon-grafting.  Here  a  portion  of  another  tendon,  from  the 
same  patient,  in  cases  where  there  has  been  an  extensive  injury,  as  in 
a  partially  crushed  hand,  or  a  tendon  from  an  animal  is  made  use  of. 

Mr.  Mayo  Robson^"  successfully  grafted  four  and  a  half  inches  of  a  flexor  tendon  from 
a  finger  too  much  smashed  to  save,  on  to  the  dorsum  of  the  hand,  so  as  to  form  a  new 
extensor  for  the  index 
finger,  the  tendon  of  which 
had  been  completely  torn 
away.  The  proximal  end 
was  stitched  to  the  belly 
of  the  extensor  communis, 
where  the  missing  tendon 
had  been  originally  at- 
tached, the  distal  end  being 
fixed  to  the  small   portion 

left  near  its  insertion  into  the  phalanx.  The  case,  which  is  an  excellent  instance 
of  conservative  surgery,  ended  in  recovery  with  a  most  useful  hand.  During 
extension  of  the  index  the  new  tendon  could  be  felt  to  move  under  the  skin. 

Grafts  from  tendons  of  animals  are  extremely  likely  to  slough  or 
to  be  absorbed.  Even  if  no  suppuration  occur  the  grafts,  in  all  prob- 
ability, only  act  as  conductors  for  new^  fibrillse  as  in  the  case  of  distance 
sutures. 

Dr.  Rochet,  of  Lyons,  has  described  a  case  in  which  he  successfully 

practised  a  method  of  tendon-grafting,  which  he  called   autochthonous, 

the  graft  being  taken  from  one  of  the  divided  tendons  themselves  (Fig.  -16). 

This  method  is  especially  applicable  to  the  flexor  tendons  of  the  fingers. 

1  Semaim  Mediccde,  1892,  p.  198.  "   ^^oc.  supra  cit. 

3  Clin.  Soc.  Trans.,  vol.  xxii,  p.  291. 


Fig.  45.     Method  of  Hibbs. 


102        OPERATIONS  ON  THE  UPPER  EXTREMITY 


The  patient  had,  two  months  before,  suffered  division  of  the  flexor  tendons  at 
the  root  of  liis  right  index  finger.  The  two  lower  phalanges  were  constantly  extended, 
all  power  of  flexion  being  lost.  At  the  operation  an  interval  of  6  cm.  was  found 
between  the  divided  ends  which  by  no  means  could  be  reduced  to  less  than  2  cm. 

To  fill  this  gap  an  incision  was  made 
over  the  lower  ])art  of  the  middle  phalanx 
and  the  base  of  the  last,  just  where  the 
flexor  jirofundus  emerges  from  between 
the  two  slips  of  the  sublimis.  Dr. 
Rochet  divided  the  former,  and  then, 
returning  to  his  first  wound,  drew  the 
piece  of  the  flexor  pi'of  undus,  which  was 
now  cut  above  and  l)elow,  ujiwards  to 
All  the  gap,  the  attachments  of  the  ten- 
don to  the  sheath  yielding  readily.  The 
lower  end  of  this  tendon-slip  was  then 
sutured  to  the  distal  end  of  the  flexor 
sublimis,  and  its  u])])er  end  to  the 
proximal  ends  of  the  flexor  sublimis  and 
pi'ofundus — directly  to  the  former  ten- 
don, and  latterly  to  the  later.  Lastly, 
the  small  slip  of  the  flexor  profundus, 
which  had  been  left  attached  to  the  last 
phalanx,  was  sutured  to  the  two  slips  of 
the  flexor  sublimis  a  little  above  its  in- 
sertion into  the  phalanx.  On  the  fif- 
teenth day  some  power  of  flexion  was 
already  present.  Eventually  the  second 
phalanx  could  be  flexed  as  freely  as  that 
of  the  other  hand.  Flexion  of  the  third 
phalanx  was  more  limited,  this  not  pass- 
ing beyond  a  very  obtuse  angle. 

Dr.  Rochet  observes  that  it  would 
be  possible  to  carry  out  this  method  by 
taking  the  graft  from  the  ])roximal  por- 
tion of  the  divided  tendon  without  in- 
terfering with  its  insertion  or  making  a 
fresh  wound. 

M.  Desquin  has  devised  another  method  of  tendon -grafting,  by 
which  the  use  of  a  flexor  tendon  was  restored. 

A  carpenter,  a^t.  25,  had  the  right  middle  finger  in  permanent  extension,  owing 
to  the  severance  of  the  flexor  tendons  by  broken  glass  thirteen  months  before.  A 
free  incision  having  been  made  along  the  course  of  the  tendons  in  the  finger  and  in 
the  palm,  an  interval  of  4-5  em.  was  found  between  the  divided  ends  of  the  super- 
ficial tendon,  while  it  was  impossible  to  find  the  deep  tendon.  By  strong  traction  on 
the  central  end  of  the  superficial  tendon,  it  could  be  brought  into  contact  with  and 
sutured  to  the  jihalangeal  end.  This  could  only  be  done  by  strongly  flexing  the 
finger,  and  it  would  have  been  impossible  to  unite  the  superficial  parts  over  the 
strongly  flexed  tendon.  Returning  to  the  wrist,  therefore,  th(>  operator  divided  the 
tendon  with  a  small  piece  of  muscle  adhering.  The  flnger  was  then  extended  and 
the  tendon  just  divided  stitched  to  that  for  the  index  finger,  so  that  the  flexor  for 
the  latter,  on  its  contraction  acted  ujion  both  fingers.     The  result  was  perfect. 

Resection  of  bone  in  aid  of  tendon-suture.  It  will  suffice  merely  to 
allude  to  this  method,  which  can  only  rarely  be  justifiable.  K.  Lobker^ 
seems  to  have  been  the  first  to  make  use  of  it.  In  a  case  of  long-standing 
division  of  the  tendons  above  the  wrist,  portions  of  the  radius  and  ulnar 
were  resected.  The  result  was  only  a  partial  success,  and  the  bones  took 
three  months  to  unite  firmly.  Mr.  R.  P.  Rowlands  has  used  this  method 
most  successfully.- 

TENDON  SHORTENING 

This  may  be  occasionally  called  for  in  some  cases  of  acquired  talipes 
calcaneus,  where  the  tendo  achillis  is  elongated.     As  these  cases  are 
1  Centr.f.  Chir.,  1884,  No.  50.  2  Lancet,  Oct.  21,  1905. 


Fig.  40.  Autochthonous  tendon-grafting. 
(Rochet.)  To  the  right  is  seen  the  gap 
between  the  tendons  found  on  exploration; 
to  the  left  the  manner  in  which  it  was  filled  up. 


TKNDON  SHORTENING 


103 


usiuilly  due  to  inliintilc  paralysis  a  careful  examination  of  the  electrical 
reaction  of  th(>  calf  muscles  should  be  made  before  the  operation.  When 
these  muscles  arc  com])letely  paralysed  and  have  undergone  fatty  de- 
generation, shortening  ot  the  tendo  achillis  is  useless.  Conversely,  if  the 
electrical  examination  shows  that  tiiere  is  some  healthy  muscle  ti.ssue  left, 
it  is  well  to  postpone  tiie  shortening  of  the  tendon  till  as  much  good  as 
possible  has  oeen  obtained  by  a  systematic  course  of  electrical  treat- 
ment, combined  with  massage  of  the  calf  muscles.  In  suitable  cases 
the  tendo  achillis  may  be  shortened  by  one  of  the  following  methods  : 

(1)  Willets  method. "^  A  Y-shaped  incision,  some  two  inches  in 
length,  is  made  over  the  lower  end  of  the  tendo  achillis  down  to  the 
tendon.  At  the  lower  or  vertical  point  of  the  incision  the  dissection 
is  continued  until  the  tendon  is  fully  exposed  over  its  superficial  and 
lateral  surfaces  for  the  space  of  one  inch  in  length,  its  deep  connections 
being  left  undisturbed.  The  tendon  is  now  cut  across  at  the  point 
of  junction  of  the  obliipie  portion  of  the  wound  with  the  vertical.  Next 
the  proximal  portion  of  the  tendon  is  raised,  with  its  superficial  con- 
nections to  the  integument  undisturbed,  to  the  extent  of  fully  three- 
quarters  of  an  inch,  by  dissecting  along  its  upper  surface,  i.e.  by  re- 
versing the  dissection  made  upon  the  distal  segment.  A  wedge-shaped 
slice  of  the  tendon  is  now  cut  o£E  from  both  segments,  that  from  the 
proximal  being  removed  from  the  deep  surface,  whilst  from  the  distal 
it  is  taken  from  the  superficial ;  in  both  instances  the  face  of  the  wedge- 
shaped  portion  removed  being  at  the  point  where  the  tendon  has  been 
divided.  The  heel  being  now  pressed  upwards,  the  proximal  portion, 
including  both  skin  and  tendon,  is  drawn  down  and  placed  over  the 
distal,  thus  bringing  the  prepared  cut  surfaces  of  the  tendon  into  apposi- 
tion. In  this  position  they  are  held  by  an  assistant  whilst 
four  sutures,  two  on  either  side,  are  passed  deeply  through 
the  integument,  then  through  both  portions  of  the  tendon, 
and  again  out  through  the  integument,  and  fastened. 
When  the  operation  is  completed,  the  united  edges  of  the 
w^ound  assume  a  V-shaped  appearance,  owing  to  the  angle 
of  the  proximal  portion  being  now  attached  to  the  terminal 
point  of  the  distal  portion  of  the  original  incision." 

(2)  Z-shaped  method.  This  is  described  in  the  oper- 
ations on  the  lower  extremity. 

(3)  outer's  method  of  tendon  shortening  without  in- 
terrupting its  continuity.-  When  the  tendon  is  large,  he 
removes  wdth  a  very  small  knife,  the  central  part.  A  window 
having  been  thus  made,  the  upper  and  lower  ends  are 
brought  together  with  sutures,  and  the  lateral  bands,  folding 
upon  either  side,  contribute  to  the  joining  of  the  two  ends. 

Where  the  tendon  is  narrow,  instead  of  making  a 
window,  M.  Oilier  adopts  the  plan  shown  in  Fig.  -17. 
In  either  case  sutures  of  fine  sterilised  silk  should 
strengthen  the  spot  where  the  folded  portions  join  the  main  tendon. 


Fig.  47. 


TENDON-TRANSPLANTATION,  MORE    ESPECIALLY    IN   RELATION 
TO  ITS  EMPLOYMENT  IN  INFANTILE  PARALYSIS 

It  will  be  convenient  to  study  here,  owing  to  their  association  with 
operations   on   tendons,   the   surgical  treatment   of  infantile   paralysis, 

1  St.  Bartholomew'' s  Hospital  Reports,  vol.  xvi.  p.  309. 
-   Traite  des  Resection,  vol.  ii,  p.  473. 


104       OPERATIONS  ON  THE  UPPER  EXTREMITY 

spastic  paralysis,  and  the  so-called  ischsemic  paralysis,  though  most  of 
these  concern  the  lower  extremity.  Arthrodesis,  or  the  artificial  stiffen- 
ing of  frail  joints,  which  has  often  to  be  combined  with  transplanta- 
tion of  tendons  in  infantile  paralysis,  will  be  considered  in  the  surgery 
of  the  low^er  extremity  (q.v.). 

The  object  of  tendon-transplantation  is  to  reinforce  a  paralysed 
muscle  by  attaching  to  its  tendon  one  or  more  tendons  of  adjacent  healthy 
muscles.  This  mode  of  treatment  deserves  most  careful  consideration 
owing  to  the  great  frequency  of  infantile  paralysis,  especially  in  our 
large  towns ;  the  lifelong  crippling  which  it  entails,  including,  not 
infrequently,  it  should  be  remembered,  amputation  in  early  adult  life 
on  account  of  established  trophic  ulcers  ;  the  expense  involved  by 
mechanical  treatment,  extending,  as  this  usually  does,  over  a  lifetime  ; 
the  limited  amount  of  good  w^hich  other  operations — e.g.  tenotomy — 
usually  effect ;  and  the  fact  that  transplantation  of  tendons,  of  itself 
not  a  severe  operation,  can  be  employed  early  in  life,  when  the  muscles 
on  which  additional  work  is  placed  have  not  yet  reached  their  full 
development,  and  when  at  the  same  time  the  paralysed  muscles  have 
not  yet  had  time  to  undergo  those  secondary  changes  which  are  so 
baffling  to  the  surgeon.  On  the  other  hand,  it  is  necesi^aiy  to  point  out 
the  discredit  which  will  fall  upon  this  method  if  the  conditions  which 
surround  it,  owing  to  the  pathology  of  the  disease  which  may  call  for  it, 
are  forgotten,  if  too  much  is  expected  of  it,  if  operations  be  performed 
indiscriminately,  if  no  definite  plan  is  formulated,  based  on  very  careful 
previous  examination,  before  any  transplantation  is  undertaken,  and 
if  the  need  of  unremitting  after-attention  for  long  periods  be  lost 
sight  of. 

As  long  ago  as  1882  Nicoladoni  ^  recorded  a  case  of  paralytic  tahpes 
calcaneus  in  which  he  reinforced  the  tendo  achillis  with  the  two  peronei, 
with  a  good  result.  Drobnik,  of  Posen,  published  in  1892  ^  the  first 
series  of  cases,  sixteen  in  all.  Dr.  Milliken^  and  Dr.  E.  H.  Bradford,^ 
Surgeon  to  the  Children's  Hospital  at  Boston,*  were  amongst  the  pioneers 
in  this  work  in  America.  In  this  country,  first  Mr.  R.  J.  Jones,  of 
Liverpool,  and,  later,  Mr.  A.  H.  Tubby,  have  brought  this  method  of 
treatment  of  a  very  disheartening  disease  prominently  before  the  pro- 
fession in  the  Medical  Amiual  for  1889  and  the  Liverpool  Medico- 
Chirurgical  Revieiv  1899,  p.  270,  and  more  recently  in  their  "  Surgery  of 
Paralyses,"  1903.  The  credit  of  whatever  time  proves  to  be  of  real 
value  in  the  account  that  follows  must  be  given  to  these  writers  especially. 

PRELIMINARY  POINTS  IN  TENDON-TRANSPLANTATION  ^ 

"  Before  it  is  decided  to  perform  the  operation  the  case  must  be  carefully  studied, 
and  a  definite  plan  of  procedure  formulated.  The  electrical  reactions  of  the  muscles 
should  be  pre\aously  ascertained,  and  an  attempt  made  to  estimate  the  strength  of 
those  which  it  is  intended  to  transplant.  In  the  case  of  the  foot  all  secondary 
conditions,  such  for  instance  as  contraction  of  the  plantar  fascia  should  be  remedied. 
For  mechanical  reasons  it  is  advisable  to  select  the  reinforcing  tendon  from  a  muscle 
whose  line  of  action  is  as  nearly  as  possible  parallel  with  that  of  the  muscle  to  be 
reinforced.  For  instance,  in  a  case  of  paralytic  valgus  it  may  be  better  to  graft  a 
strip  of  the  tendo  achillis  into  the  tibialis  po.sticus  rather  than  to  bring  the  tendon  of 
the  peroneus  longus  across  the  front  of  the  ankle,  and  into  the  tibialis  posticus.  It 
is  also  miportant  to  remember  that  muscles  which  before  the  operation  appear  to 
be  hopelessly  paralysed,  exhibit  after  the  operation  signs  of  returning  strength.  The 
operation  is  rarely  called  for  when  onty  one  muscle  is  jiaralysed,  nor  should  it  be 

1  Arch.  j.  Hin.  rhir.,  Bd.  xxvii,  S.  G60.  -  Zeit.f.  Chir.,  Bd.  xliii,  S.  473. 

3  New  York  Med.  Record,  Nov.  28,  1896.  4  Ann.  of  Surg.,  Aug.  1897. 

^  Tubby  and  Jones,  p.  159. 


TENDON-TRANSPLANTATION 


105 


Fig.  48.  The  pero- 
neus  longus  tendon 
has  been  drawn 
through  and  fixed 
on  to  the  back  of 
the  tendo  achillis. 
The  ends  of  the  pero- 
neus  tendon  are  sewn 
on  to  the  back  of  the 
tendo  achillis  at  d 
and  E,  having  been 
first  drawn  through 
the  tendon  at  c. 
(Tubby  and  Jones.) 


done  when  nearly  all  the  muscles  round  a  joint  are  implicated.  Tlic  latter  cases  aro 
suitable  only  for  artliroil(>His  {(/.v.,  operations  on  the  lower  extremity),  and,  indeed, 
there  is  a  fear  that  an  indiscriminate  use  of  transplantation  may  lead  to  unsatisfactory 
results,  and  so  bring  the  operation  into  undeserved  discredit.  A  great  point  is  the 
choice  of  cases." 

The  selected  muscle  should  belong,  if  possible,  to  the  same  group  as  the  paralysed 
one,  because  it  is  nearest,  and  restoration  of  voluntary  function  is  thus  more  quickly 
and  perfectly  secured.  "  The  reinforcing  tendon  should  be 
carried  as  directly  as  possible  to  the  paralysed  muscle,  and 
not  bent  round  at  an  angle,  a  manreuvre  which  has  the  effect  of 
considerably  lessening  the  transfer  of  power.  For  instance, 
if  the  peroucus  brevis  were  used  to  reinforce  the  extensor 
communis  digitorum,  the  former  should  be  attached  to  the 
latter  above  the  ankle,  and  not  below  and  in  front  of  the  ex- 
ternal malleolus.  When  an  opponent  of  a  paralysed  muscle 
is  selected,  it  gives  emphasis  to  this  principle,  namely,  that 
by  selecting  one  of  the  opponents  of  a  paralysed  muscle  we 
not  only  reinforce  that  weak  muscle,  but  we  lessen  the  an- 
tagonism which  exists  between  the  two  groups.  And  by  trans- 
ferring, for  example,  the  insertion  of  the  peroneus  longus  in  a 
case  of  paralytic  talipes  valgus  from  the  outer  to  the  inner 
border  of  the  foot,  we  effect  an  equality  between  the  forces 
acting  upon  the  two  borders."  Mr.  Tubby  ^  mentions  the 
following  methods  of  tendon-transplantation  : 

A.  Intermediate  Methods.  (1)  The 
tendon  of  a  healthy  muscle  is  completely 
cut  across  near  its  peripheral  extremity, 
and  its  central  end  is  inserted  into  the 
paralysed  tendon  (Figs.  48  and  49). 

(2)  The  central  end  of  the  divided 
healthy  tendon  is  attached  to  a  strip  from  the  distal  part  of  the 
paralysed  tendon. 

(3)  The  healthy  and  the  paralysed  tendons  are  divided, 
the  central  end  of  the  active  one  is  joined  to  the  distal  end  of 
the  paralysed,  and  the  proximal  end  of  the  paralysed  is  joined 
to  the  distal  end  of  the  active.  This  is  the  "  complete  in- 
terchange "  method. 

(4)  The  paralysed  tendon  is  cut  across,  and  its  distal  end 
is  sutured  to  that  of  a  healthy  muscle. 

(5)  A  strip  is  taken  from  the  central  part  of  a  healthy 
tendon,  and  is  attached  directly  to  the  undivided  paralysed 
tendon  (Figs.  51  and  52). 

(6)  A  strip  from  the  central  part  of  the  healthy  tendon  is 
joined  to  a  strip  from  the  distal  part  of  the  paralysed  tendon. 

This  method  gives  better  results  than  others,  because  the 
continuity  of  the  healthy  tendon  is  not  destroyed  completely, 
and  its  action  is  fully  conserved.  Moreover,  as  the  continuity 
of  the  paralysed  tendon  is  not  interrupted,  if  some  recovery 
takes  place  later  in  the  apparently  paralysed  muscle,  or  if 
any  power  remains  in  it,  aid  is  given  to  the  reinforcing  strip 
from  the  healthy  tendon. 

B.  The  Immediate  Method.  Here  the  healthy  tendon  is 
divided  and  is  then  directly  attached  to  the  periosteum. 

This  method  has  been   strongly  advocated    by  Lange,  of 
Munich,  who  ascribes  many  of  the  failures  in  tendon-grafting 
to  subsequent  stretching  of  the  paralysed  and  degenerated  ten- 
don.2     Where  the  distance   between  the  sound  tendon  and 
its  new  insertion  is  too  great,  this  surgeon  employs  artificial 
tendons  of  silk  (Fig.  50).  He  reports  fifty-six  cases.      In  only 
two  was  the  result  unsatisfactory.      In  a  case  of  paralysis  of 
the  quadriceps  extensor,  where  attempts  to   correct   the  de- 
formity by  suture  of  the  sartorius  had  failed,  Lange  brought  the  semi-tendinosus 
and  biceps  forward  under  the  skin,  after  freeing  them  from  their  insertions.     The 
ends  were  now  found  to  be  so  far  above  the  patella  that  it  was  impossible  to  suture 
^  Deformities,  vol.  ii,  p.  626. 

2  Munch.  Med.  Woch.,  April  1900,  Jan.  7,  1902,  and  Med.  Record,  vol.  v,  No.  3,  pp. 
143-145. 


Fig.  49.  Tendon- 
grafting  for  relief  of 
paralji;ic  talipes  cal- 
caneus by  insertion  of 
the  peroneus  longus 
tendon  a  into  the 
tendo  achillis  at  h. 
At  c  is  seen  the  distal 
end  of  the  peroneus 
longus.  (Tubby  and 
Jones.) 


106       OPERATIONS  ON  THE  UPPER  EXTREMITY 


Biceps 


Semilcndinosus. 


Fig.  50.  Langc's  method  of 
artificially  elongating  the  trans- 
planted hamstring  tendons  by  silk 
sutures,  so  as  to  effect  a  junction 
with  the  tubercle  of  the  tibia. 
(Tubby  and  Jones,  after  Liinge). 


them  to  the  ligameutum  patellae.     A  serviceable  silk  tendon  was  provided  by  the 
passage   of  a  number  of   silk  threads  through  the  tendinous  ends  of  the    trans- 

jilanted  muscles  above,  and  the  jieri- 

osteum  of  the  tubercle  of  the  tibia 

below,    giving   eventually  excellent 

power  of  extension.     Several  of  the 

artificial  tendons  were  eight  inches 

long.     When,  some  months  after  the 

operation,  the  transplanted  muscles 

began  to  act,  and  render  the  silk  cords  constantly 

tight,  these  steadily  increased  in  thickness.     It  is 

probable  that  the  increase  in  size  was  due  to  the 

formation  of  fibrous  tissue  around  the  silk. 

Of  this  method  Mr.  Tubby  says  :  "  There  is  no 
doubt  that  the  immediate  method  of  I^ange  marks 
a  great  advance  over  the  older  methods  and  has 
rapidly  displaced  them." 

Before  the  operation  all  secondary  deformities, 
such  as  contraction  of  fascia%  must  be  remedied. 
The  importance  of  electrically  testing  the  muscles 
has  already  been  emphasised.  Care  must  be  taken 
to  select  such  tendons  as  will  improve  function 
and  diminish  deformity.  Mr.  Tubby  insists  on 
the  necessity  of  a  clear  con-  .    - 

ception  of  the  relative  import- 
ance of  the  functions  of  the 
part.  He  also  points  out  that 
the  operation  should  be  em- 
ployed in  the  stationary  stage  of  infantile  paralysis  when  if 
is  quite  certain  that  the  trouble  is  otherwise  irremediable. 

Technique  of  the  Operation.  Needless  to  say  the  most  careful 
precautions  must  be  taken  to  avoid  sepsis.  "In  many  cases 
a  single  incision  will  suffice,  but  it  sometimes  happens  that,  to 
avoid  a  single  large  incision,  two  smaller  ones  are  made,  e.g. 
when  the  ])croneus  longus  is  transferred  to  the  inner  border  of 
the  foot.  In  this  case  one  incision  is  made  over  the  front  of  the 
fibula,  and  a  second  over  the  scaphoid.^  By  burrowing  through 
the  subcutaneous  tissues  of  the  dorsum  of  the  foot  with  a 
director,  a  channel  is  made  for  the  passage  of  the  tendon  to  the 
scaphoid.  It  is  curious  to  remark  that  no  adhesion  of  the 
transplanted  tendon  takes  place  to  the  subcutaneous  tissue 
doubtless  from  the  endothelium  on  its  surface :  hence  we 
learn  the  necessity  of  handling  the  tendons  very  carefully." 
As  regards  the  actual  method  to  be  adopted  Mr.  Tubby  re- 
marks :  "  If  we  use  the  intermediate  method,  it  is  generally 
conceded  that  the  best  results  have  been  obtained  by  one  of 
two  procedures.  Either  joining  a  strip  of  the  reinforcing  tendon 
to  one  taken  from  the  paralysed  one,  or,  better  still,  laying  the 
strips  side  by  side  and  firmly  uniting  them.  Undoubtedly, 
however,  the  most  reliable  results  are  reached  by  Lilnge's 
direct  periosteal  implantation."  2  Great  care  must  be  taken  to 
avoid  any  twisting  of  the  tendon  or  bending  it  at  an  angle. 
Mr.  Tubby  advises  that  sterilisable  electrodes  should  be  at 
hand  in  case  it  should  be  thought  necessary  to  ascertain  the 
condition  of  the  muscles.     This  may  also   be  determined  by 

inspection.     "Thus  a  healthy  muscle  is  dark  red,  and  its  tendon    divided  at  ?>.  (Tubby 
is  glistening  white  ;  a  paralysed  muscle  and  tendon  are  yellow-  'i"d  Jones.) 

white,  a  partially  paralysed  muscle  is  mottled,  red  and  yellow, 

^  Needless  incisions  for  exploration  should  be  avoided.  These  cases,  long  the  subjects 
of  trophic  lesions,  are  not  ideal  ones  for  securing  primary  union.  Further,  any  incisions 
required  should  not  be  too  long  ;  the  scars  are  undoubtedly  liable  to  become  keloid,  a 
result  which  may  interfere  with  the  after-treatment,  and  the  pressure  of  boots. 

2  When  Lange's  method  is  employed,  the  silk  for  artificial  tendons  should  be  prepared 
as  follows  :  "  The  skein  of  silk  is  undone  and  soaked  for  half  an  hour  in  ether,  and  then 
for  a  few  minutes  in  alcohol.  It  is  then  boiled  for  one  hour  and  placed  for  a  week  in  a 
solution  of  1  in  1000  biniodide  of  mercury.  It  is  finally  wound  on  glass  reels  and  always 
kept  in  this  solution." 


Fig.  51.  Operation 
for  relief  of  paralytic 
talipes  equino-val- 
gus.  The  inner  part 
of  the  gastrocnemius 
andtendo  achillis  is 
split  off  at  u,(i.  and 


TENDON-TRANSPLANTATION 


107 


and  the  tendoii  is  wliifo.      Tho  last-named  muscles  will  respond  partly  to  stimuli, 
and  cannot  be  regarded  as  entirely  useless. 

After -trentmcnt.  "The  j)ar(s  are  kept  absolutely  at  rest  in  the  new  position  for  at 
least  six  weeks,  in  ])laster  of  Paris.  The  greatest  danger  of  relapse  is  when  this  is 
taken  olf,  so  that  suitable  su])])orts  should  be  einployi-d  both 
by  night  and  day  to  limit  the  movements.  And  here  no 
fixed  rules  can  be  given;  experience  alone  is  useful.  Move- 
ments must  be  limited  at  first,  and  then  very  gradually  in- 
creased. The  nutrition  of  the  nuisele  of  the  transplanted  \ 
tendon  should  be  maintained  at  its  highest  i)oint  by  very 
careful  massage,  and  by  weak  electric  currents,  and  efforts 
arc  made  to  re-educate  the  transplanted  nuisde  and  tendon 
to  their  new  function." 

Details  of  tlie  various  operations  will  be  found  in 
the  description  of  the  operative  treatment  of  the 
different  forms  of  talipes  in  vol.  ii. 

Infantile  Spastic  Paralysis,  or  Cerebral  Paralysis  of  Chil- 
dren.^ The  two  authors  from  whom  the  above  quotations 
have  been  made  group  their  cas(»s  into  (1)  infantile  hemiplegia  ; 
(2)  cerebral  diplegia  ;  (3)  s[)astic  paralysis.  In  cerebral 
tliplegia,  while  rigidity  and  paralysis  are  associated,  rigidity 
is  the  more  striking  feature  ;  in  the  hemiplegic  form  paralysis 
preponderates,  the  rigidity  being  secondary  to  it.     Again,  in 

the   hemiplegic   form,    the    arm    is 

more  affected  than  the  leg,  but  this 

is  not  so  with  the  diplegic  form. 
The  following  facts  are  of  chief 

interest  to    the   surgeon :     (a)   The 

upper  limb,  when  affected,  is  more 

seriously  implicated  than  the  lower. 

(b)  The  lesion  of  the  upper  limb  is 

more  permanent,     (c)  The  power  of 

dorsi-tlexion  of  the    hand  and  the 

simultaneous  extension  of  the  fingers 

is    lost,      (d)  The    movements    are 

performed  without  precision,  spas- 
modically   and    slowly.        (e)    The 

power  of  the  thumb  is  often  lost. 
The    disabilities    of    the    lower 

limb  are  generally :  (a)  Contraction 


Fig.  52.  The  second 
stage  of  the  operation 
for  the  relief  of  para- 
lytic talipes  equino- 
valgus.  The  inner 
half  of  the  gastroc- 
nemius and  tendo 
achillis  a  is  brought 
forward  and  united 
either  to  the  tibialis 
posticus  b,  or  the  peri- 
osteum of  the  sca- 
phoid. The  third  stage 
consists  in  division  of 


Fig.  53.  Tendo-transplan- 
tation  for  the  relief  of 
talipes  valgus.  The  pero- 
nsus  brevis,  a,  is  divided 
and  inserted  into  the 
tibialis  anticus,  c,  at  e.  At 
d  is  seen  the  distal  end  of 
the  peroneus  brevis,  and  b 
marks  the  peroneus  longus. 
(Tubby  and  Jones.) 


the  outer  half  of  the 
tendo  achillis  in  order 
to  relieve  the  equinus. 
(Tubby  and  Jones.) 

Clinically  this  group 


of  the  knee,  (b)  Extension  of  the 
foot.  {('.)  Internal  rotation  of  the 
femur,  with  adduction,  (d)  Rigidity. 
The  cerebral  diplegic  form  is  by 
far  the  most  serious,  as  we  have  to 
deal  here  with  both  arms  and  legs. 

may  be  divided  into :  (a)  Cases  with  and  without  severe 
mental  complications,  (b)  Complete  and  partial  dis- 
ability of  the  hands,  (c)  Complete  and  partial  disability 
of  the  limbs,  (rf)  Cases  associated  with  athetotic  move- 
ments. 

A.  The  classes  of  cases  which  are  and  are  not  adapted 
to  treatment.  "  A  suitable  case  for  treatment  is  a  child 
or  young  adult  of  fair  intellectual  development,  who  has 
had  no  fits  for  tliree  or  four  years.  Such  a  case  may  be 
brought  with  the  following  conditions  :  The  feet  are  in 
a  state  of  talipes  equinus  or  equino-varus.  The  knees  are  flexed  owing  to  the 
tightly  contracted   hamstrings,  and  they   knock   together   on    account  of    the  ad- 

^  Though  the  lesions  of  this  disease  also  are  chiefly  met  with  in  the  lower  extremities, 
they  are  dealt  with  here  for  convenience'  sake.  For  a  full  description  of  the  deformities 
due  to  this  hitherto  most  unpromising  disease,  readers  are  referred  to  Messrs.  Tubby 
and  Jones's  Surgery  of  Paralyses,  and  to  Mr.  Tubby's  Deformities  (1912)  from  which 
this  account  is  taken. 


108       OPERATIONS  ON  THE  UPPER  EXTREMITY 

duction  of  the  thighs.     The  thiglis  are  flexed  and  inverted,  and  the  tensor  fascia; 
femoris.  sartorius.  and  ilio-tibial  band  are  rigidly  contracted. 

B.  The  classes  of  cases  which  are  entirely  unsuited  for  treatment  ar?  the  idiotic, 
th?  microcephalic  and  the  violently  irritable  diplegic  who  is  .'subject  to  fits,  active 
athetotic  movements  and  convulsions,  and  the  patient  who  has  no  control  over  the 
sphincters.  Another  cla.ss  of  case  which  is  not  hopeful  for  treatment  is  where  the 
affection  of  the  hands  is  of  such  a  character  as  to  promise  but  slight  hope  of  their 
assistance  to  the  lower  limbs  dm-ing  walking  with  crutches.  That  is  to  say,  if  the 
paralysis  is  complete,  or  if  spasm  of  the  hand  and  arm  never  relaxes,  treatment  is 
of  little  avail. 

It  is  important  to  recognise  the  length  of  treatment  required.  Active  treatment 
may  be  required  for  many  months,  and  it  is  therefore  unwise  to  undertake  a  case  in 
the  hospital  for  a  month  or  two,  and  then  to  send  it  to  a  miserable  home,  where 
neglect  will  be  the  inevitable  consequence.  Even  after  active  treatment  has  ceased, 
massage,  skilfully  directed  exercises,  with  careful  and  thorough  education  of  the 
muscles  in  acquiring  new  movements,  must  be  carried  out  for  some  years.  It  is 
therefore  necessan,'  to  secure  the  co-operation  of  intelligent 
parents,  anxious  to  do  all  they  can  for  their  cliild  and 
w  illing  to  face  all  the  trouble  involved  in  careful  training. 
The  principles  upon  which  operative  treatment  is  ad- 
vised are  as  follows:  (1)  A  constant  Ij-  over-stretched  para- 
lysed muscle  tends  to  become  progressivelj-  weak  and 
degenerate.  By  tenotomy  they  are  placed  in  a  state  of 
rest  and  may  then  recover.  (2)  Excessive  deep  reflexes 
are  characteristic  of  thir.  disease  ;  it  is  therefore  of  the 
greatest  importance,  if  possible,  to  limit  tliis  excitabiUty. 
The  tension  of  a  muscle  is  reflexly  dependent  upon  the 
tension  of  its  tendon.  If  the  tendon  of  a  tightly  con- 
tracted muscle  is  divided,  the  stimuli  wliich  it  sends  to  the 
cord,  and  which  are  thence  reflected  to  the  muscles,  abate. 
The  vicious  circle  is  thus  broken,  and  the  muscle  is  no 
longer  tonically  contracted. 

Thus,  in  spastic  talipes  equinus.  division  of  the  tendo 
Fig.  54.  Transplantation  achiUis  will  enable  the  pointed  condition  of  the  foot  to  be 
of  the  sartorius  into  the  remedied,  and  prevent  over-stretching  of  the  paretic  ex- 
patella  at  a  to  reinforce  tensors  which  are  in  this  way  placed  in  a  state  of  rest  and 
a  paralysed  quadriceps,  therefore  in  a  position  of  recover^'.  Again  by  division  of 
The  distal  part  of  the  the  tendo  achillis,  the  reflex  excitability  of  the  calf  muscles 
divided  sartorius  is  seen  has  been  largely  abohshed  ;  and  not'  only  so,  but  the 
at  6.  (Tubby  and  Jones.)  authors  believe  that  the  removal  of  this  excessive  reflex 
excitability  of  the  cord  permits  of  that  quiescence  of  the 
nerve  centres  so  essential  to  the  welfare  of  these  children. 

Treatment.  This  falls  into  the  following  divisions  :  A.  Operative  and  B.  post- 
operative. (1)  Treatment  of  the  upper  extremities  ;  (2)  Treatment  in  the  case  of  the 
lower  extremities. 

(1)  Treatment  in  the  case  of  the  upper  extremities.  The  most  pronounced 
deformities  here  are  flexion  of  the  elbow,  pronation  of  the  forearm,  and  flexion  of  the 
wrist  and  fingers.  The  operative  procedures  consist  of  tenotomy,  tendon  trans- 
plantation, and  lengthening  of  tendons.  In  all  cases  it  is  best  to  commence  bj- 
relieving  the  spasm  of  the  flexor  tendons  at  the  wrist,  remembering  that  in  spastic 
conditions  there  is  danger  of  over-correction.  Mr.  Tubby  recommends  (a)  lengthen- 
ing the  tendons  of  the  flexor  sublimis  and  profundus  at  the  wrist  by  the  Z-method. 
(h)  In  order  to  overcome  spasm  of  the  caqial  flexors,  transplantation  of  the 
flexor  carpi  radiahs  and  the  flexor  carpi  ulnaris  to  the  dorsal  surface  of  the  bases 
of  the  second  and  fifth  metacarpals,  as  originally  suggested  by  ]\Ir.  R.  Jones. 
When  the  tendons  are  not  long  enough,  Lange"s  method  of  prolonging  them  by 
strands  of  silk  may  be  employed.  Great  care  must  be  taken  to  avoid  matting  of 
tendons  or  much  stiffness  may  result.  To  relieve  the  flexion  of  the  elbow  and  ex- 
cessive pronation  of  the  forearm  Mr.  Tubby  describes  an  operation  for  converting 
the  pronator  radii  teres  into  a  supinator  by  transplanting  its  tendon  behind  the 
radius,  through  an  incision  in  the  interosseous  membrane,  to  the  outer  side  of  the 
radius.^ 

The   after-treatment   consists   in   educating   and    training    the    limb   in  its   new 
1  This  operation  is  described  by  Mr.  Tubby  in  the  Brit.  Med.  .Journ.,  Sept.  7,  1901,  and 
with  several  important  modifications,  in  Deformities  (1912),  vol.  ii,  p.  729. 


TENDON-TRANSPLANTATION 


109 


position.  Passive  movements  are  at  first  limited,  so  as  not  to  stretch  the  bands 
of  union  unduly,  and  after  the  sixth  week  they  are  more  extensive.  At  the 
latter  date  active  movements  are  begun.  The  principles  which  should  guide 
them  are  as  foUo.v:  (a)  The  movements  should  bo  pra'tisod  slowly  without 
excitement.  (6)  They  sliould  bo  made  interesting  to  the  patient,  (c)  Those 
movements  wliicli  are  op[)osed  to  the  direction  of  the  deff)rMiity  should  predomi- 
nate,    (d)  Those  presenting  the  greatest  difficulty  should  be  chiefly  jjractised. 

(2)  Treatment  in  the  ca^c  of  the  lower  extremities.  The  following  series  of  operations 
on  the  hip.  knee,  and  ankle  may  be  required,  and  aro  per- 
formed, if  necessary,  in  stages.  Open  operation  is  always 
indicated.  The  adductors  of  the  thigh  are  first  dealt 
with.  The  adductor  longus  is  exposed  through  a  longi- 
tudinal incision  and  three-quarters  of  an  inch  of  its  tendon 
is  excised.  The  limb  is  abducted  and  the  adductor  brevis 
and  the  gracilis  are  treated  in  the  same  way.  If  needful, 
the  horizontal  ])art  of  the  adductor  magnus  and  the  pec- 
tineus  are  divided ;  in  fact,  every  tissue  which  limits  free 
abduction;  the  sartorius,  tensor  fasciEe  femoris,  and  ilio- 
tibial  band  are  divided  in  the  same  way.  The  knee  is  then 
dealt  with  by  longitudinal  incisions,  one  on  either  side 
usually  sufficing.  By  burrowing  under  the  subcutaneous 
tissue,  and  retracting  the  skin,  the  various  bands  of  fascia 
can  be  reached  and  divided  as  well  as  the  hamstrings. 
Finally  the  tendo  achillis  is  elongated  by  the  Z-method 
(q.v.)  and  the  patient  is  then  secured  comfortably  in  Jones's 
abduction  frame  with  the  Icnees  straight  and  the  feet  at 
right  angles.  At  the  end  of  three  months  the  splint  is 
taken  off  dm-ing  the  day  and  the  movements  are  regularly 
practised.  A  Uttle  later,  when  the  patient  has  been  taught 
to  stand  unsupported,  walking  is  begun  with  crutches.  At 
first  the  nurse  must  take  great  care  that  the  limbs  are 
not  approximated.  The  limbs  must  be  kept  abducted  at 
night,  and  massage  of  the  muscles,  with  active  and  passive 
movements  of  the  different  joints  and  adduction  of  the  Yig.  55.  Muscle-trans- 
limbs  must  be  assiduously  practised.  In  from  twelve  to  plantation  for  the  relief 
twenty-four  months,  with  careful  supervision  and  after-  of  paralysed  quadriceps 
treatment,  and  with  the  intelligent  co-operation  of  the  by  reinforcement  of  the 
parents,  the  child  should  be  able  to  walk  a  considerable  paralysed  muscle  from 
distance,  aided  by  sticks,  and  this  with  perfectly  straight  the  biceps  and  sartorius. 
limbs,  and  toes  and  heels  on  the  ground.  Later  on.  At  a  a  ^IJP  i^  brought 
many  cases  will  manage  to  walk  with'one  stick  only,  and  forward] from  tjhe 
others  will  be  able  to  dispense  with  all  kinds  of  artificial  biceps;  at  &  theproxi- 
.,  ^  mal    part   of    the    sar- 

The  conclusions  of  Messrs.  Tubby  and  Jones  have  been  ^^rd  and  the  muscular 
given  at  length  because  of  the  pains  which  they  have  taken  gjjpg  „  ^nd  h  are  in- 
to develop  the  different  operations  and  the  authority  with  serted  into  the  patella 
which  they  speak  upon  orthopaedic  subjects.  But  it  is  right  at  e.  The  distal  por- 
to  state  that  there  is  another  side  to  this  question,  and  tions  of  the  biceps  and 
that  other  opinions  are  less  favourable.  In  this  country  sartorius  are  shown  at 
neither  Mr.  Keetlev  nor  Mr.  Jackson  Clarke  speaks  highly  d  and  c.  If  the  sar- 
of  the  result  in  their  books  on  Orthopcedic  Surgery.  And  torius  bo  paralysed,  the 
it  must  be  remembered  that  both  are  men  of  large  ex-  seraitendmosus  may  be 
perience  and  well-known  fairness. 

From  America,  where  every  fresh  operation  is  at  once 
tested  largely  and  with  much  zest,  we  have  warnings  not 
to  expect  too  much  from  tendon -transplantation  m  infantile  paralysis. 

Thus  Dr.  Hibbs,  speaking  at  a  meeting  of  the  New  York  Academy  of  Medicine, 
from  an  experience  of  150  cases  operated  on  at  the  New  York  Orthopjedic  Hospital 
said  :  "  Where  sufficient  time  is  allowed  to  elapse,  the  ultimate  compared  with  the 
immediate  results  are  as  a  rule  very  disappointing.  In  itself  tendon-transplantation 
practically  never  fulfils  expectation,  and  is  only  a  help  to  the  use  of  apparatus.  It 
is  not  an  independent  orthopaedic  measure  ;  it  does  not  prevent  deformity,  but 
may  be  used  as  an  adjunct  to  facilitate  the  use  of  apparatus,  and  thus  enable  the 
orthopaedic  surgeon  to  use  any  possible  bit  of  force  which  the  patient  can  exert. 
The  operation  undoubtedly  deserves  a  place  in  the  armamentarium  of  the  orthopaedic 


used  instead.     (Tubby 
and  Jones.) 


110        OPERATIONS  ON  THE  UPPER  EXTREMITY 

surgeon,  but   has   nothing  like  the  marvellous  effect  which  is  sometimes  claimed 
for  it."  1 

Later  opinions  are,  however,  more  favourable.  Thus  Dr.  R.  W.  Lovett,  of 
Boston  (Sixteenth  International  Congress  of  Medicine,  section  7,  p.  12),  says,  "  In 
some  instances  the  results  are  brilliant,  in  some  the  extent  and  character  of  the 
paralysis  prevent  us  from  obtaining  as  good  functional  results  as  we  would  desire. 
We  know  of  no  case  in  our  series  made  worse  by  operation'.  Under  these  conditions 
we  now  regard  the  operation  in  suitably  selected  cases  as  one  strongly  to  be  recom- 
mended to  patients  and  in  the  great  majorty  of  such  cases  as  one  followed  by  most 
satisfactory  results." 

The  method  must  therefore  be  still  regarded  as  sub  judice.  All  will 
allow  that  the  results  of  treatment  of  infantile  paralysis  are  amongst 
the  least  creditable  to  us.  If  tendon-transplantation  does  no  more 
it  may  at  least  do  good  by  attracting,  with  its  glamour  of  a  new  opera- 
tion, more  attention  to  a  neglected  subject.  Whether  the  results  claimed 
by  some  are  verified  in  the  future  depends  not  so  much  on  perfection 
of  technique — already  largely  arrived  at — as  on  a  wise  selection  of 
cases,  more  careful  attention  to  after-treatment,  in  which  the  patient 
and  friends  must  share  a  larger  responsibility,  and,  above  all,  to  medical 
men  ceasing  to  look  upon  these  cases  as  ones  in  which  nothing  can 
be  done  and  allowing  them  to  drift  on  until,  early  childhood  past, 
the  mischief  is  advanced  and  confirmed,  and  not  only  the  tendons — 
to  which  too  much  attention  has  been  directed — but  the  ligaments, 
joints,  bones,  fasciae,  and  skin  are  all  concerned.  Finally  the  literature 
of  this  subject,  which  has  rapidly  increased,  would  gain  greatly  in  value 
if  those  reporting  cases  of  operation  would  do  so  in  more  detail  and 
with  greater  accuracy,  and  also  would  give  us  the  later  as  well  as  the 
earlier  results,  telling  us  especially  how  far  tendon-transplantation 
does  away  with  that  worst  of  all  sequelae  of  infantile  paralysis,  viz. 
the  trophic  ulceration,  which  is  so  liable  to  set  in  in  late  adolescence 
and  early  adult  life,  and  which  may  call  for  amputation  of  the  thigh. 

1  Med.  News,  April  12,  1902. 


CHAPTER  V 
OPERATIONS  ON  THE  WRIST 

I.  EXCISION  OF  THE  WRIST-JOINT 

This  operation  is  not  often  performed.  Extensive  tuberculous  disease, 
with  abscesses  and  sinuses,  is  practically  the  only  indication.  The 
conditions  needful  for  success  and  the  reasons  for  it  often  failing  may 
first  be  considered. 

(1)  Whether  the  tuberculous  disease  begins  in  the  synovial  membrane 
or  in  the  bones  it  extends  rapidly,  not  only  to  the  wrist-joint,  but  to 
the  two  rows  of  carpal  bones  and  the  bases  of  the  metacarpals,  along 
the  complicated  synovial  membranes,^  which  bring  all  these  bones 
into  contiguity  with  each  other.  The  disease  thus  extensive,  is  also 
most  obstinate,  and  is  often  further  complicated  by  other  tuberculous 
lesions,  and.  in  adults  especially,  by  a  tendency  to  phthisis.  Thus 
partial  operations  are  useless  and  often  worse  than  useless.  Lord  Lister  ^ 
was  the  first  to  insist  on  the  importance,  and  to  show  the  possibility, 
of  remo\dng  every  trace  of  the  disease,  including  the  ends  of  the  radius 
and  ulna,  the  two  rows  of  carpal  bones,  and  the  bases  of  the  meta- 
carpals (Fig.  58). 

(2)  From  the  close  relation  of  the  flexor  and  extensor  tendons  in  front 
and  behind  these  complicated  joints,  and  from  the  numerous  grooves 
on  the  bones,  it  is  most  difficult  to  extirpate  the  disease  without  dis- 
turbing the  tendons.  The  tendon-sheaths  too  may  be  extensively 
invaded  by  the  disease.  However  stiff  the  wrist  may  be  left,  flexion 
and  extension  of  the  fingers  are  absolutely  needful  for  the  operation  to 
be  a  success  ;  hence  it  is  imperative  that,  throughout  the  prolonged 
operation,  the  tendons  should  be  disturbed  as  little  as  possible,  a  direction 
very  difficult  to  follow,  since  the  sheaths  are  frequently  tuberculous, 
and  the  necessary  manipulations  during  the  operation  may  easily  lead 
to  the  tendons  sloughing,  and  thus  to  a  useless  "  fin-like  "  hand. 

(3)  Passive  movement  of  the  fingers  should  be  begun  as  early  as 

^  The  arrangement  of  these,  usually  five  in  number,  must  be  remembered,  and  their 
close  proximity  to  each  other.  («)  The  membrana  sacciformis  of  the  inferior  radio- 
ulnar joint,  which  also  lines  the  upper  surface  of  the  triangular  fibro-cartilage.  (6)  That 
of  the  wrist-joint  proper,  passing  from  the  lower  end  of  the  radius  and  the  inter-articular 
fibro-cartilage  above  to  the  bones  of  the  first  row  below,  (c)  The  common  synovial 
membrane  of  the  carpus,  the  most  complex  of  all,  extending  transversely  between  the 
bones  of  the  two  rows  and  sending  upwards  two  vertical  prolongations  between  the 
scaphoid  and  the  semi-lunar  and  the  semi-lunar  and  cuneiform,  and  downwards  three 
prolongations  between  the  four  bones  of  the  second  row  usualh',  but  not  always  communi- 
cating with  the  inner  four  carpo-metacarpal  joints,  (d)  A  separate  membrane  for  the 
joint  between  the  pisiform  and  the  cuneiform,  (e)  Another  separate  one  between  the 
trapezium  and  the  first  metacarpal.  Fig.  56  shows  a  variety  of  this  arrangement  in  which 
seven  sj-novial  sacs  are  present. 

2  Lancet,  1865,  vol.  i,  p.  308. 

Ill 


112        OPERATIONS  ON  THE  UPPER  EXTREMITY 

possible,  and  most  perseveringly  maintained.  Owdng  to  the  unsatis- 
factory character  which  this  operation  inherited  by  the  very  poor  results 
to  which  it  attained  before  the  days  of  aseptic  surgery,  and  owing  to 
the  unsatisfactory  conditions,  both  general  and  local,  with  which  the 

surgeon  is  called  upon 
to  deal  —  the  estab- 
lished tuberculous 
trouble,  often  not  iso- 
lated in  the  wrist- 
joint,  the  joint  itself 
and  tendons,  it  may 
be,  riddled  with 
sinuses,  and  the 
fingers  swollen  and 
stiff- — excision  of  the 
wrist  has  not  found 
the  favour  with  Eng- 
lish surgeons  which  it 
perhaps  deserves. 

In  spite  of  the 
above  disadvantages 
and  difficulties,  it  is 
much  to  be  desired 
that,  as  no  less  than 
the  saving  of  hand 
and  fingers  is  at  stake, 
this  operation  should, 
mth  the  advantages 
of  modern  surgery, 
be  persevered  with, 
and  that  all  cases,  whatever  the  result,  be  fully  published. 

Two  methods  only  will  be  described.  Excision  of  the  wrist  is  not 
a  common  operation  ;  it  must  be  a  difficult  one  ;  and  the  operating 
surgeon  will  do  well  to  make  himself  famiUar  with,  and  to  practise,  one 
method.  The  two  methods  given  below  bear  the  names  of  surgeons 
who  are  authorities  on  the  subject — (1)  Lord  Lister's,  introduced  to  the 
profession  as  long  ago  as  1865  ;  (2)  that  of  the  late  M.  Oilier,  whose 
name  stands  second  to  none  as  an  authority  on  excision  of  joints,  and 
w^ho  has  done  more  than  any  other  surgeon  to  place  excision  of  the 
wrist  on  a  sound  basis.  The  second  method  may  be  recommended  as 
the  less  complicated  of  the  two.  In  young  children,  o'wdng  to  the 
weakness  of  the  ligamentous  and  other  fibrous  single  structures,  the 
single  longitudinal  dorsal  incision  of  van  Langenbeck  or  Boeckel — for 
they  are  practically  the  same^ — ^may  suffice. 

(1)  Lister's  Operation  (Figs.  57,  58).  In  this  method  two  incisions  are 
required,  one  on  the  radial  side  of  the  dorsum,  the  other  on  the  imier  side  of  the 
wrist.  Before  the  operation  the  fingers  are  forcibly  moved  so  as  to  break  down  any 
adhesions.  An  Esmarch's  bandage  or  tourniquet  should  be  employed.  The 
radial  incision,  angular  in  direction,  is  then  made,  as  in  Fig.  57.  This  incision  is 
plamied  so  as  to  avoid  the  radial  artery  and  also  the  tendons  of  the  extensor  secundi 
internodii  and  extensor  indicis.  It  commences  above  at  the  middle  of  the  dorsal  aspect 
of  the  radius  on  a  level  with  the  styloid  process.  Thence  it  is  at  first  directed  towards 
the  inner  side  of  the  metacarpo-phalangeal  joint  of  the  thumb,  running  parallel 
in  this  course  to  the  extensor  secundi  internodii  ;    but  on  reaching  the  line  of  the 


Fig.  56.  The  bones  and  the  seven  synovial  sacs  which 
enterinto  joints  about  the  wrist.  The  seventh,  that  between 
the  cuneiform  and  pisiform,  is  not  shown.     (MacCormac.) 


EXCISION  OF  THE   WRIST 


11.3 


radial  Imrdcr  of  (he.  srcoiid  metacarpal  hone  i(  is  carried  downwards  loii<;itudinally 
for  lialf  its  Ictij^tli,  the  radial  artery  iK-iiifj;  thus  avoided,  as  it  lies  a  littK^  further  out. 
The  tendon  of  the  extensor  carj)!  radialis  lougior  is  next  detached,  together  with 
that  of  the  extensor  brevior,  while  tiio  extensor  secundi  iuternodii,  with  the  radial 
artery,  is  thrust  somewhat  outwards.  The?  next  step  is  the  sciparation  of  the 
trapezium  from  tlic  rest  of  the  oarpus  by  cutting  forceps  applied  in  a  line  with  the 
longitudinal  part  of  the  incision,  great  care  being  taken  of  the  radial  artery.  The 
removal  of  tho  trapezium  is  left  till  the  rest  of  the  (sarpus  has  been  taken  away, 
when  it  can  be  dissected  out  without  much  diflliculty,  whereas  its  intimate  relations 
with  the  artery  and  neighbouring  parts  would  cause  much  trouble  at  an  earlier 
stage.  The  hand  being  bent  back  to  relax  the  extensors,  the  ulnar  incision  should 
next  bo  made  very  free  by  entering  the  knife  at  least  two  inches  above  the  end  of 


Fig.  57.     a,    Radial     artery.      b,    Extensor 
secundi  internodiipollicis.  c,  Extensor  indicis. 

D,  Extensor  communis,     e,  Extensor  minimi  _,        ^o      t>     i       ™     „j  ; „;^,-„„ 

digiti.     F,  Extensor  primi  intcrnodii.     g.  Ex-  ^ig.  58      Parts  removed  m  excision 

tensor   ossis   metacarpi.      h,   Extensor  carpi  of  the  wrist.     (Lister.) 

radialis   longior.     i,   Extensor  carpi   radialis 
brevior.    k.  Extensor  carpi  ulnaris.     L  L,  Line 
of  radial  i  ncision.     ( Lister. ) 

the  uhia  immediately  anterior  to  the  bone,  and  carrying  it  down  between  the  bone 
and  the  flexor  carpi  ulnaris,  and  on  in  a  straight  line  as  far  as  the  middle  of  the  tifth 
metacarpal  bone  at  its  palmar  aspect.  The  dorsal  lip  of  the  incision  is  then  raised, 
and  the  tendon  of  the  extensor  carpi  ulnar  is  cut  at  its  insertion,  and  its  tendon 
dissected  up  from  its'groove  in  the  ulna,  care  being  taken  not  to  isolate  it  from  the 
integuments,  which  would  endanger  its  vitality.  The  linger  extensors  are  then  sepa- 
rated from  the  carpus,  and  the  dorsal  and  internal  lateral  ligaments  of  the  wrist- joint 
divided,  but  the  connections  of  the  tendons  with  the  radius  are  purposely  left  un- 
disturbed. Attention  is  now  directed  to  the  palmar  side  of  the  incision.  The 
anterior  surface  of  the  ulna  is  cleared  by  cutting  towards],the  bone  so  as  to  avoid 
the  artery  and  nerve,  the  articulation  of  the  pisiform  bone  opened,  if  that  has  not 
abeady  been  done  in  making  the  incision,  and  the  flexor  tendons  separated  from 
the  carpus,  the  hand  being  depressed  to  relax  them.  While  this  is  being  done,  the 
knife  is  arrested  by  the  unciform  process,  which  is  clipped  through  at  it  base  with  bone- 
forceps.  Care  is  taken  to  avoid  carrying  the  knife  further  down  the  hand  than  the 
bases  of  the  metacarpal  bones,  for  this,  besides  inflicting  unnecessary  injury,  would 
involve  risk  of  cutting  the  deep  palmar  arch.  The  anterior  ligament  of  the  wrist- 
joint  is  also  divided,  after  which  the  junction  between  carpus  and  metacarpus  is 
severed  with  cutting  forceps,  and  the  carpus  is  extracted  from  the  uhiar  incision 
with  sequestrum-forceps,  any  ligamentous  connections  being  divided  with  the  knife. 
The  hand  being  now  forcibly  everted,  the  articular  ends  of  the  radius  and  uhia 
will  protrude  at  the  ulnar  incision.  If  they  appear  sound,  or  very  superficially 
effacted,  the  articular  surfaces  only  are  removed.     The  ulna  is  divided  obliquely 

SURGERY   I  8 


114        OPERATIONS  ON  THE  UPPER  EXTREMITY 

with  a  small  saw,  so  as  to  take  away  the  cartilage-covered  rounded  part  over  which 
the  radius  sweeps,  while  the  base  of  the  styloid  jirocess  is  retained.  The  ulna  and 
radius  are  thus  left  of  the  same  length,  which  greatly  promotes  the  symmetry  and 
steadiness  of  the  hand,  the  angular  interval  between  the  bones  being  soon  filled  uj) 
with  fresh  ossific  deposit.  A  thin  slice  is  then  sawn  off  the  radius  parallel  with  the 
articular  surface. 

For  this  it  is  scarcely  necessary  to  disturb  the  tendons  in  their  grooves  on  the 
back,  and  thus  the  extensor  secundi  inteniodii  may  never  appear  at  all.  This 
may  seem  a  refinement,  but  the  freedom  with  which  the  thumb  and  fingers  can  be 
extended,  even  within  a  day  or  two  of  the  operation,  when  this  point  is  attended  to, 
shows  that  it  is  important.  The  articular  facet  on  the  ulnar  side  of  the  bone  is  then 
clipped  away  with  forceps  applied  longitudinally. 

If  the  bones  prove  to  be  deeply  carious,  the  forceps  or  gouge  must  be  used  with 
the  greatest  freedom.  The  metacarpal  bones  are  next  dealt  with  on  the  same 
principle.  If  they  seem  sound,  the  articular  surfaces  only  are  clipped  off,  the 
lateral  facets  being  removed  by  longitudinal  application  of  the  bonc-forcei:)s. 

The  trapezium  is  next  seized  with  forceps  and  dissected  out  without  cutting  the 
tendon  of  the  flexor  carpi  radialis,  which  is  firmly  bound  do\\'n  in  the  groove  on  the 
palmar  aspect  ;  the  knife  being  also  kept  close  to  the  bone  so  as  to  avoid  the  radial. 
The  thumb  being  then  pushed  up  by  an  assistant,  the  articular  end  of  its  metacarpal 
bone  is  removed.  Though  this  articulates  by  a  separate  joint,  it  may  be  affected, 
and  the  symmetry  of  the  hand  is  promoted  by  reducing  it  to  the  same  level  as  the 
other  metacarjoals. 

Lastly,  the  articular  surface  of  the  pisiform  is  clipped  off,  the  rest  being  left  if 
sound,  as  it  gives  insertion  to  the  flexor  carpi  uhiaris  and  attachment  to  the  anterior 
annular  ligament.  But  if  there  is  any  suspicion  as  to  its  soundness,  it  should  be 
dissected  out  altogether  ;  and  the  same  rule  applies  to  the  process  of  the  unciform. 

The  only  tendons  di\aded  are  the  extensors  of  the  carpus,  for  the 
flexor  carpi  radialis  is  inserted  into  the  second  metacarpal  below  its 
base,  and  so  escapes.  Only  one  or  two  small  vessels  require  ligature. 
Free  drainage  must  be  given.  The  hand  and  forearm  are  put  up  on  a 
special  splint  with  a  cork  support  for  the  hand,  which  helps  to  secure 
the  principal  object  in  the  after-treatment — viz.  frequent  movements 
of  the  fingers — while  the  wrist  is  kept  fixed  during  consolidation.  Passive 
movement  of  the  fingers,  whether  the  inflammation  has  subsided  or 
not,  is  begun  on  the  second  day  and  continued  daily.  Each  joint 
should  be  flexed  and  extended  to  the  full  extent  possible  in  health,  the 
metacarpal  bone  being  held  quite  steady  to  avoid  disturbing  the  A^Tist. 
By  this  means  the  suppleness  gained  by  breaking  down  the  adhesions 
at  the  time  of  the  operation  {see  p.  113)  is  maintained. 

Pronation  and  supination,  flexion  and  extension,  abduction  and 
adduction,  must  be  gradually  encouraged  as  the  new  ^\Tist  acquires 
firmness.  When  the  hand  has  acquired  sufficient  strength,  freer  play 
for  the  fingers  should  be  allowed  by  cutting  off  all  the  splint  beyond 
the  knuckles.  Even  after  the  hand  is  healed,  a  leather  support  should 
be  worn  for  some  time,  accurately  moulded  to  the  front  of  the  limb, 
reaching  from  the  middle  of  the  forearm  to  the  knuckles,  and  sufficiently 
turned  up  at  the  ulnar  side.  This  is  retained  in  situ  by  lacing  over 
the  back  of  the  forearm. 

(2)  Ollier's  Operation^  (Fig.   59).      No  surgeon  speaks  ^\ith  greater 

weight  on  excision  of  the  wrist  than  the  late  celebrated  surgeon  of  Lyons  : 

none  have  had  so  much  operative  experience,  and  no  one  worked  so 

hard  in  order  to  bring  the  operation  into  better  favour,  and  to  insist 

on  the  necessity  of  attention  to  minuteness  of  detail  both  during  the 

^  M.  oilier  claimed  that  by  his  method,  which  must  be,  as  far  as  possible,  subperiosteal, 
not  one  attachment  of  the  tendons  need  be  lost.  By  other  methods  the  attachments 
of  the  extensors  of  the  carpus,  those  of  the  flexor  carpi  ulnaris  and  radialis,  and  perhaps 
that  of  the  supinator  longus,  arc,  he  maintains,  usually  sacrificed. 


EXCISION  OF    illK  WHIST 


115 


perforniaiico  of  the  operation  and  in  the  al'tei-treatnient.  Finally^ 
M.  Olher  not  only  had  uniivalh'd experience  i)i  the  excision  of  this  joint/ 
but  he  lias  repeatedly,  either  liiinself  oi'  hy  his  pupils,  placed  his  results 
before  the  profession. - 

M.  Oilier,  having  tried  sevei'al  dilTerent  incisions,  recommends  the 
following.  At  first  sight 
the  number  (three)  ap- 
pears complicated,  but 
it  will  be  remembered 
that  the  third  —  that 
over  the  radial  styloid 
process — is  merely  for 
drainage.  With  a  view 
to  simplify  as  much  as 
possible  what  must  in 
any  case  be  a  very  com- 
plicated operation,  a 
single  dorso -radial  inci- 
sion, the  chief  or  meta- 
carpo-radio- dorsal  one  of 
Oilier,  may  be  employed.'^ 
From  respect  and  in 
justice  to  that  excellent 
surgeon,  his  operation  is 
given  in  detail.  Much  of 
it  refers  to  advanced  cases 
of  disease.  It  should  be 
the  object  of  all  con- 
cerned to  antedate  this 
stage.  The  parts  having  b 
been  made  evascular  by 
an  Esmarch's  bandage, 
and  all  adhesions  broken 
down,  the  hand  is  sup- 
ported, extended,  and 
pronated  by  a  sand 
pillow. 

First  stage 


Fig.  59.  The  tendons  concerned  in  excision  of  the  wrist. 

A  a',  b  b',  c  c',  The  three  incisions  usually  emijloyed  by 

M.  Oilier,   d,  the  incision  of  Boeckel,  sometimes  described 

as    Langenbeck's,   the  two   being  practically  identical. 

Incision    R-  Radius,     u,  Ulna.     1  and  2,  Radial  extensors  of  the 

nf    Sh'r)    nnrJ     TinnrnP-nt^      carpus.    3.  Extensor  ossis  metacarpi  pollicis.  4,  Extensor 

OJ    i^Kin    ana    lAgameniS.     primiinternodii.     5,  Extensor  secundi  internodii.    6,  Ex- 

tnsor    communis.     7,    Extensor    indicis.     8,    Extensor 
minimi  digiti.     9,  Extensor  carpi  ulnaris  (Oilier.) 


The  surgeon,  comfort- 
ably seated,  makes  the 
first  and  chief  incision, 
metacarpo  -  radio  -  dorsal,  starting  from  a  point  in  the  centre  of  a 
line  drawn  between  the  two  styloid  processes,  and  running  down- 
wards,   at    first   vertically   and    then    somewhat    obliquely    outwards 

^  Traite  des  Res^zdious,  1888,  t.  ii,  p.  448 ;  Resections  des  grandes  Articulations,  18S5. 

2  M.  Oilier  himself,  loc.  supra  cit.  Congres  Franc,  de  Chir.,  1894,  p.  872  ;  and 
Resections  des  grandes  Articulations,  1895.  M.  Gangolphe,  "  Turaeur  blanche  du  Poignct," 
Tr.  de  Chir.,  1896,  t.  iii,  p.  595;  Dr.  Mondan,  "  La  Tuberculose  du  Poignet,"  Rev.  de 
Chir.,  1896,  p.  186. 

*  This  method  of  excision  by  a  single  dorso- radial  incision  was  first  employed  by 
Boeckel  and  Langenbeck.  Kocher  (Text  Book  of  Operative  Surgery,  1911)  describes  a 
mode  of  excision  through  a  single  dorso-ulnar  incision,  extending  from  the  middle  of  tlie 
fifth  metacarpal  upwards  over  the  middle  of  the  wrist  joint,  and  from  thence  along  the 
middle  of  the  back  of  the  forearm. 


116       OPERATIONS  ON  THE  UPPER  EXTREMITY 

along  the  outer  side  of  the  extensor  indicis,  and  ending  below 
over  the  second  metacarpal  bone  at  the  junction  of  its  upper  two 
and  lower  thirds.  A  subcutaneous  branch  of  the  radial  nerve  having 
been,  if  possible,  avoided,  the  incision  is  carried  down  to  the  perios- 
teum and  dorsal  ligaments,  great  care  being  taken  not  to  injure 
the  extensor  indicis  and  the  extensor  carpi  radialis  brevior.  The 
extensor  indicis  is  first  recognised,  but  its  sheath  should  not  be  opened 
as  the  incision  is  deepened.  It  should  be  drawn  aside  with  a  blunt  hook 
so  as  to  expose  the  tendon  of  the  extensor  carpi  radialis  brevior,  the 
insertion  of  which  it  conceals.  The  periosteum  over  the  base  of  the 
third  metacarpal  is  next  incised  so  as  to  admit  of  the  detachment  of 
the  last-mentioned  extensor,  together  with  its  periosteal  sheath,  which 
constitute  the  radial  lip  of  the  deeper  part  of  the  wound.  The  incision 
is  then  prolonged  upwards  along  the  forearm  according  to  the  amount 
of  bone  to  be  removed,  and  over  the  annular  ligament  outside  the  parti- 
tion common  to  the  extensor  indicis  and  communis.  A  little  higher  up 
the  incision  passes  between  the  extensor  indicis  and  the  extensor  secundi 
internodii,  these  tendons  being  drawn  respectively  inwards  and  out- 
wards. In  the  highest  part  of  the  incision  the  periosteum  over  the  lower 
end  of  the  radius  should  be  divided.  This  incision  should  be  four  inches 
or  more  in  length,  so  as  to  avoid  needless  bruising  of  the  soft  parts, 
and  to  give  adequate  access  to  the  disease.  The  ulnar  incision  is  next 
made,  starting  about  one  inch  above  the  styloid  process  of  the  ulna, 
and  ending  below  over  the  base  of  the  fifth  metacarpal  bone,  the  incision 
being  kept  rather  towards  the  palmar  surface  so  as  to  leave  the  tendon 
of  the  extensor  carpi  ulnaris  above  in  the  dorsal  lip  of  the  wound.  The 
incision  should  be  made  carefully  so  as  not  to  injure  a  filament  of  the 
ulnar  nerve  which  crosses  it,  and  thus  not  compromise  the  sensibility 
of  the  little  finger.  The  incision  is  deepened  down  to  the  cuneiform 
and  unciform.  A  third  incision,  for  drainage  only,  is  made  about  an 
inch  long  over  the  styloid  process  of  the  radius.  It  should  be  made 
now,  before  the  landmarks  have  disappeared. 

Second  stage.  Removal  of  the  Bones.  This  is  facilitated  by  division 
of  the  posterior  annular  ligament,  which  allows  of  easy  separation  of 
the  tendons.  The  radio-carpal  joint  having  been  opened,  the  periosteal 
and  ligamentous  connections  of  the  carpus  are  gradually  divided,  and, 
the  carpus  having  been  made  to  project  more  and  more  above,  the 
flexor  tendons  are  safely  detached  and  held  aside  in  front.  It  does  not 
matter  which  of  the  carpal  bones  is  taken  first,  whether  those  that  lie 
beneath  the  radio-dorsal  or  the  ulnar  incisions  ;  as  soon  as  one  is  removed 
the  extraction  of  the  others  becomes  easier.  The  great  aim  of  the 
surgeon  is  to  remove  each  diseased  bone  completely.  Being  very  friable 
they  are  easily  crushed,  and  any  diseased  part  that  is  left  adherent  is 
liable  to  cause  a  focus  of  infection  and  tedious  suppuration. 

Each  bone  should  be  turned  out  of  its  periosteal  and  ligamentous 
adhesions  with  a  periosteal  elevator  or  gently  seized  with  small  forceps 
and  any  adhesions  carefully  divided.  The  pisiform  usually,  and  often 
the  trapezium,  may  be  left,  and  the  unciform  if  sound.  Otherwise, 
if  difficulty  be  met  with  in  shelling  out  this  bone,  the  process  may  be 
cut  through,  the  bone  itself  turned  out,  and  the  process  subsequently 
taken  away.  The  lower  ends  of  the  radius  and  ulna  are  now  examined, 
each  from  the  incision  over  them,  and  dealt  with  according  to  the  amount 
of  disease  present.     Thus  in  some  cases  erasion  with  a  sharp  spoon  or 


EXCISION  OF  THE  WRIST  117 

gouge  may  be  sufficient.  In  others  the  ends  may  be  removed,  a  small 
saw  being  so  used  as  to  form  a  new  articular  end.  The  styloid  processes 
shouKl  always  be  left,  if  possible  ;  and  even  when  all  the  articular  cavity 
of  the  radius  nnist  go,  some  of  the  expaiuled  end  of  the  bone  should 
be  left  so  as  to  furnish  a  soHd  support  for  the  hand.  The  periosteum 
all  round  each  bone,  and  lateral  ligaments,  should  be  carefully  retained 
when  healthy.  In  young  subjects  the  operator  must  be  careful  not  to 
leave  a  caseating  se(iuestruni  in  the  epiphysial  line  above  a  section  of 
bone  which  is  apparently  healthy.  The  same  remarks  apply  to  the 
treatment  of  the  four  inner  metacarpals,  which  alone  are  usually  diseased. 
The  bases  of  any  of  these  which  require  removal  must  be  most  carefully 
shelled  out  of  their  fibrous  coverings,  or  the  tendons  and  deeper  palmar 
arch  may  be  damaged.  If  more  than  gouging  is  required,  the  section 
is  better  made  with  a  fine  saw  than  with  cutting  forceps. 

Question  of  Preservin<j  the  Periosteum.  This  step  has  been  objected 
to  on  account  of  its  increasing  the  risk  of  leaving  tuberculous  mischief 
behind.  M.  Oilier  strongly  advocates  the  subperiosteal  method.  Though 
riddled  with  fistula?  and  infiltrated  with  tuberculous  granulation-tissue, 
the  periosteum  should  be  preserved,  as  much  as  is  possible,  after  thorough 
curetting.  This  will  aid  in  making  the  connection  between  the  meta- 
carpus and  the  forearm  strong  and  not  fiail-like,  while  it  will  also  help  in 
the  preservation  of  the  carpal  tendons.  Professor  Oilier  meets  the  above 
objection  by  a  thorough  use  of  the  curette  until  only  the  actual  fibrous 
tissue  of  the  capsule,  ligaments,  and  periosteum  is  left.  The  op8ration  is  a 
tedious  and  difficult  one,  requiring  the  minutest  care  throughout  to  avoid 
injury  to  important  structures,  and  to  get  away  all  the  diseased  tissue. 

Third  stage.  Toilette,  Cauterisation,  and  Drainage.  M.  Oilier  attaches 
great  importance  to  these  points. 

Toilette.  The  tendons  usually  lie  buried  in  tuberculous  granulation- 
tissue  extending  upwards  and  downwards  to  a  varying  degree.  Every 
infected  tendon-sheath  must  be  slit  up,  and  the  tuberculous  material 
followed  into  every  nook  with  scissors  and  curette.  Each  tendon  must 
be  individually  drawn  up  with  a  blunt  hook  and  inspected.  To  render 
the  deeper  ones  accessible  they  should  be  pushed  up  from  the  palm 
and,  if  it  be  needful  to  get  directly  at  the  flexor  tendons,  one  or  two 
incisions  should  be  carefully  made  in  the  palmar  surface. 

Cauterisation.  M.  Oilier  advises  the  use  of  the  actual  cautery  to 
the  most  aftected  spots,  with  the  \'iew  (1)  of  helping  to  eradicate  the 
disease  ;  (2)  to  prevent  haemorrhage  ;  and  (3)  to  obviate  the  risk  of 
tuberculous  infection  from  the  wound. 

Drainage.  Drains  of  gauze  should  be  freely  employed  between  the 
different  incisions,  not  only  to  prevent  collections  of  fluid,  but  to  keep 
the  incisions  open  in  case  further  curetting  should  be  called  for.  The 
dressings  should  be  voluminous  and  firmly  applied,  so  as  to  distribute  the 
free  oozing  through  a  large  amount  of  material.  The  Esmarch's  bandage, 
which  should  have  been  put  on  high  up  in  the  forearm  so  as  to  admit  of  the 
application  of  the  above-mentioned  dressings,  is  then  removed,  and  the 
limb  put  on  a  Lister's  splint,  while  the  WTist  is  kept  extended.  Another 
very  efficient  splint  which  can  be  more  readily  sterilised  is  one  recom- 
mended by  Mr.  R.  Jones,  of  Liverpool.  It  consists  of  a  simple  anterior  bar 
of  sheet  iron  with  two  -\  -shaped  extremities.  These  are  bent  round  and 
grasp  the  limb  just  below  the  elbow- joint  above  and  just  above  the 
metacarpo-phalangeal  joints  below.     The  part  on  which  the  hand  rests 

SURGERY   I  8' 


118        OPERATIONS  ON  THE  UPPER  EXTREMITY 

should  be  bent  at  an  angle  of  about  forty  degrees,  so  that  the  hand 
be  kept  extended.  "  If  any  one  wishes  to  grip  powerfully  the  wrist 
is  first  instinctively  extended.  One  cannot  effectively  grip  with  the 
hand  in  the  flexed  position."  The  first  dressing  should  be  left  on,  if 
possible,  for  eight  or  ten  days.  If  needful  the  incisions  must  be  kept 
open  with  drains  for  three  or  four  weeks,  that  any  suspicious  granulation- 
tissue  may  be  repeatedly  attacked  with  the  sharp  spoon,    &c.^ 

After-treatment.  This  must  be  begun  a  day  or  two  after  the  operation, 
and  be  persevered  with  for  six  or  nine  months,  the  patient  lending  an 
untiring  aid  throughout  the  whole  of  this  time.  A  day  or  two  after  the 
operation  the  finger- joints  should  be  moved  daily,  care  being  taken  not 
to  disturb  the  wounds,  and  especial  attention  should  be  given  to  the  meta- 
carpo-phalangeal  joints,  which  are  liable  to  escape  attention.  Moreover, 
the  thumb  and  index  finger  must  be  kept  well  apart.  About  eight  or 
ten  days  after  the  operation,  or  as  soon  as  the  parts  are  sufficiently 
solid,  careful  movement  of  the  wrist  may  be  begun.  There  is  a  per- 
sistent tendency  for  the  tendons  to  remain  adherent  in  their  sheaths, 
only  to  be  overcome  by  persevering,  assiduous  movements,  with  the 
help  of  nitrous  oxide  gas  from  time  to  time.  Galvanism,  faradism, 
friction,  massage,  are  all  of  service  when  the  wound  is  healed.  If  the 
surgeon  wishes  for  a  good  result  in  the  case  of  hospital  patients,  he  will 
not  allow  them  to  leave  too  early.  As  M.  Oilier  points  out,  and  as  his 
cases  show,  in  addition  to  excellent  movements  of  the  fingers,  extension 
and  flexion,  abduction  and  adduction  of  the  hand  on  the  carpus  should 
be  very  largely  recovered  by  long-continued  perseverance.  Extension 
of  the  fingers  and  wrist  is  more  slowly  regained  than  flexion,  owing  to 
atrophy  of  the  dorsal  muscles  and  matting  of  their  tendons.- 

Even  if  the  other  fingers  are  stiff,  mobility  and  power  of  approximation 
of  the  thumb  and  index  will  be  much  more  useful  than  any  artificial  limb. 

The  following  is  one  of  the  cases  of  excision  of  the  wrist  by  Ollier's 
method  previously  referred  to  : 

Mrs.  D.,  aet.  37,  was  sent  to  Mr.  Jacobson  in  January  1896,  by  Dr.  Wood,  of  Dover, 
with  tuberculous  disease  of  the  right  wrist.  There  was  characteristic  swelling  on 
both  aspects  of  the  wrist,  the  fingers  were  stiff  and  extended,  and  the  hand  useless, 
but  there  were  no  sinuses.  The  age  and  the  personal  history  of  the  patient  were  also 
favourable.  Excision  was  performed  by  an  extension  of  Ollier's  median  dorsal 
incision.  The  pisiform  and  the  trapezium  were  left.  Thin  slices  of  the  articular 
ends  of  the  radius  and  ulna  were  removed,  but  it  was  only  needful  to  treat  the  bases 
of  the  four  inner  metacarpals  by  vigorous  curetting.  Two  lateral  incisions  were 
made  for  drainage.  The  wounds  healed  quickly.  After-treatment  could  not  be 
satisfactorily  carried  out  owing  to  the  irregular  attendance  of  the  patient.  In 
November  1898,  Dr.  Wood  wrote  :  ".There  is  some  undue  prominence  and  mobility 
of  the  end  of  the  ulna.  Pronation  and  supination  are  perfect  and  painless.  The 
hand  can  be  flexed  and  extended  to  about  half  the  normal  amount.  The  movements 
of  the  thumb  are  perfect.  The  movements  of  the  fingers  at  the  interphalangeal 
joints  are  perfect,  but  there  is  some  stiffness  at  the  metacarpo-phalangeal  joints 
which  prevents  her  from  '  making  a  fist.'  Generally,  she  has  a  thoroughly  useful, 
though  at  present  not  a  strong  hand." 

This  rigidity  at  the  metacarpo-phalangeal  joints  was  due,  in  part,  to  too  much 

^  The  above  remarks  refer  only  to  cases  of  advanced  tuberculous  disease.  When 
excision  is.  performed  early  before  the  stage  of  sinuses,  &c.,  as  should  always  be  the  case,  it 
will  often  be  possible  to  eradicate  the  tuberculous  disease  at  the  time  of  the  operation  ; 
the  dressings  will  be  few,  and  the  after-use  of  the  curette  only  occasionally  needed. 

2  It  has  been  suggested  that  some  of  the  loss  of  power  in  the  fingers  and  wrist  depends 
on  the  tendons  remaining  too  long  after  the  removal  of  the  diseased  bones,  and  that 
shortening  of  the  tendons  should  be  practised.  M.  Oilier  only  recommends  shortening 
of  tendons  when  the  fingers  tend  to  be  obstinately  flexed  ;  he  advises  in  this  case 
ehortening  of  the  dorsal  tendons  by  his  method  given  at  p.  104. 


EXCISION  OF  THE  WRIST  119 

atfontion  bring  given  to  the  interphalangeal  joints,  and  to  the  patient  being  lost  sight 
of  too  soon.  It  is  rigidity  at  the  fonnei' joints  wliiefi  prevents  a  good  result  being  an 
exeellent  one,  entailing,  as  it  does,  a  eertain  degree  of  open  elaw,  instead  of  a  closed  (ist. 

Question  of  Amputation  in  Tuberculous  Disease  of  the  Carpus.   As  has 

been  stated  above,  tuberculous  disease  of  the  carpus  more  rarely 
occurs  alone  and  isolated  than  any  other  tuberculous  joint  affection. 
Thus  the  existence  and  degree  of  other  tuberculous  lesions,  the  extent 
of  the  disease  in  the  wrist,  the  age  and  vitality  of  the  patient,  the  personal 
and  family  history,  the  presence  of  albuminuria  and  lardaceous  disease, 
are  some  of  the  chief  points  which  will  help  in  deciding  the  above  ques- 
tion. M.  Oilier  has  recorded  seven  cases  in  which,  owing  to  the  exist- 
ence of  a  cough,  haemoptysis,  and  suspected  or  actual  disease  of  the 
apices,  he  ad\dsed  amputation,  but  performed  resection  owing  to  his 
advice  being  rejected.  The  results  were  not  encouraging.  While 
excision  of  the  wrist  deserves  a  trial  on  a  larger  scale  than  it  has  hitherto 
received,  it  should  only  be  attempted  in  patients  whose  vitality  is 
sufficient,  and  who  are  not  handicapped  by  serious  disease  elsewhere. 
Where  amputation  is  decided  on  it  must  be  through  the  forearm. 

Excision  of  the  Wrist  for  Injury.  This  will  be  still  more  rarely  required. 
Partial  excision  may  be  indicated  in  rare  cases  of  dislocation  of  the 
wrist  which  are  otherwise  irreducible,  in  some  cases  of  unreduced  separa- 
tion of  the  lower  radial  epiphysis,  and  possibly  in  some  of  compound 
fractures  of  the  lower  extremities  of  the  radius.  . 

Excision  of  Wrist  for  Gunshot  Injury.  The  first  step  will  be  to  render 
the  wound  aseptic  if  possible,  to  remove  any  shattered  fragments,  or 
to  perform  a  partial  excision  (according  to  the  amount  of  damage),  and 
provide  sufficient  drainage.  If  the  wound  suppurate  it  should  be 
irrigated  ;  and,  if  the  infection  prove  intractable,  the  wrist  excised. 
M.  Oilier^  gives  an  instructive  case  of  primary  partial  excision  (first  row 
of  carpal  bones  and  the  ends  of  the  radius  and  ulna)  for  a  gunshot  injury 
in  a  lad,  set.  13.  The  shot  had  "  balled,"  and  the  extensor  tendons  were 
severely  damaged.  The  case  was  kept  under  observation  for  seven  years, 
and  the  last  report  ends  :  "  As  far  as  the  daily  use  of  my  hand  goes,  I 
might  say  that  I  have  never  had  a  wound." 

These  injuries  are  most  likely  to  occur  in  military  surgery.  In 
former  days,  when  the  projectile  was  large  and  the  velocity  slow,  injuries 
of  joints  were  extensive  and  serious,  and  likely  to  require  amputation. 
Excision  on  the  whole  gave  poor  results.  Thus  Gurlt  (quoted  by  M. 
Oilier),  in  examining  into  the  results  obtained  by  the  German  surgeons 
in  the  Franco-German  War,  only  found  one  good  result,  eight  moderately 
good,  six  bad.  and  one  very  bad. 

The  conditions  of  modern  warfare  have  so  altered,  and  the  arrange- 
ments for  treating  the  wounded  have  so  improved  that  the  experiences 
of  surgeons  in  the  South  African  War  as  to  the  treatment  and  prognosis 
of  these  injuries  are  of  very  great  interest. 

Mr.  Makins^  does  not  mention  any  case  of  injury  to  the  wrist- joint, 
but  at  p.  237  the  words  occur  :  "I  never  saw  any  troublesome  results 
from  perforation  of  the  carpus." 

Colonel  Hickson,  R.A.M.C..''  writes  as  follows  : 

^  Traite.  des  Resections,  t.  ii,  p.  494. 

2  Surgical  Experiences  in  South  Africa,  1899-1900. 

3  Be  ports  in  Surgical  Cases  in  the  South  African  War,  1899-1902.  Edited  by 
Surgeon- General  W.  F.  Stevenson,  C.B.  In  the  present  war  the  prognosis  in  these  and 
other  similar  injuries  is  much  less  favourable,  the  special  conditions  greatly  increasing  the 
danger  of  infection  and  suppuration. 


120        OPERATIONS  OX  IHE  UPPER  EXTREMITY 

■■  Only  ten  examples  of  wounds  of  the  \n-i.st-joint  have  been  collected.  When 
produced  by  the  hard-cased  bullet,  injuries  of  this  joint  appear  to  be  almost  in- 
variably pure  perforations,  healing  quickly  under  a  scab  when  aseptic,  and  causing 
little  or  no  permanent  limitation  of  movement.  In  two  of  the  recorded  cases  frag- 
ments of  the  carpal  bones  were  removed,  the  injuries  having  been  caused  by  revolver 
or  Martiiii-Hennk-  bullets.  Xo  case  necessitating  amputation  has  been  noted,  and 
there  is  only  one  recorded  instance  of  excision  of  the  wTist-joint.  The  case  in 
question,  one  of  my  o^ti.  in  which  the  bullet,  considered  to  be  a  ricochet,  com- 
pletely shattered  the  left  ^vrist-joint.  disorganising  the  carpus,  and  fissuring  the 
lower  end  of  the  radius.  The  wound  was  verj'  septic.  At  first  the  injurj^  seemed 
to  call  for  amputation,  but  complete  excision  was  carried  out  as  an  alternative." 

"Convalescence  was  prolonged,  the  arm-bath  being  constantly  u.sed  for  weeks,  but 
he  eventually  recovered.  At  the  time  of  invaliding,  the  movements  of  the  fingers 
were  fair,  but  those  of  the  -^^Tist  very  limited." 

Causes  of  Failure  after  Excision  of  the  Wrist.  These  are  mainly  : 
( I )  Persistent  sinuses  and  discharge  set  up  by  remaining  foci  of  infective 
tuberculous  granulations,  caries,  or  necrosis.  Sir  "\V.  Fergusson^  showed 
a  specimen  in  which  all  the  bones  were  supposed  to  have  been  removed 
by  a  single  incision  on  the  ulnar  side.  The  pisiform,  trapezium,  and 
part  of  the  unciform  had  been  left.  The  movement  of  the  fingers  was 
good,  but  sinuses  remained  on  both  sides  communicating  with  a  bare 
piece  of  radius.  Death  took  place  from  phthisis.  (2)  Matting  and 
sloughing  of  tendons  and  consequent  stiffness  of  fingers.  (3)  Phthisis 
or  other  tuberculous  visceral  disease. 

OPERATION  IN  CASES  OF  OLD  MAL-UNITED  COLLES  S  FRACTURE 
AND  SEPARATION  OF  LOWER  EPIPHYSIS  OF  RADIUS 

In  some  cases  of  Colless  fracture,  where  the  fracture  has  not  been 
reduced  and  the  hand  is  therefore  greatly  disabled,  if  the  patient's  age 
and  vitality  be  satisfactory  operative  steps  will  lead  to  great  improve- 
ment. A  long  incision  is  made  over  the  radius  on  the  dorsum,  and  the 
line  of  union  exposed  by  retraction  of  tendons.  di\asion,  and  separation 
of  the  perio.steum.  The  union  is  then  dissected  through  from  behind 
downwards  and  forwards,  the  fragments  completely  detached  and 
placed  in  correct  position.  As  their  surfaces  are  broad  they  will  remain 
in  position  without  the  aid  of  wire,  &c.  As  the  fracture  is  now  com- 
pound and  the  patient  probably  no  longer  young,  splints  must  be  kept  on 
for  about  four  weeks,  and  some  support  given  afterwards.  Passive  move- 
ment of  the  fingers  should  be  begun  at  once,  and  the  wrist  moved,  carefully; 
in  about  ten  days.  In  separation  of  the  lower  epiphysis,  which  has  been 
overlooked,  deformity  and  arrest  of  the  growth  of  the  radius  are  very 
likely  to  follow.  This  condition  must  be  treated  on  similar  lines,  with 
a  view  of  rectification  of  the  displaced  parts.  If  this  step  is  not  taken 
or  fails,  removal  of  part  of  the  lower  end  of  the  ulna  may  be  required 
later  on.  in  order  to  keep  the  articular  surfaces  at  their  proper  levels, 
and  to  prevent  radial  displacement  of  the  hand. 

AMPUTATION  THROUGH  THE  WRIST-JOINT 

(Figs.  60,  61,  62) 

The  value  of  this  operation  has  been  a  good  deal  disputed.  It  has 
been  thought  by  some  that  it  possesses  no  particular  advantage  ;  the 
length  of  the  stump  is  of  no  great  consequence  ;  the  flaps  \\'ith  the 
numerous  tendons  in  them  may  not  heal  readily.  Others  have  gone 
further,  and  said  that  the  long  stump  is  found  by  instrument-makers 
1  Path.  Soc.  Trans.,  vol.  viii,  p.  391. 


AMPUTATION  THHOICJH  THE  WRIST-JOIXT       121 

dillicult  to  fit  with  un  artificial  liaiid.  That  this  is  certainly  not  always 
the  case  is  shown  by  Mr.  H.  Bigg  ^  from  two  cases,  one  a  commander 
R.N.,  the  other  an  artisan  in  the  Woolwich  Arsenal,  both  of  whom, 
after  being  fitted  witii  artificial  hands,  were  able  to  engage  actively 
in  their  respective  employments. 

As  the  above  objections  are  scarcely  sufficient,  and  as  this  amputa- 
tion preserves,  if  the  parts  heal  quickly,  good  pronation  and  supination, 
it  should  be  practised  whenever  opportunities  arise.  These,  however, 
as  is  shown  below,  will  not  be  numerous. 

Indications.  (1)  Extensive  injuries  (gunshot  and  otherwise)  of  a 
hand  not  admitting  of  the  preservation  of  any  fingers,  and  in  which 
the  damage  of  soft  parts  does  not  necessitate  amputating  through  the 
forearm.  On  this  subject  reference  should  be  made  to  the  section 
on  "  Conservative  Surgery  of  the  Hand,"  p.  71. 

(2)  Some  cases  of  tuberculous  disease  of  the  carpus,  where  sufficient 
skin  and  soft  parts  are  healthy,  but  which  are  too  far  advanced,  or  are 
rendered  by  age,  condition  of  health.  &c.,  unsuitable  for  excision. 

(3)  Cases  of  failed  excision.  But  in  carpal  disease  the  soft  parts 
are  often  so  much  damaged  by  sinuses  and  other  results  of  the  disease 
that  the  surgeon  is  driven  to  amputate  higher  up  ;  and  where  this  may 
not  be  the  case,  the  articular  surfaces  of  the  radius  and  ulna,  owing  to 
disease,  have  to  be  removed,  the  operation  thus  ceasing  to  be  correctly 
amputation  through  the  wrist-joint.^ 

(4,  5,  and  6)  More  rarely  still,  for  the  results  of  palmar  suppuration, 
gangrene,  or  burns. 

(7)  Some  cases  of  malignant  disease,  e.g.  epithelioma.  All  the  above 
are  rare. 

Operations.  As  in  other  amputations  where  the  amount  of  skin 
available  varies  considerably,  several  methods  will  be  given.  The  first 
of  these  is  the  best. 

Different  methods.  ( 1 )  Long  palmar  flap  (Figs.  60  and  61 ).  (2)  Equal 
antero-posterior  flaps.  (3)  Method  of  Dubreuil  (Fig.  62).  (-t)  Circular 
amputation. 

(1)  Ainputation  by  a  Long  Palmar  flap  (Figs.  60  and  61).  This  has 
the  advantage   of  preserving    skin  thick,   well   used   to   pressure,   and 


Fig.  60.     Amputation  through  wrist  by  long  palmar  flap.     Amputation 
through  forearm  by  long  anterior  and  .short  posterior  flaps. 

abundantly  supplied  with  blood  ;    the  nerves  are  also  cut  square,  and 
disarticulation  is  easy. 

^  Artificial  Limbs  and  Amputations,  p.  83. 

~  Disarticulation  has  these  advantages  over  entire  removal  of  the  styloid  processes 
(cidc  infra) :  (1)  There  is  no  risk  of  necrosis.  (2)  Rotation  of  the  forearm  is  not  interfered 
with,  the  inferior  radio-ulnar  joint  being  left.  (3)  The  supinator  iongiis  is  left  to  powerfully 
flex  the  forearm.     (4)  The  stump  is  longer  and  more  useful 


122        OPERATIONS  ON  THE  UPPER  EXTREMITY 


The  brachial  artery  being  controlled  by  a  tourniquet,  the  limb  is 
brought  to  a  right  angle  to  the  patient's  side,  and  the  hand,  supinated,* 
is  supported  by  an  assistant,  or  rests  on  a  sterilised  towel  on  a  small 
table.  The  wrist  is  now  extended,  the  styloid  processes  defined,  and 
the  thumb  abducted  so  as  to  make  the  palmar  tissues  tense.  An  incision 
is  next  made  (on  the  left  side)  from  the  tip  of  the  styloid  process  of  the 
radius^  straight  down  well  on  to  the  thenar  eminence,  and  then  curving 
across  (about  on  a  line  with  the  level  of  the  superficial  palmar  arch), 
and  marking  out  a  well-rounded  flap  by  passing  over  the  hypothenar 
eminence  to  the  tip  of  the  styloid  process  of  the  ulna.  This  flap  is 
next  dissected  up,  without  scoring,  to  ensure  its  vitality,  cleanly  of? 
the  flexor  tendons,  as  far  as  the  level  of  the  wrist-joint :  it  should  contain 
on  its  under  surface  some  of  the  fibres  of  the  thenar  and  hypothenar 
muscles. 

If  this  precaution  be  taken,  the  flap,  if  sound,  will  contaiii  the  super- 
ficial volse  and  ulnar  arteries,  and  thus  run  no  risk  of  sloughing.  In 
cases  where  the  flap  is  damaged  it  will  be  wisest 
in  making  the  flap  to  cut  all  the  structures 
down  to  the  bones.  Cheyne  and  Burghard 
advise  that  it  facilitates  the  operation  to 
detach  the  pisiform  bone  and  raise  it  with  the 
palmar  flap ;  it  can  easily  be  dissected  out 
afterwards.  The  hand  being  now  pronated  and 
flexed  at  the  wrist- joint,  an  incision,  shghtly 
convex,  is  made  across  the  wrist  from  one 
styloid  process  to  the  other.  The  palmar  flap 
being  now  retracted,  the  hand  is  strongly  flexed 
and  the  joint  opened  on  the  other  side  first ;  the 
soft  parts  in  front  and  behind  are  next  severed 
with  a  circular  sweep  (the  assistant  pulling 
slightly  on  the  hand),  the  remaining  ligaments 
divided,  and  the  hand  removed.  At  this  stage  the 
extensor  tendons  must  be  cut  JDoldly  and  cleanly, 
otherwise  they  will  be  ragged.  If  the  articular  cartilages  of  the  radius  are 
diseased,  they  must  be  dealt  with  either  by  gouging  or,  if  necessary,  by  a 
clean  section  above  the  articular  cartilage,  a  step  which  will  interfere 
with  free  pronation  and  supination  later  on.  The  apices  of  the  styloid 
processes  should  in  any  case  be  removed,  but  the  base  of  that  of  the 
radius  should  always  be  left,  if  possible,  to  secure  the  action  of  the 
supinator  longus.  In  amputating  at  the  wrist- joint  care  should  be 
taken,  by  keeping  the  point  of  the  knife  towards  the  carpus,  not  to 
open  the  radio-ulnar  joint,  so  that  there  be  no  interference  with 
pronation  and  supination.  The  radial,  ulnar,  the  two  interosseous, 
and  the  superficialis  volee  arteries  will  probably  need  securing.     Any 


Fl.!.   111. 


^  If  the  operation  is,  thus,  commenced  from  the  front,  the  hand  need  only  be  turned 
over  once.  If  the  dorsum  is  attacked  first,  the  hand  must  be  turned  twice,  first  to  make 
the  palmar  flap,  and  secondly  to  disarticulate  (Farabeuf). 

2  The  tip  of  this  is  nearly  on  a  level  with  the  intercarpal  joint,  being  half  an  inch 
below  and  somewhat  in  front  of  the  styloid  j^rocess  of  the  ulna.  On  a  level  with  the 
latter  will  be  found  the  hne  of  the  wrist-joint.  The  two  furrows  in  front  of  the  wrists 
are  both  below  the  level  of  this  joint.  The  lower  one  corresponds  to  the  uoper  edge 
of  the  anterior  annular  ligament  and  the  intercarpal  joint.  If  the  soft  parts  are 
much  swoUon,  comparison  with  and  measurements  taken  from  the  opposite  wrist,  wiU  be 
helpful. 


AMPUTATION  THROUGH  THE  WRIST- JOINT      123 

sinuses  present  are  now  scraped  with  sharp  spoons,  and  the  tendons 
trinnned.  From  the  facility  with  whicli  these  last  slip  up  into  their 
sheaths,  precautions  should  be  carefully  taken  to  avoid  infection. 

Another  Method.- — This  consists  in  inarkiiig  out  tho  palmar  Hap  (but  not 
dissecting  it  up),  opcMiing  tlio  joint  by  a  dorsal  incision  as  given  above,  and  then 
cutting  tlie  ])ahnar  tlaj)  by  transfixion,  tlie  knife  being  passed  behind  the  bones.  As 
in  this  method  it  is  diftieuH  to  avoid  hitching  the  knife  on  the  pisiform  and  unciform 
l)ones,  and  to  obviate  a  jagged  edge  to  tlie  palmar  tlaj),  and  as  the  Hexor  tendons, 
being  relaxed,  are  pulled  out  by  the  knife  instead  of  being  cut  cleanly,  it  is  not 
recommended. 

(2)  Amputation  by  Equal  Antero-Posterior  Flaps.  The  surgeon  may  be  obliged, 
where  the  soft  parts  are  scanty,  to  make  use  of  this  method.  The  objections  to  it 
are  that  if  the  tissues  are  thin  there  is  some  risk  that  the  cicatrix  maybe  adherent  to 
the  bones,  and  that  these  will  be  but  poorly  covered. 

.  (3)  Ainputationalthe  Wristbi/ the  Method  of  Duhreuil  {Fig.  (52).  In  a  very  few  rare 
cases,  e.g.  where  the  soft  parts  on  the  back  and  front  of  the  wrist  arc  much  damaged, 
perforated  by  sinuses,  &c.,  this  ingenious 
method  may  be  made  use  of.  But  the  objec- 
tion to  it  is  obvious.  Where  the  thumb  is 
sufficiently  healthy  to  afford  soft  parts  for  a 
ffap,  it  should  be  saved.  The  hand  being 
pronated,  the  surgeon  commences,  at  a  point 
at  the  junction  of  the  outer  with  the  middle 
third  of  the  back  of  the  forearm  a  little  below 
the  level  of  the  wrist-joint,  a  convex  incision, 
which  reaches  at  its  summit  the  middle  of  the 
dorsal  surface  of  the  thumb,  and  terminates  in 
front,  just  below  the  palmar  aspect  of  the  wrist, 
at  the  junction  of  the  outer  with  the  middle 
thirds  of  the  forearm.  The  flap,  consisting  of 
skin  and  fascia;,  having  been  raised,  the  two 
ends  of  its  base  are  joined  by  an  incision  at  a 
right  angle  to  the  long  axis  of  the  forearm. 
Finally,  disarticulation  is  performed,  beginning 
at  the  radial  side.  If  needful,  the  flap  may  be 
taken  from  the  hypothenar  eminence,  by  I'e- 
versing  the  incisions. 

(4)  Circular  Amputation  at  the  Wrist.  This  method  is  only  suitable  to 
patients  with  thin,  lax  skin,  and  even  to  them  it  is  often  difficult  to  raise  the  skin 
quickly  and  neatly,  for  it  is  here  adherent  to  some  of  the  adjacent  parts,  as  at  the 
base  of  the  hypothenar  eminence.  Moreover,  cutting  through  such  a  thin,  lax 
skin  may  be  followed  by  sloughing,  especially  if  its  vitality  is  impaired  by  sinuses,  &c. 

The  hand  being  supported  by  an  assistant,  the  surgeon  draws  up  the  skin  of  the 
forearm,  and  makes  his  flrst  circular  incision  through  the  skin  on  a  level  with  the 
carpo- metacarpal  joints  of  the  little  flnger  and  thumb,  encroaching  thus  upon  the 
thenar  and  hypothenar  eminences,  two  inches  below  the  styloid  process.  The 
skin  being  retracted  by  freeing  the  soft  parts  with  light  touches  of  the  knife,  another 
circular  sweep  is  made  just  above  the  level  of  the  j^isiform  bone,  so  as  to  sever  cleanly 
the  numerous  tendons,  together  with  the  vessels  and  nerves.  The  joint  is  then 
opened  and  the  styloid  process  removed. 


Fig.  62.     Dubreuil's  amputation. 


LIGATURE  OF  THE  RADIAL  ARTERY  ON  THE  BACK  OF 
THE  WRIST  1 

(Fig.  63). 

Guide.     A  hne  drawn  from  a  point  just  internal  to  the  apex  of  the 
styloid  process  to  the  back  of  the  interosseous  space. 

^  The  so-called  "  tabatiere  anatomique,"  a  triangular  space  bounded  externally  by 
the  extensor  ossis  metacarpi  and  extensor  primi  internodii,  internalty  by  the  extensor 
secundi  internodii ;  its  apex  is  formed  by  the  meeting  of  these  tendons,  and  its  base  by 
the  lower  edge  of  the  posterior  annular  ligament  or  base  of  the  radius. 


124       OPERATIONS  ON  THE  UPPER  EXTREMITY 

Relations. 

Superficial 
Skin,  fasciae;    branches  of  superficial  vein,  and  of  radial  ami  musciilo- 
cutaneous  nerves  ;   fibro-fatty  tissue  beneath  deep  fascia. 

Three  extensor  tendons  of  the  thumb. 

Outside  Deep  Inside 

V.  comes  Styloid  process  ;    scaphoid.  V.  comes 

trapezium  ;  external  lateral 

ligament  of  the  wrist 

Indications.  Few;  usually  wounds,  e.g.  by  the  slipping  of  a  chisel. 
by  breaking  crockery,  &c.  In  such  cases  both  ends  ^  would,  of  course. 
be  secured,  and  the  surgeon  would  examine  as  to  injury  of  any  of  the 
extensor  tendons. 

Operation.  The  limb  should  rest  upon  its  ulnar  margin,  steadied 
by  an  assistant,  who  with  one  hand  holds  the  fingers,  and  with  the  other 
so  moves  the  thumb  as  to  make  the  tendons  prominent.  In  the  living 
subject  these  should  be  thrown  into  action,  and  their  position  and  that 
of  the  radial  vein  defined  before  the  operation.  The  incision,  one  and 
a  half  to  two  inches  long,  may  be  in  the  above  line  or  parallel  with  the 
tendons.  In  either  case  it  should  be  over  the  lower  part  of  the  vessel, 
just  before  it  dips  between  the  heads  of  the  first  dorsal  interosseous 
into  the  palm.  It  should  be  made  hghtly,  so  as  not  to  damage  the 
radial  vein  or.  deeper  down,  the  tendons.  The  radial  vein  having  been 
drawn  aside  ^ith  a  blunt  hook,  and  the  deep  fascia  carefully  opened, 
the  tendons  are  drawn  aside  as  needed  and  the  artery  separated  from 
its  veins.  The  ligature  may  be  passed  from  either  side.  The  artery 
lies  deeper  than  would  be  expected,  usually  covered  by  fatty  tissue. 
It  will  usually  be  tied  between  the  bases  of  the  first  two  metacaipals 
and  to  the  radial  side  of  the  extensor  secundi  internodii.  If  the  parts 
need  relaxing,  the  hand  should  be  hyperextended.  All  injury  to  the 
closely  contiguous  tendon-sheaths  or  joints  must  be  avoided  ;  and. 
for  the  same  reason,  union  of  the  wound  without  suppuration  is  parti- 
cularly indicated  here. 

In  the  following  case  aseptic  surgery  and  the  tying  of  diseased  arteries 
with  sterilised  silk,  and  not  too  tightly,  answered  well  : 

M.  A.  S.,  at.  60,  was  sent  to  Mr.  Jacobson,  November  1899,  by  Dr.  Verrall.  with 
an  aneurv'sm  of  the  right  ardial  arterj^  Patient,  old  for  her  years,  was  operated 
on  for  cataract  at  46.  Superficial  arteries  tortuous  and  hard.  Xo  evidence  of 
heart  di.sease.  An  aneurysm  the  size  of  a  large  walnut  on  the  outer  and  dorsal 
aspect  of  the  right  ladius,  just  where  the  shaft  and  styloid  process  join,  and  extend- 
ing into  the  "  tabatii're  anatomique,"  had  begun  four  years  before.  At  first  of  the 
size  of  a  nut,  it  gradually  increased  till  a  month  before,  when  it  became  rapidly 
larger.  The  radial  was  tied  just  above  the  swelling,  and  agaui  where  the  arterj-  dips 
between  the  heads  of  the  abductor  indicis.  Sterilised  silk  was  used,  and  the  veins, 
were  included  in  the  fiist  ligature.  Specks  of  atheroma  were  seen  in  the  radial 
arter\-  when  exposed  above.  The  aneurysm  was  then  incised  and  a  good  deal  of 
pink  laminated  clot  turned  out.  The  wound  ran  an  aseptic  cour.se  ;  the  aneurysm 
shrank  and  disappeared,  the  only  trouble  being  some  dermatitis  caused  by  the 
iodoform  gauze  on  a  very  aged  skin. 

^  It  may  be  difficult  to  find  the  di:=tal  end  of  the  artery,  owing  to  its  tendency  to 
retract. 


LICxATURE  OF  THE  RADIAL  ARTERY  12; 


EXTENSOR 
3ECUND/  INTERHODII- 


EXTENSOR     CARPI 
RADI/^LIS    BREVIOR 


EXTENSOR  C/JRPI 
R/^DIAUS    lONQI 


ABDUCTOR 
/NDICJS 


-_--_---    BRANCHES     OF 
RADIAL  N. 


EXTENSOR 

OSSIS     M  ETA  CARP  I 


RADIAL    VESSELS 


EXTENSOR 
PR/HI    INTERHODII 


Fig.  G3 


CHAPTER  VI 
OPERATIONS  ON  THE  FOREARM 

LIGATURE  OF  THE  RADIAL  ARTERY  IN  THE  FOREARM 

(Figs.  64,  65,  66  and  67) 

In  the  upper  two-thirds  the  artery  is  sub-muscular ;    in  the  lower  third 
it  is  sub-fascial. 

Line.  From  the  centre  of  the  bend  of  the  elbow  (where  the  brachial 
artery  divides,  opposite  the  neck  of  the  radius)  to  a  point  just  internal 
to  the  styloid  process  of  the  radius. 

Guide.  The  above  line,  and  the  intermuscular  groove  to  the  inner 
side  of  the  supinator  longus  and  its  tendon.  The  pulsation  of  the  vessel 
can  usually  be  distinctly  felt  in  the  lower  half  of  its  course. 

Relations. 

hi  Front 

Skin,  fascise,  viz.,  superficial,  deep,  and 
another  layer,  varying  in  distinctness, 
w^hich  ties  the  radial  to  the  supinator 
longus  and  pronator  radii  teres. 

Branches  of  the  musculo-cutaneous  nerve, 
especially  below. 

Superficialis  volee  below. 

Transverse  branches  of  vense  comites. 

Supinator  longus  overlapping  for  a  varying 
amount  and  extent  according  to  the 
development  of  the  muscle. 

Outside  Inside 

Supinator  longus  Pronator  radii  teres 

Radial  nerve  (middle  third)  Flexor  carpi  radialis 

Vein  Vein 

Radial  artery 
in  forearm. 

Behind 
Tendon  of  biceps. 
Supinator  bre\^s. 
Pronator  radii  teres. 

Radial  head  of  flexor  sublimis  digitorum. 
Flexor  longus  pollicis. 
Pronator  quadratus. 
Radius. 

126 


LIGATURE  OF  THE  RADIAL  ARTERY  127 

Indications.  (1)  Wounds,  stabs,  cuts  with  glass,  &c.  (2)  Trau- 
matic aneurysm.  In  these  cases,  after  the  application  of  a  tourniquet 
or  an  Esmarch's  bandage,  the  surgeon  opens  the  swelling,  turns  out 
the  clot,  and  ligatures  the  artery  above  and  below.  If  he  prefers  it  he 
may  snip  out  the  swelling  and  twist  or  tie  both  ends  of  the  artery.  The 
first  method  is  on  the  whole  the  most  generally  applicable.     (3)  Punctured 


Fig.  64.  a.  Incision  for  ligature  of 
the  brachial  at  the  bend  of  the 
elbow.  B,  Incision  for  ligature  of 
thevenseat  the  middle  of  the  fore- 
arm, c,  Incision  for  ligature  of  the 
radial  in  the  upper  third  of  the 
forearm,  d,  Incision  for  ligature  of 
the  ulnar  in  the  lower  third  of  the 
forearm,  e.  Incision  for  ligature  of 
the  radial  in  the  lower  third  of  the 
forearm,  f,  Incision  for  exposure  of 
the  median  nerve  above  the  wrist. 


Fig.  65.  Determination  of  the  centre 
of  the  bend  of  the  elbow.  The  left 
index  is  placed  upon  the  epicondyle, 
the  right  upon  the  epitrochlea,  while 
the  right  thumb  occupies  the  centre 
of  the  fold  of  the  elbow,  to  the  inner 
side  of  the  biceps  tendon  which  pro- 
jects beneath  the  soft  jiarts.  The 
line  of  the  radial  artery  has  been 
traced  in  its  intermuscular  furrow. 
(Farabeuf.) 


wounds  of  the  palmar  arch.  Ligature  of  both  the  radial  and  the  ulnar 
is  preferred  by  some,  but  reference  should  be  made  to  the  remarks  at 
p.  89. 

A.  Ligature  in  the  lower  third  of  the  forearm  (Figs.  64  and  66). 
The  forearm  having  been  completely  supinated  and  the  wrist  extended 
at  first,  the  surgeon  makes  an  incision,  two  inches  long,  midway  between 
the  tendons  of  the  supinator  longus  and  flexor  carpi  radialis,  or  (if  this 


128        OPERATIONS  ON  THE  UPPER  EXTREMITY 

be  obscured  by  fat  or  by  swelling)  exactly  in  the  line  of  the  artery,  going 
lightly  1  through  the  skin  and  subcutaneous  tissue.  A  large  branch  of 
the  radial  vein,  which  is  usually  met  with  in  the  subcutaneous  tissue 
just  under  the  incision,  is  now  drawn  aside  or  divided  between  two 
ligatures.  The  deep  fascia,  here  very  thin,  is  carefully  divided,  and 
the  wrist  now  flexed  to  relax  the  parts.  The  artery  being  separated 
from  the  venae  comites,^  the  needle  may  be  passed  in  either  direction. 
Damage  to  any  of  the  tendou-sheaths  should  be  most  carefully  avoided. 


RADIAL    y^.    S 
AND  COMR  VEINS ) 


\ 


Fig.  66.     Ligature  of  the  radial  in  its  lower  third.     Through  the  opening  in 

the  deep  fascia  the  artery  is   seen  with  its    venaj  comites.     Neither   of  the 

adjacent  tendons  has  been  exposed. 

B.  Ligature  in  the  middle  third  of  the  forearm.  Guide.  Line  of 
artery. 

Relatioyis.  The  nerve  is  now  on  the  outer  side  of  the  artery,  but 
not  very  close  to  it. 

The  steps  are  very  much  as  above,  but  the  artery  is  lying  deeper. 
The  radial  vein,  if  present,  must  again  be  avoided.  The  incision  over 
the  middle  third  of  the  artery  should  be  two  and  a  half  inches  long, 
and  the  parts  well  relaxed  when  the  deep  fascia  is  opened  ;  the  inner 
aspect  of  the  supinator  longus  is  next  defined,  and  this  muscle  drawn 
well  outwards.  The  layer  of  fascia  which  unites  the  artery  to  the 
supinator  and  pronator  must  now  be  opened.  The  needle  should  be 
passed  from  ^\ithout  inwards. 

Ligature  in  the  upper  third  of  the  forearm  (Figs.  64  and  67).  Guide. 
The  line  of  the  artery  and  the  inner  border  of  the  supinator  longus. 

^  So  as  to  avoid  the  radial  vein,  which  alwaj's,  and  the  superficialis  volse,  which 
sometimes,  lie  superficial  here,  the  one  over  and  the  other  just  under  the  deep  fascia 
which  is  very  thin. 

2  These,  owing  to  the  free  collateral  venous  currents,  may  be  included  in  the  ligature 
if  it  is  found  very  difficult  to  separate  them  from  the  artery. 


LR.A  J  I  KK  OF  THE  RADIAL  AliTKRY  120 

Relations.  The  nerve  is  on  the  outer  side,  but  well  removed  from 
the  artery.  The  vessel  itself  lies  somewhat  obliquely  as  it  passes  from 
the  middle  of  the  ante-cubital  space  to  the  outer  side  of  the  forearm. 

It  is  important  to  remember  that  the  development  of  the  supinator 
lonffus  and  the  extent  to  which  it  overlaps  the  artery  varies  consider- 
ably. In  a  nnuscular  arm  it  is  very  easy  to  get  into  difficulties  by  not 
hitting  oft'  the  right  intermuscular  septum,  and  thus  getting  too  near 
the  middle  line  of  the  forearm,  unless  the  line  of  the  artery  is  remem- 


SVPINATOK    LONQUS 


RADIAL    A 

AND  COM R /BINS 


PROHATOR.    RADII 
TERES' 


Fig.  67.     Ligature  of  the  radial  just  above  the  middle  of  the  forearm.     The 

supinator  longus  has  been  di'awn  aside.     The  vessels  are  resting  on  the  pronator 

radii  teres.     The  radial  nerve  is  to  the  outer  side  of  the  vessels  and  rather 

on  a  deeper  plane. 

bered.  An  incision,  at  least  two  and  a  half  inches  long,  is  made  over 
the  upper  third  of  the  artery  in  the  above  line.  Any  branches  of  the 
radial  vein  are  drawni  out  of  the  way,  or  secured  vrith  fine  ligatures. 
The  deep  fascia  is  slit  up  to  the  full  extent  of  the  wound,  along  a  white 
line  which  marks  the  interval  between  the  supinator  longus  and  the 
pronator  radii  teres.  These  muscles  may  be  knowTi  by  the  direction 
of  their  respective  fibres,  the  former  going  straight  do\^^l  along  the 
radius,  and  the  latter  obliquely  downwards  and  outwards  to  the  centre 
of  this  bone.  The  muscles  ha^■ing  been  relaxed  by  bending  the  elbow 
and  wrist-joints,  and  the  cellular  interval  between  them  opened  cleanly 
\A-ith  a  knife,  they  are  drawn  aside,  and,  if  the  vessel  does  not  quickly 
come  into  ^new.  its  pulsation  may  be  felt  for.  The  venae  comites  having 
been  separated,  if  possible,  the  needle  may  be  passed  from  without 
inwards. 


SURGERY    I 


130        OPERATIONS  ON  THE  UPPER  EXTREMITY 

LIGATURE  OF  THE  ULNAR  ARTERY  IN  THE  FOREARM 

(Figs.  G4,  68,  and  69) 

Line.  The  surface-marking  for  the  lower  two-thirds  of  the  vessel 
will  be  a  line  drawn  from  the  tip  of  the  internal  condyle  to  the  outer 
side  of  the  pisiform  bone.  The  upper  third,  which  is  deeply  placed 
beneath  the  superficial  group  of  flexors,  may  be  marked  out  by  a  line 
curving  slightly  inwards  from  the  bifurcation  of  the  brachial  to  the 
junction  of  the  upper  and  middle  thirds  of  the  above-mentioned  line. 

Guide.     The  above  line  and,  in  the  lower  third,  the  outer  border  of 
the  flexor  carpi  ulnaris. 
Relations  in  forearm. 

In  Front 
Skin  ;   superficial  and  deep  fascia. 
Branches  of  internal  cutaneous,  ulnar  cuta- 
neous nerve,  and  anterior  ulnar  vein. 
Median  nerve. 
Pronator  radii  teres. 
Flexor  carpi  radialis. 
Palmaris  longus. 
Flexor  digitorum  sublimis. 

Outside  Inside 

Flexor  digitorum  sublimis  Flexor  carpi  ulnaris. 

(in  lower  two-thirds).  Ulnar  nerve. 

Vein.  Vein. 

Ulnar  artery 
in  forearm. 

Behind 
Brachialis  anticus. 
Flexor  profundus  digitorum. 
Anterior  annular  hgament. 

Indications.     These  are  the  same  as  for  the  radial. 

Ligature  in  the  lower  third  of  the  forearm  (Fig.  68).  Position  of  the 
hand  supinated  and  not  too  strongly  dorsiflexed,  to  begin  with.  An 
incision,  commencing  just  above  the  pisiform  bone,  and  two  inches 
long  is  made,  lightly  at  first,  along  the  outer  border  of  the  flexor  carpi 
ulnaris,  the  superficial  veins  avoided,  and  the  deep  fascia  opened. 

The  wrist  is  then  flexed,  the  flexor  carpi  ulnaris  drawn  gently  inwards, 
the  veins  separated  from  the  artery  if  possible,  and  the  ligature  passed 
from  within  outwards  away  from  the  nerve.  Care  is  to  be  taken  to 
avoid  opening  the  sheaths  of  the  tendons. 

Ligature  in  the  middle  third  ^  of  the  forearm  (Fig.  69).  The  position 
of  the  limb  being  as  before,  an  incision,  quite  three  inches  long  in  a 
muscular  arm,  is  made  in  the  above-given  line  of  the  artery  over  its 
middle  third.  Any  superficial  veins  having  been  drawn  aside  or  secured 
with  double  ligatures,  and  the  wound  wiped  dry,  a  white  line,  which 
indicates  the  intermuscular  septum  between  the  flexor  carpi  ulnaris 
and  the  flexor  subhmis,  is  looked  for.     If  the  incision  is  not  directly 

^  The  artery  is  only  ligatured  in  its  upper  third  for  wounds  ;  it  is  necessary  to  re- 
member the  course  of  the  vessel — oblique  from  without  inwards — and  to  divide  sufficiently 
the  superficial  flexors  which  lie  over  it. 


LIGATURE  OF  THE  ULNAR  ARTERY 


131 


,  ULNAR  A 
/IND  COMR  VE.IH5 


-ULNAR.  H. 


Fig.  68.     Ligature  of  the  ulnar  artery  just  above  the  wrist.     The  process  of 

deep  fascia  given  off  from  the  flexor  carpi  ulnaris  has  been  opened  and  drawn 

aside,  exposing  the  uhiar  vessels,  with  the  nerve  lying  internal  to  them. 


FLEXOR.       CARPI      ULNARIS 


Fig.  69.     Ligature  of  the  ulnar  artery  in  the  middle  of  the  forearm.     The 

flexor  carpi  ulnaris  internally,  and  the  flexor  sublimis  externally,  have  been 

drawn  aside.     The  ulnar  vessels,  nerve,  and  part  of  the  flexor  profundus  are 

seen  at  the  bottom  of  the  wound. 


SURGERY  I 


]32        OPERATIONS  ON  THE  UPPER  EXTREMITY 

over  this,  the  edges  of  the  superficial  wound  may  be  carefully  cleared 
a  little  to  one  side  or  the  other  till  the  septum  is  found,  or,  with  the 
finger-tip,  the  sulcus  between  the  above  muscles  may  be  sought  for. 
The  deep  fascia  having  been  slit  up  to  the  full  length  of  the  wound,  a 
muscular  branch,  which  will  serve  as  a  guide  to  the  artery,  will  often 
be  found  coming  up  in  the  intermuscular  space.  The  cellular  tissue 
here  having  been  carefully  torn  through,  the  muscles  are  relaxed  by 
bending  the  wrist  and  elbow  ;  retractors  are  now  introduced  well  into 
the  wound,  this  wiped  dry,  and  the  artery  looked  for.  The  nerve, 
which  lies  to  the  inner  side,  and  joins  the  artery  at  the  junction  of  the 
middle  and  upper  thirds  of  the  forearm,  may  be  seen  first.  The  artery 
being  cleaned,  and  the  venae  comites  separated  from  it  if  possible,  the 
ligature  is  passed  from  within  outwards. 

This  is  the  only  ligature  in  the  forearm  which  wdll  give  trouble  in 
the  dead  subject,  owing  to  the  depth  of  the  vessel,  and  sometimes  the 
difficulty  of  hitting  off  the  intermuscular  septum.  Being  frequently 
set  as  an  examination-test,  the  operation  should  be  carefully  studied 
by  those  at  work  on  the  dead  body. 

Difficulties  and  mistakes.  (1)  Depth  of  the  vessel  in  a  well- developed 
limb.  (2)  Making  the  incision  too  short,  or  too  much  to  the  inner  or 
outer  side,  and  thus  finding  a  wrong  septum,  e.g.  one  between  the  flexor 
carpi  ulnaris  and  the  flexor  profundus,  or  that  between  the  flexor  sublimis 
and  the  pal  maris  longus. 

Aids.  (1)  Keeping  carefully  to  the  above-given  line.  (2)  Hitting 
oft'  the  right  intermuscular  septum  and  corresponding  sulcus.  (3)  Finding 
a  muscular  branch,  and  using  it  as  a  guide  to  the  artery. 

If  a  wrong  space  is  much  opened  up  in  the  living  subject  the  con- 
tiguous muscles  should  be  brought  together  with  sterilised  sutures  cut 
short,  due  drainage  being  provided,  if  needful. 

PARTIAL  EXCISION  OF  THE  RADIUS  OR  ULNA 

Indications.  (1)  New  growths,  especially  myeloid  sarcoma.  (2)  Tuber- 
culous osteitis,  e.g.  of  the  lower  end  of  the  radius,  caseating,  and  resisting 
erasion. 

Operation  for  Removal  of  the  Radius.  This  is  the  bone  of  the  forearm 
in  which  myeloid  sarcomata  more  commonly  originate.  The  following 
is  taken  from  a  most  successful  case  by  Sir  H.  Morris,^  in  which  he 
removed  the  radius  and  ulna  extensively,  for  a  myeloid  growth  originating 
in  the  former,  becoming  firmly  attached  to  the  ulna. 

A  long  incision  was  made  over  the  outer  side  of  the  radius,  from  the  styloid 
process  to  the  ujiper  third.  The  radial  nerve  was  used  as  a  guide  to  the  interval 
between  the  supinator  longus  and  extensor  carpi  radialis  longior,  Sir  H.  Morris 
having  found  on  the  dead  subject  that  he  could  most  readily  separate  the  soft 
structures  from  the  front  and  back  of  the  radius  by  going  between  those  muscles, 
and  keeping  the  supinator  to  the  fore  part  of  the  incision.  The  supinator  longus 
and  pronator  teres  at  their  insertions  having  been  detached  from  the  radius,  the 
bone,  when  freed  of  its  muscles  in  front  and  behind,  was  sawn  through  at  the  lower 
edge  of  the  supinator  brevis.  A  second  longitudinal  incision  of  less  extent  than  the 
first  was  made  along  the  inner  side  of  the  ulna  from  the  wrist-joint  upwards,  and 
through  it  the  rest  of  the  soft  parts  separated  from  the  tumour  and  ulna.  This  bone 
was  sawn  between  three  and  four  inches  above  the  wrist,  and  the  lower  ends  of  both 
bones  disarticulated  by  opening  the  wTist-joint  on  the  inner  side.  The  entire 
tumour,  with  the  ulna  and  pronator  quadratus,  was  then  removed  en  masse.     Four 

^  Clin.  Soc.  Trans.,  vol.  x,  p.  138. 


PARTIAL  EXCISION  OF  RADIUS  OF  ULNA        133 

years  lati-r  8ir  H.  Morris  brought  tho  patient  before  tlie  Clinical  Society.i  There 
was  no  recurrence.  By  the  aid  of  a  leather  splint  the  |)a(i<'nt  was  able  to  nurse, 
dress,  carry,  and  wash  and  care  for  her  cliildren,  and  do  all  her  household  work. 
Latterly,  since  conti'action  had  taken  place,  she  could  hold  her  hand  out  straight 
without  any  support. 

The  late  Mr.  Glutton  reported  three  instructive  cases  of  endosteal 
sarcoma  of  the  radius.-  Two  of  the  cases  affected  the  lower  end  of  the 
bone.  In  one  not  only  the  lower  end  of  the  radius  (the  diseased  bone),  but 
that  of  the  ulna  also  was  removed,^  "  so  that  the  hand  might  be  left  in 
a  straight  line  with  the  forearm."  The  result  of  this  step  was  that, 
while  the  limb  was  useful  in  the  patient's  occupation — that  of  a  painter 
— as  long  as  he  wore  a  leather  gauntlet,  without  this  aid  he  could  do 
nothing.  Examination  of  the  specimen  showed  that  the  ulna  was  quite 
free.  In  the  second  case,  also  of  the  lower  end  of  the  radius,  amputation 
was  performed,  as  the  growth  was  thought  to  be  parosteal  or  periosteal. 
Examination  of  the  specimen  showed  that  it  was  endosteal,  and  Mr. 
Glutton  allowed  that  a  free  incision  might  have  shown  that  resection 
and  saving  the  hand  were  possible.  The  third  was  a  myeloid  growth 
of  the  upper  end,  head  and  neck  of  the  radius. 

This  was  successfully  removed  by  an  incision  on  the  outer  side  over 
the  most  prominent  part  of  the  tumour,  "  the  radius  being  divided  an 
inch  below  the  growth."  This  patient  died,  eighteen  months  later, 
of  renal  disease  present  before  the  operation.  No  recurrence  took  place 
in  any  of  the  three  cases. 

Slowness  of  growth  and  regularity  of  expansion  of  the  bone  are  the 
most  important  guides  in  the  diagnosis  of  endosteal  from  periosteal 
sarcomata.  Grackling  and  pulsation  are  also  very  valuable,  if  present. 
Skiagraphy  will  also  help.  The  first  two  were  absent  in  all  Mr.  Glutton's 
cases,  and  it  is  noteworthy  that,  while  the  growth  which  involved  the 
upper  end  of  the  radius  appeared  to  be  exceedingly  hard  and  resistant, 
as  if  entirely  bony,  it  turned  out  to  be  soft,  almost  diffluent.  A  free 
exploratory  incision  is  the  only  reliable  guide,'*  as  it  is  certain  that  the 
malignancy  of  endosteal  sarcomata  varies  within  wide  limits,  some 
growing  slowly  and  evenly  inside  the  bone,  others  perforating  it  in  one 
or  more  places.  In  such  cases,  after  resection,  the  patient  should  be 
watched  carefully  and  for  several  years. 

Operation  for  Partial  Removal  of  the  Ulna.  In  the  very  much  rarer 
cases  of  myeloid  tumours  springing  from  the  ulna,  the  following  may 
be  the  course  adopted.     The  account  is  taken  from  a  paper  by  Mr.  Lucas. ** 

A  longitudinal  incision,  about  four  inches  long,  exposed  the  tumour  between 
the  flexor  and  extensor  carpi  ulnaris.  In  making  this  the  dorsal  branch  of  the  ulnar 
nerve  was  divided.  The  soft  parts  having  been  next  retracted,  the  bone  was  ex- 
posed above  the  level  of  the  tumour  and  sawn  through.  The  piece  connected 
with  the  tumour  was  next  drawn  out  of  the  wound,  while  the  interosseous  membrane 
was  divided,  and  the  extensor  indicis  on  the  posterior,  and  the  pronator  quadratus 

^  Trans,  vol.  xiii,  p.  155,  pi.  vi. 

2  Clin.  Soc.  Trans.,  vol.  xxvii,  p.  86. 

3  This  step  is  not  to  be  recommended.  Only  the  bone  affected  should  be  removed 
Lateral  displacement  of  the  hand  will  follow,  but  it  will  not  be  a  flail,  and,  as  contraction 
takes  place,  the  hand  will  rapidly  gain  strength,  and  no  apparatus,  requiring  frequent 
renewal,  wiU  be  needed. 

*  Involvement  of  the  soft  parts,  especially  when  these  are  complicated  and  difficult  to 
deal  with,  as  in  the  case  of  those  around  the  head  of  the  tibia  as  compared  with  those  around 
the  lower  extremity  of  the  radius,  and  the  extensive  implication  of  the  meduiia,  will 
be  the  chief  indication  for  amputation. 

^  Clin.  Soc.  Frans.,  vol.  x,  p.  135. 
SURGERY  I  9" 


134        OPERATIONS  ON  THE  UPPER  EXTREMITY 

on  the  anterior,  separated  from  the  tumour.  The  removal  was  completed  by  dividing 
the  ligaments  of  the  lower  radio-ulnar  joint,  the  attachment  of  the  triangular  fibro- 
cartilage  to  the  ulna,  and  the  internal  lateral  ligament.  The  patient  left  the  hospital 
in  five  weeks,  the  resulting  usefulness  being  excellent. 

Further  reniurks  on  the  treatment  of  myeloid  growths  will  be  found 
in  the  Surgery  of  the  Lower  Extremity,  when  those  affecting  the  head 
of  the  tibia  are  considered  (q.v.). 

Excision  of  the  Radius  and  Ulna  in  Military  Surgery.  By  this  is  meant 
deliberate  removal  of  portions  of  these  bones  damaged  by  gunshot  or 
other  injuries,  not  the  mere  picking  away  of  spicules  and  fragments. 
Experience  gained  in  the  South  African  War  shows  that  this  mode  of 
treatment  will  be  but  rarely  called  for.  Lieutenant-Colonel  Hickson^ 
collected  sixty  cases  of  gunshot  fractures  of  the  bones  of  the  forearm, 
none  of  which  terminated  fatally,  though  six  required  amputation. 
The  number  is  made  up  of  injuries  to  both  radius  and  ulna,  fifteen  ; 
of  the  radius  alone,  twenty-seven  ;  of  the  ulna  alone,  eighteen.  Taking 
the  regulation  Mauser  bullet  as  the  standard,  the  varieties  of  wounds 
ranged  within  very  wide  limits,  from  extreme  shattering  and  pulverisa- 
tion to  simple  perforation  without  solution  of  continuity.  The  former, 
involving  the  shafts  and  often  associated  with  extensive  laceration  of 
soft  parts,  were  usually  septic  ;  the  latter,  usually  involving  the  extremities 
which  are  largely  composed  of  cancellous  tissue,  often  escaped  infection 
and  healed  readily.  Colonel  Hickson  sums  up  the  treatment  of  these 
injuries  as  follows  : 

"  The  most  important  measure  in  the  treatment  of  all  gunshot  injuries  of  bones, 
whatever  their  nature  and  position,  is  the  prevention  of  sejitic  changes  in  the  wounds. 
It  is  the  occurrence  of  suppuration  that  threatens  life  and  necesitates  amputation 
in  the  vast  majority  of  cases  requiring  that  operation.  Everytliing  else  sinks  into 
insignificance  beside  it,  and  a  fracture  presenting  the  highest  degree  of  comminution  is, 
if  aseptic,  of  less  moment  than  a  trivial  one  in  which  sui3i:)uration  has  occurred. 
Not  only  does  suppuration  cause  delay  in  union  and  lead  to  necrosis,  but  it  is  only 
too  often  the  precursor  of  septic  osteomyelitis  and  general  septicaemia.  Un- 
fortunately, owing  to  the  conditions  attendant  on  service  in  the  field,  suppuration 
occurs  in  a  considerable  number  of  comminuted  fractures.  .  .  .  On  the  subject  of  the 
advisability  of  exploring  comminuted  fracture  and  removing  loose  fragments, 
differences  of  opinion  seem  to  exist.  Some  surgeons  are  strongly  opposed  to  this 
practice,  and  others  as  firmly  convinced  of  its  nece.-sity.  The  truth  seems  to  lie 
between  the  two  extremes.  If  the  fracture  be  septic  and  highly  comminuted,  the 
exit  wound  should  be  explored  and  all  loose  fragments  removed.  It  is  useless  and 
dangerous  to  leave  them  in  situ.  Should  the  fracture  be  aseptic  and  badly  com- 
minuted, fragments  of  bone,  separated  from  their  attachments  and  lying  loose  in 
the  surrounding  tissues,  should  also,  I  think,  be  removed  with  the  most  careful 
aseptic  precautions.  If  the  fracture  be  aseptic,  the  comminution  not  very  severe, 
and  the  fragments  not  much  displaced,  nothing  is  to  be  gained  by  interference,  and 
harm  may  result." 

The  advantages  of  treatment  on  the  above  lines  over  the  excision 
of  portions  of  the  injured  bone,  as  practised  in  former  days,  are  well 
seen  by  contrasting  with  the  above  the  following  remarks  by  Dr.  Otis  :  ^ 

"  Of  this  large  number  of  excisions  in  the  continuity  of  the  forearm  there  is 
Uttle  to  remark  save  that,  in  the  aggregate,  the  mortality  of  shot  fractmes  appears 
to  have  been  sensibly  augmented  by  operative  interference,  and  that  I  have  sought 
in  vain  for  a  single  instance  in  which  a  formal  excision  of  a  portion  of  the  shaft  of 
either  radius  or  ulna  had  a  really  satisfactory  result  as  regards  the  functional  utility 
of  the  limb.  .  .  .  The  cases  are  divided  into  three  groups:  (1)  primary  ;   (2)  inter- 

^  Rept.  on  Surg.  Casea  noted  in  the  South  African  War,  edited  by  Surg.-Gen.  Stephenson, 
2  Med.  and  Surg.  Hist,  of  the  War  of  the  Rebellion,  pt.  ii,  p.  935,  et  seq. 


VOI.KMANN'S  CONTRACTION  135 

DU'diaiy  (hcforo  tlic  thirtieth  day),  and  secondary  (after  the  thirtieth  day).  Of 
the  primary  10  per  eeiit.,  and  of  the  intermediary  I!)  ])er  cent,  ended  fatally  ;  the 
mortality  of  the  secondary  was  nearly  as  higli  as  that  of  the  ])rimary  excisions. 

Operative  Treatment  of  Volkmanns  Contraction  (Ischsemic  Paralysis). 
This  deforinity  as  a  rule  occurs  iti  the  forearm,  though  in  rare  cases  it 
may  aftect  the  lower  extremity.  It  usually  occurs  in  children,  and 
generally,  though  by  no  means  always,  follows  the  application  of  bandages 
or  splints  especially  for  such  injuries  as  fractures  of  the  bones  of  the 
forearm  or  the  lower  end  of  the  humerus,  or  for  separation  of  the  lower 
epiphysis  of  the  latter  bone.  In  many  cases  there  can  be  no  doubt 
that  the  bandages  have  been  too  tightly  applied,  or  that  the  splints 
have  been  allowed  to  remain  too  long  unchanged.  Though  the  severity 
of  the  contraction  varies,  the  deformity  in  a  typical  case  is  characteristic. 
The  forearm  is  firmly  fixed  in  a  position  of  full  pronation,  the  wrist  is 
flexed,  the  proximal  phalanges  are  hyperextended,  while  the  second 
and  third  are  fully  flexed.  Though  the  pathology  of  the  condition  is 
not  quite  clear,  it  is  certainly  due  to  interference  with  the  arterial  supply 
of  the  affected  muscles.  The  diminished  supply  of  oxygen  probably 
leads  to  a  coagulation  of  the  contractile  substance,  analogous  to  the 
change  occurring  in  rigor  mortis,  and  followed  by  fibroid  change  and 
contraction.  The  deformity  develops  in  about  four  to  six  weeks  after 
the  injury.  Jenks  Thomas  ^  discusses  fully  the  pathology,  causation, 
and  treatment,  in  a  paper  based  on  107  collected  cases. ^ 

When  the  deformity  is  but  slight,  gradual  stretching  of  the 
contractions  may  be  tried,  combined  with  massage  and  electrical  treat- 
ment. In  severe  cases  these  measures  are  useless  :  some  form  of  opera- 
tive treatment  is  recpiired.  The  following  methods  may  be  employed  : 
(1)  tendon-lengthening;  (2)  resection  of  bones;  (3)  freeing  nerves; 
(4)  myotomy.  In  some  cases  a  combination  of  two  or  more  of  these 
methods  may  be  desirable. 

(1)  Tendon-lengthening.  The  methods  of  tendon-lengthening  are 
described  at  p.  99.  Owing  to  the  number  of  tendons  to  be  dealt  with, 
the  operation  is  long  and  tedious.  Mr.  Barnard '^  has  fully  reported 
two  cases  treated  in  this  way. 

In  the  first,  the  patient,  »t.  13,  had  been  treated  for  a  fracture  of  both  bones  of 
the  right  forearm.  When  the  splints  were  readjusted  at  the  end  of  a  week,  a  pressure- 
sore  was  found  on  the  front  of  the  forearm.  A  month  later,  the  fingers  began  to 
be  fixed,  and,  six  weeks  after  the  fracture,  the  hand  was  in  the  position  of  main  en 
griffe.  There  was  no  definite'  anasthesia,  but  voluntary  movements  were  lost 
in  the  hand  and  wrist.  Operative  interference  was  delayed  by  the  healing  of  the 
pressure-sore,  and  a  whitlow  on  the  tip  of  the  right  index  finger.  Six  months  after 
the  injury  an  incision  was  made  along  the  forearm,  skin-flaps  were  reflected,  and 
the  tendons,  no  thicker  than  stout  twine,  split  for  one  and  a  half  inches  and  the 
halves  severed  above  and  below,  on  opposite  sides.  The  fingers  were  then  extended, 
and  the  two  halves  of  the  divided  tendons  allowed  to  slide  upon  each  other  as  much 
as  was  necessary,  and  then  united  with  one  or  two  sutures  of  fine  silk.  The  tendons 
of  the  flexor  profundus  digitorum  were  so  blended  and  adherent  in  the  depths  of  the 
wound  that  there  seemed  no  end  to  the  tiny  strips  which  were  separated  from  the 
mass  and  divided  until  all  the  terminal  phalanges  could  be  extended.  Confusion 
was  prevented  by  employing  guide-sutures.  The  deepest  tendons  were  sutured 
first.  No  form  of  tourniquet  was  emiiloyed  ;  the  whole  operation,  which  lasted  two 
hours,  was  strangely  bloodless.   The  muscles,  where  exposed,  were   pale,  firm,  dry 

^  Annals  of  Surgeri/,  vol.  xlix,  p.  330. 

2  See  also  a  papcr'by  Dr.  E.  G.  Alexander  on  the  Treatnaent  of  Volkmann's  Contrac- 
tion.    Annals  of  Surgery,  vol.  Ivii,  1913,  p.  555. 

3  Lancet,  vol.  i,  1901,  p.  1138. 


136        OPERATIONS  ON  THE  UPPER  EXTREMITY 

and  fibrous.  The  limb  was  put  up  on  a  back-splint  with  the  fingers  fully  extended 
Healing  took  place  by  first  intention.  A  fortnight  after  the  operation,  massage  and 
passive  movements  were  begun. 

The  second  case  was  a  boy  let.  4,  whose  forearm  had  been  severely  crushed 
with  much  effusion  of  blood,  but  without  fracture.  The  limb  was  placed  oa  an 
external  angular  splint,  and  light  bandaging  employed.  Five  weeks  later  the  trouble 
began  to  appear.  At  the  operation  the  flexor  tendons  were  treated  as  described 
above,  but  the  pronators  were  not  interfered  with.  Improvement  after  four  months 
was  so  marked  that  the  mother  wished  something  done  for  the  loss  of  rotation  of  the 
forearm.  The  insertion  of  the  pronator  radii  teres  was  exposed  and  the  radial  vessels 
and  nerve  separated  from  it.  The  muscle  was  then  split  and  divided  on  opposite  sides 
as  the  flexor  tendons  had  been.  As  supination  was  still  imperfect,  an  incision  was 
made  over  the  lowest  part  of  the  ulna,  between  the  extensor  and  flexor  carpi  ulnaris. 
The  pronator  quadratus  was  separated  with  a  periosteal  elevator  from  the  ulna. 
The  pronator  radii  teres  was  then  sutured  in  the  upper  j)art  of  the  wound.  The 
forearm  could  now  be  fully  supinated  on  a  splint. 

Five  to  eight  months  after  operation  both  children  could  grasp  a  stick  or  pick 
up  a  pin  ;  neither  could  make  a  fist,  but  both  cases  were  steadily  improving. 

(2)  Resection  of  bones.  In  this  method,  portions  of  the  radius  and 
ulna  are  excised,  the  shortening  of  the  forearm  thus  obtained  allowing 
the  wrist  and  fingers  to  be  straightened  without  interfering  with  the 
tendons.  Mr.  R.  P.  Rowlands^  describes  a  case  in  which  he  employed 
this  method,  giving  interesting  operative  details. 

The  patient,  a  girl  set.  6,  had  six  months  before  admission  a  fracture  of  the  radius 
and  ulna  near  the  middle  of  their  shafts.  The  arm  was  much  bruised  and  swollen 
before  splints  were  applied.  The  skin  sloughed  in  three  places.  When  seen  the 
deformity  was  severe  and  quite  typical.  An  incision  was  made  along  the  middle  third 
of  the  radial  border  of  the  forearm.  The  tendon  of  the  extensor  carpi  radialis  longior 
and  the  radial  nerve  were  drawn  forwards  and  the  extensor  carpi  radialis  longior  was 
retracted  in  the  opposite  direction.  This  gave  an  excellent  view  of  the  insertion  of 
the  pronator  radii  teres  and  the  outer  surface  of  the  radius  as  far  as  the  extensor 
ossis  metacarpi  poUicis,  where  the  latter  passes  obliquely  forwards  across  the  bone. 
At  the  lower  end  of  the  wound  the  upper  fibres  of  the  pronator  quadratus  were  also 
displayed.  The  radius  having  been  cleared  of  soft  parts  was  drilled  at  two  points 
one  and  a  quarter  inches  apart,  and  then  a  portion  of  it  one  and  a  quarter  inches  long 
was  removed  by  means  of  a  fine  saw.  The  piece  removed  extended  from  the  inser- 
tion of  the  pronator  radii  teres  to  the  pronator  quadratus.  A  similar  portion  of  the 
ulna  was  removed  through  an  incision  along  its  subcutaneous  border,  but  one  inch 
higher  up.  The  bones  were  united  by  silver  wire  :  the  drill  holes  in  the  radius  were 
so  directed  that  when  the  wire  was  tightened  the  lower  fragment  of  the  radius  was 
rotated  into  a  position  of  semi-pronation.  During  the  operation  it  was  noticed 
that  the  deep  flexors  were  firm  and  fibroid.  At  the  end  of  the  operation  the  wi'ist  and 
fingers  could  be  extended  almost  into  a  line  with  the  forearm.  Massage  was  com- 
menced on  the  ninth  day  and  passive  movements  as  soon  as  union  had  occurred. 
When  seen  eighteen  months  later  the  muscles  of  the  forearm  had  increased  very  con- 
siderably and  the  limb  had  lost  its  sunken  appearance.  The  child  could  use  the  hand 
for  most  purposes  and  could  pick  up  a  pin  or  a  penny  with  ease  and  rapidity. 
There  was  a  good  range  of  movement  in  the  fingers,  and  a  powerful  grip.  Supination 
and  pronation  were  well  performed. 

The  advantages  of  this  method  are  (1)  that  the  operation  is  easier 
and  shorter  than  tendon-lengthening.  (2)  The  radius  can  be  drilled 
in  such  a  manner  as  to  correct  the  crippling  limitation  of  supination. 
(3)  The  tendons  are  not  interfered  with.  The  chief  disadvantage  is 
that  there  is  a  possibility  of  non-union. 

(3)  Freeing  the  nerves.  Though  a  lesion  of  the  nerves  is  not  the 
cause  of  the  deformity,  yet  secondary  affection  of  the  nerve-trunks 
from  involvement  in  connective-tissue  overgrowth  is  frequent.  Jenks 
Thomas  -  says  :    "  Disturbance  of  sensation  in  the  hand  can  only  be 

^  Lancet,  1905,  vol.  ii,  p.  1168.  2  j^qc.  swpra  cil. 


AMPUTATION  OF  THE  FOREARM       137 

produc(xl  ill  this  way,  especially  when  it  is  limited  to  the  area  of  skin 
corresponding  to  the  distribution  of  one  of  the  nerves  of  the  arm.  The 
same  thing  is  true  of  atrophy  of  the  small  muscles  of  the  hand,  and  the 
presence  of  the  reaction  of  degeneration  in  these  muscles  is  positive 
evidence  of  involvement  of  the  nerve-trunks.  Paralysis  of  these  hand 
muscles  can  only  be  due  to  nerve  involvement,  and  this  point  is  one 
frequently  overlooked."  In  such  cases  considerable  benefit  may  be 
obtained  by  freeing  the  affected  nerve  or  nerves.  Jenks  Thomas  ^  mentions 
one  case  in  which  the  ulnar  nerve  was  freed,  dissected  clear  of  the  internal 
condvlar  groove,  and  followed  downwards  through  the  flexor  carpi 
ulnaris.  It  was  then  transferred  to  a  point  anterior  to  the  internal 
condvle,  the  fascia  being  sutured  beneath  it,  leaving  the  nerve  between 
the  deep  fascia  and  the  subcutaneous  fat.  Though  this  was  the  only 
operative  treatment,  a  marked  improvement  followed,  and  six  months 
later  there  was  good  functional  use  of  the  hand  in  every  way  in  spite 
of  slight  shortening  of  the  flexors.  It  is  only  fair  to  point  out  that 
that  some  surgeons  have  found  freeing  of  the  nerves  a  matter  of  great 
difficulty  or  even  an  impossibility. 

AMPUTATION  OF  THE  FOREARM 

(Figs.  60,  70,  71  and  72) 

This  operation  is  frequently  performed,  usually  for  extensive  injuries, 
but  occasionally  for  malignant  growths  or  severe  and  intractable  tuber- 
culous or  septic  trouble  in  the  wrist  or  hand. 

Practical  Anatomical  Points,  (a)  The  two  bones  are  not  fixed,  like 
those  in  the  leg,  but  movable.  This  mobility  may  prevent  their  being 
parallel  when  the  knife  is  sent  across  in  transfixion,  and  thus  lead  to 
penetration  of  the  interosseous  membrane  :  it  must  also  be  remembered 
in  sawing  off  the  bones.  Lastly,  on  this  mobility  in  pronation  and 
supination  depends  the  usefulness  of  the  stump,  which  must  therefore 
be  left  as  long  as  possible,  the  bones  being  always,  when  practicable, 
sawn  well  below  the  insertion  of  the  pronator  radii  teres  into  the  middle 
of  the  outer  surface  of  the  radius.  If  the  bones  be  divided  above  the 
insertion  of  the  pronator  teres,  the  radius  will  become  supinated  and 
further  rotation  movements  will  be  lost.  (6)  In  the  upper  part  of  the 
forearm,  both  in  front  and  behind,  are  fleshy  bellies  ;  below,  the  soft 
parts  are  increasingly  tendinous.  Furthermore,  the  anterior  border 
of  the  radius  and  the  posterior  of  the  ulna,  especially  the  latter,  are 
largely  subcutaneous. 

These  facts  render  the  forearm  an  unsuitable  locality  for  amputa- 
tion by  the  circular  method. 

Different  methods.  (1)  Skin  flaps,  antero-posterior  or  lateral,  with 
circular  division  of  muscles,  &c.  (2)  Modified  circular  method  with 
equal  anterior  and  posterior  flaps.     (3)  Transfixion  flaps. 

(1)  Anifutationof  the  Forearm  by  Skin  Flaps,  ivith  Circular  Division  of 
Muscles,  &c.  (Figs.  70  and  71).  While  in  an  amputation  so  often 
called  for  it  is  well  to  practise  several  methods,  none,  on  the  whole, 
answers  so  well  as  this,  for  the  following  reasons  :  (a)  By  cutting  one 
flap  a  little  longer  than  the  other,  sufficient  skin  can  always  be  obtained 
to  give  a  good  stump.     (6)  Transfixion,  while  quite  unsuited  to  the 

^  See  also  a  paper  by  Jenks  Thomas  on  "  Nerve  Involvement  in  the  Ischaemic  Paralysis 
of  Volkmann,"  Annals  of  Surgery,  vol.  xlix,  1909,  p.  330. 


138       OPERATIONS  ON  THE  UPPER  EXTREMITY 

lower  third,  owing  to  the  numerous  tendons,  can  only  be  performed 
in  the  upper  third  in  moderately  muscular  forearms  with  ultimate 
satisfaction.  For  in  a  bulky,  fleshy  limb  (as  in  a  case  of  accident  in  a 
male  adult)  it  is  not  easy  always  to  cut  the  skin  longer  than  the  muscles 
in  bringing  out  the  knife,  and  so  to  prevent  the  tendency  of  the  fleshy 
bellies  to  protrude  while  the  flaps  are  being  united  ;  and  a  little  later, 
these  muscles,  with  large  surfaces  cut  obliquely,  give  rise  to  a  good 
deal  of  blood-stained  oozing,  which  is  very  likely  to  cause  tension.  The 
brachial  ha^-ing  been  controlled  by  a  tourniquet,  the  arm  extended 
from  the  side,  ^^•ith  the  forearm  pronated  and  the  hand  steadied  by  an 
assistant,   the  surgeon,   standing  outside  the  limb  on  the    right,   and 


Fig.  70. 

inside  it  in  the  case  of  the  left  side,  places  his  left  index  and  thumb 
on  the  borders  of  the  radius  and  ulna,  at  the  spot  where  he  intends 
to  saw  the  bones.  The  point  of  a  narrow-bladed  knife  (about  four 
inches  long)  is  then  inserted  just  below  the  index,  carried  along  the 
bone  for  three  inches,  then  curved  suddenly  across,  so  as  to  mark  out 
a  broadly  arched,  not  a  pointed,  flap  (Fig.  70),  and  finally  carried 
up  along  the  bone  nearest  to  the  surgeon  to  a  point  just  below  the 
thumb. 

This  flap  is  then  dissected  up.  consisting  of  skin  and  fascia,  and  of 
even  thickness  throughout. ^  The  forearm  is  next  raised  by  the  assistant 
holding  the  hand,  so  that  its  palmar  aspect  faces  the  surgeon,-  who 
marks  out,  by  a  curved  cut  joining  the  two  horns  of  the  other  incision, 
a  similar  flap  on  the  anterior  surface,  but  one  only  about  two  inches 
in  length.  This  flap  having  been  raised  and  both  retracted,  the  soft 
parts  are  di\aded  with  a  circular  sweep  close  to  the  base  of  the  flaps, 
this  being  repeated  once  or  twice  till  the  bones  are  quite  exposed.  The 
knife  is  then  passed,  with  due  care  of  the  severed  arteries,  between  the 
bones,  so  as  to  di^ide  the  interosseous  membrane,  and  the  periosteum 
next  cut    circularly   where  the  saw  is    to  pass.     The  bones  are  sawn 

^  The  under  surface  of  a  so-called  skin  flaji  should  always,  when  possible,  show  a  few 
muscular  fibres  ;  this  shows  that  the  deep  fascia  is  present,  in  which  the  vessels  run 
from  which  branches  pass  to  the  skin. 

~  Care  must  be  taken  to  keep  the  bones  parallel,  now,  and  throughout  the  operation. 


AMPUTATION  OF  THE  FOREARM 


130 


throu^'h,  with  the  following  precautions  :  The  heel  of  the  saw  having 
been  placed  on  the  bones,  it  is  drawn  lightly,  but  firmly,  towards  the 
operator  two  or  three  times,  so  as  to  make  a  groove.  With  a  series  of 
light  sweeps,  in  which  the  whole  length  of  the  saw  is  used,  the  two  bones 
are  then  cut  through  together,  the  limb  being  kept  supinatcd  during  the 
use  of  the  saw,  so  as  to  keep  the  bones  as  parallel  as  possible. 

The  assistant  in  charge  of  the  lower  part  of  the  limb  must  be  most 
careful  to  hold  it  steady  ;  if  he  depress  at  all,  the  bones  will  certainly 
splinter  when  half  sawn 
through  ;  if,  on  the  other 
hand,  he  raise  the  parts 
the  saw  will  be  locked.  Any 
tendons  requiring  it  are  then 
trimmed,  nerves  cut  short 
and  square,  and  the  vessels 
ligatured  or  twisted.  There 
are  usually  four,  viz.  the 
radial,  under  cover  of  the 
supinator  longus,  close  to 
its  bone  ;  the  ulnar,  covered 
by  the  flexor  carpi  ulnaris, 
on  the  front  of  the  ulna. 

Their  respective  nerves 
are  good  guides  to  the 
arteries,  save  quite  low 
down,  when  the  radial  has 
gone  to  the  back  of  the 
limb.  The  anterior  inter- 
osseous is  found  on  the 
front  of  the  interosseous 
membrane,  and  the  pos- 
terior interosseous  betw^een 
the  deep  and  superficial 
extensors. 

If  the  surgeon  prefer  it, 
instead  of  having  the  fore- 
arm raised  so  as  to  face 
him  (Fig.  71)  while  he 
shapes   the   flap   from   the 

anterior  or  flexor  surface,  he  ^vill  tell  the  assistant  to  completely 
supinate  the  forearm,  and  proceed  to  make  the  flap  with  the  limb  in 
this  position. 

If,  owing  to  the  condition  of  the  soft  parts,  lateral  flaps  are  preferred, 
the  limb  having  been  pronated,  the  surgeon  marks  the  site  of  bone- 
section  with  his  left  forefinger  and  thumb  placed  on  the  centre  of  the 
extensor  and  flexor  aspects  of  the  limb  at  this  level.  Then,  looking 
over  the  forearm,  he  enters  his  knife  in  the  middle  of  the  flexor  surface, 
and  carries  it,  cutting  a  broadly  arched  flap,  about  two  and  a  half  inches 
long,  to  a  corresponding  point  on  the  centre  of  the  back  of  the  limb, 
and  then  from  this  point  down  again  over  the  side  nearest  to  him,  to 
the  spot  where  the  knife  was  first  entered.  The  flaps  are  next  dissected 
up  wath  the  precautions  already  given,  and  the  operation  completed  as 
before, 


Fig.  71. 


140        OPERATIONS  ON  THE  UPPER  EXTREMITY 

(2)  Modified  Circular  Method  with  equal  Anterior  and  Posterior  Flaps. 
In  this  method  the  anterior-posterior  flaps  being  of  equal  length  seldom 
have  to  be  more  than  one  and  a  half  inches  long,  the  bones  can  be  divided 
at  a  lower  level  than  any  other,  and  thus  the  largest  possible  stump  is 
given. 

While  the  scar  lies  directly  over  the  ends  of  the  bones,  this  will, 
under  most  circumstances,  be  the  point  where  there  is  least  friction, 
because  the  pressure  of  an  artificial  limb  must  fall  either  upon  its  anterior 
or  posterior  aspect,  and  not  upon  the  end  of  it,  as  is  the  case  in  the 
lower    extremity.     Should,    however,    the    occupation    of    the    patient 


Fig.  72. 

involve  pushing,  it  is  difficult  to  see  how  the  face  of  the  stump  and  the 
scar  will  escape  pressure. 

The  limb  being  abducted  and  fully  supinated,  the  surgeon  standing 
to  the  right  of  the  Hmb  places  his  left  forefinger  and  thumb  on  either 
side  of  the  limb  at  the  point  proposed  for  division  of  the  bones.  The 
knife  is  then  entered  about  half  an  inch  below  one  of  these  points,  and 
is  made  to  trace  a  short  anterior  flap  terminating  at  a  corresponding 
point  on  the  opposite  side.  When  this  is  done  a  similar  posterior  flap 
is  marked  out.  In  a  forearm  of  ordinary  size  the  lower  limit  of  the 
flaps  will  be  about  one  and  a  half  inches  below  the  seat  of  circular  division 
of  the  muscles,  and  this  again  about  one  and  a  half  inches  from  the 
point  of  section  of  the  bones.  The  periosteum  is  divided  cleanly  right 
round  the  bones  and  stripped  up  with  a  rugine,  together  with  the  muscles. 
This  provides  a  cap  of  periosteum  for  the  cut  ends  of  the  bones  and  a 
nicely  rounded  end  for  them,  and  in  the  forearm  guards  against  a  fusion 
of  the  cut  ends,  which  would  cause  a  loss  of  pronation  and  supination. 

The  muscles  should  never  be  first  stripped  off  the  periosteum,  and 
the  latter  then  separated  from  the  bones. 


AMPUTATION  OF  THE  FOREARM  141 

(3)  Amputation  of  the  Forearm  hy  Transfixion  FUips  (Fig.  72).  In 
the  case  of  a  moderately  imiscular  forearm  the  surgeon  may  make  use 
of  this  method  in  amputating  through  the  michlle  of  the  forearm.  For 
reasons  ah'eady  given  {see  p.  iH),  this  inetliod  is  not  recommended, 
but  tlie  rapidity  with  wliich  it  cai\  be  done  commends  it  to  the  notice 
of  those  who  may  have  to  treat  wounded  in  war  on  a  large  scale,  or 
in  railway  accidents  where  more  than  limb  requires  amputation.  The 
limb  being  abducted,  and  the  forearm  supported  and  pronated,  with 
the  bones  as  parallel  as  possible,  the  surgeon,  standing  outside  the  right 
and  inside  the  left  limb,  lifts  up  the  soft  parts  at  the  spot  where  he 
intends  to  saw  the  bones,  and  sends  a  narrow-bladed  knife  (four  to 
five  inches  long)  across  the  limb,  entering  it  and  bringing  it  out  just 
above  the  bones.  He  then,  by  cutting  downwards  and  forwards,  shapes 
as  broad  a  flap  as  possible  with  a  steady  sawing  movement,  taking  care, 
before  bringing  out  the  knife,  to  cut  the  skin  longer  than  the  muscles 
by  continuing  the  use  of  the  knife  after  the  latter  are  felt  to  be  cut 
through.  The  flap  should  be  three  to  four  inches  long,  according  to 
the  condition  of  the  tissues  on  the  other  side,  each  flap  being  made  as 
broad  as  possible  and  bluntly  rounded  as  it  is  finished. 

The  tissues  on  the  front  are  then  lifted  from  the  bones  and  trans- 
fixed by  passing  the  knife  across. immediately  above  the  bones  at  the 
base  of  the  first-made  flap,  the  limb  being  now  supinated.  As  in  this 
second  transfixion  the  skin  on  the  farther  side  of  the  limb  may  be 
punctured,  it  is  well  for  the  surgeon  to  hold  down  its  cut  edge  with  a 
finger. 

The  second  flap  is  then  cut,  broad,  well-rounded,  and  two  and  a  half 
to  three  inches  long,  according  to  the  length  of  the  anterior. 

In  making  either  flap,  while  the  muscles  are  being  severed,  the  wrist 
should  be  kept  flexed.  The  flaps  are  then  retracted,  the  soft  parts 
severed  with  a  circular  sweep,  the  interosseous  membrane  divided,  and 
the  rest  of  the  operation  completed  as  in  the  method  first  described. 
If  this  method  is  used,  the  nerves  should  always  be  cut  short  and 
square  ;   otherwise  painful,  bulbous  ends  may  follow. 

A  very  rapid  and  effective  modification  of  the  above  is  the  following  : 
As,  owing  to  the  inequality  of  the  soft  parts  on  the  back  as  compared 
with  those  on  the  front  of  the  forearm,  and  also  from  the  proximity  of 
the  ulna  to  the  surface  here,  transfixion  of  a  dorsal  flap  is  not  always 
easy,  a  quicker  method  is  as  follows  :  A  skin  flap,  three  and  a  half  inches 
long,  broad,  and  w^ell  rounded,  being  marked  out  on  the  posterior  aspect 
of  the  hmb,  the  knife  is  immediately,  without  being  taken  off,  pushed 
across  in  front  of  the  bones  and  made  to  cut  a  flap,  by  transfixion, 
two  and  a  half  inches  long,  the  skin  being  cut  longer  than  the  muscles 
{vide  supra).  The  dorsal  skin  flap  is  then  dissected  up,  the  flaps  retracted, 
and  the  bones  cleared  as  before. 


CHAPTER  VII 

OPERATIONS  IN  THE  NEIGHBOURHOOD  OF 
THE  ELBOW-JOINT 

AMPUTATION  AT  THE  ELBOW-JOINT  (Figs.  73,  74,  and  75) 

This  operation  gives  excellent  results,  good  flaps  being  obtainable  from 
the  thick  soft  parts  in  front  and  from  the  skin  behind,  which  is  well 
used  to  pressure.  It  has  not  been  performed  so  often  as  it  might  have 
been,  owing  perhaps  to  the  fact  that  disarticulation,  however  simple, 
is  considered  by  some  to  be  inferior  to  an  amputation ;  and  because, 
owing  to  the  expanded  end  of  the  humerus,  the  flaps  required  are  some- 
what larger  than  in  amputation  through  the  lower  third  of  the  humerus. 
New  growths  of  the  bones  of  the  forearm  and,  occasionally,  severe 
crushes  are  the  chief  indications. 

Practical  points,  (a)  The  internal  condyle  is  nearly  half  an  inch 
below  the  level  of  the  external,  (b)  The  joint  is  opened  most  easily 
on  the  outer  side,  where  the  head  of  the  radius  is  the  best  guide, 
(c)  There  are  thick  masses  of  muscles  on  the  front  and  sides  ;  of  the 
latter  those  on  the  outer  side  (owing  to  the  presence  of  the  supinator 
longus)  retract  more  powerfully  than  those  on  the  inner,  {d)  The  skin 
at  the  back  of  the  joint  is  well  used  to  pressure,  and  is  connected  by 
fibrous  bands  to  the  back  of  the  ulna. 

Methods.  Owing  to  the  vascularity  of  the  parts  many  methods 
may  be  employed.  The  first  three  are  especially  recommended.  (1)  A 
large  antero-internal  flap  and  a  short  postero-external  one.  (2)  Long 
anterior  and  short  posterior  flaps.     (3)  By  a  single  lateral  flap. 

The  condition  of  the  soft  parts  may  render  it  desirable  to  employ 
one  of  the  following  :  (4)  Circular  method.  (5)  Long  posterior  flap. 
(6)  Long  anterior  flap. 

(1)  Amputation  by  a  large  Antero- Internal  and  a  short  Postero- External 
Flap.  The  elbow  is  shghtly  flexed,  and  the  antero-internal  flap  is  first  cut. 
The  incision  begins  at  the  centre  of  the  bend  of  the  elbow  and  is  continued 
down  parallel  with  the  long  axis  of  the  humerus  for  about  three  inches  ; 
with  the  arm  flexed  to  an  angle  of  L35  degrees  the  incision  will  meet  the 
inner  border  of  the  forearm  at  about  this  point.  The  incision  is  then 
curved  backwards  and  upwards  to  the  olecranon  to  mark  out  a  rect- 
angular flap  vnth.  rounded  angles.  A  somewhat  similar  flap  is  next  cut 
from  the  external  surface,  but  this  should 'only  be  about  one  inch  long. 
The  soft  parts  are  taken  up  with  the  flaps  right  down  to  the  bone.  Any 
remaining  structures  in  front  are  severed,  the  joint  is  opened  preferably 
on  the  outer  side  between  the  head  of  the  radius  and  the  capitellum, 
and  the  forearm  is  then  removed  by  dividing  the  lateral  ligaments  and 

the  triceps. 

142 


AMPUTATION  AT  TIIK  ELBOW  JOINT 


14.3 


(2)  Long  Anterior  and  short  Posterior  Fhips  (Figs.  73  and  74).  This 
method  fjivos  an  excollent  covering  to  the  front  of  the  humerus,  allows 
of  easy  drainage,  and  preserves  skin  which  is  well  used  to    pressure. 


Fig.  73.     Amputation   through   the    elbow-joint    by   anterior   and    posterior 
flaps,  at  the  moment  of  disarticulation. 

The  brachial  being  controlled  above  its  centre,  the  forearm  being  held 
somewhat  flexed  and  completely  supinated.  the  surgeon  standing  on 
the  inner  side  in  the  case  of  the  left,  and  outside  the  right  limb,  raises 


Fig.  74.     Completion   of   amputation   through   the   elbow-joint    by   anterior 

and  posterior  flaps.     The  arrows  indicate  the  saw-like  action  with  which  the 

knife  should  be  used.     (Farabeuf.) 

the  soft  parts  in  front  of  the  elbow  triangle,  and  sends  his  knife,  held 
horizontally,  across,  just  in  front  of  the  joint.  Thus  entering  it  one 
inch  below  the  internal  condyle,  and  bringing  it  out  one  and  a  half  inches 
below  the  external  one,  or  vice  versa,  he  cuts  a  well-rounded  flap,  three 


144        OPERATIONS  ON  THE  UPPER  EXTREMITY 

inches  long,  taking  care,  as  the  knife  emerges,  that  the  skin  is  cut  longer 
than  the  muscles.  Then,  passing  his  knife  behind  the  limb,  and  looking 
over,  the  surgeon  joins  the  two  ends  of  the  base  of  his  first  incision  by 
a  convex  cut  through  the  skin  over  the  back  of  the  olecranon,  so  as  to 
mark  out  a  flap  an  inch  and  a  half  in  length.  This  is  raised  without 
scoring,  care  being  taken  to  keep  the  knife  towards  the  ulna  for  fear 
of '■  button-holes."  The  joint  is  then  opened  and  the  forearm  removed 
as  described  above.  During  this  stage  the  assistant  in  charge  of  the 
forearm  pulls  this  away  from  the  arm. 

The  brachial  artery  is  then  secured,  together  with  any  other  vessels 
which  continue  to  bleed  on  removal  of  the  tourniquet.  Any  nerves 
which  require  it  are  cut  short,  drainage  is  pro\dded,  and  the  flaps  care- 
fully united. 

Should  the  surgeon  prefer  to  do  so,  the  anterior  flap  may  be  cut 
from  the  surface  instead  of  by  transfixion.  This  course  should  be 
adopted  in  the  case  of  a  bulky,  muscular  limb. 

(3)  Amputation  by  one  Lateral  Flap  or  by  Lateral  Skin  Flaps.  The 
advantages  of  these  methods  are  that  they  are  very  easily  done,  and 
that,  if  more  skin  is  available  on  one  side  than  on  the  other,  flaps  un- 
equal in  length  can  readily  be  made.  If  the  surgeon  amputate  by 
lateral  flaps — standing  as  before,  and  having  his  left  index  finger  on  the 
centre  of  the  elbow-triangle  and  left  thumb  at  the  corresponding  point 
behind,  he  looks  over,  and  entering  the  knife  close  to  his  thumb,  marks 
out,  on  the  side  furthest  from  him,  a  flap  well  rounded  and  about  two 
and  a  half  or  three  inches  long,  reaching  to  the  finger  in  front.  He 
then  marks  out  a  corresponding  flap  from  this  point,  on  the  side 
nearest  to  him,  to  that  where  he  began.  These  flaps  are  then  dissected 
up  of  skin  and  fascia  as  thick  as  possible,  the  soft  parts  severed  with 
a  circular  sweep,  and  disarticulation  performed,  beginning  at  the  outer 
side. 

(4)  Circular  Method.  The  surgeon,  standing  as  before,  makes  a 
circular  incision  round  the  forearm  two  and  a  half  or  three  inches  below 
the  joint,  going  through  skin  and  fascia.  A  cuff  of  skin  is  then  turned 
back  as  far  up  as  the  joint,  the  muscles  severed  with  one  or  two  firm 
sweeps,  the  lateral  ligaments  divided,  and  disarticulation  performed  as 
before.  The  edges  of  the  w^ound  may  be  united  either  horizontally  or 
vertically  from  above  downwards. 

Mr.  A.  G.  Miller,  of  Edinburgh,^  suggests  the  following  modifica- 
tion :  2 

The  limb  being  held  out  quite  straight,  a  circular  incision  is  made  one  and  a  half 
inches  below  the  condyles  downi  to  the  deep  fascia.  The  skin  on  the  anterior  or 
flexor  aspect  at  once  retracts  considerably,  making  the  line  of  incision  oblique. 

The  extensor  flap  is  now  dissected  up  as  far  as  above  the  olecranon,  care  being 
taken  to  cut  on  the  deep  fascia,  and  so  to  reflect  the  subcutaneous  deep  fascia,  and 
its  contained  blood-vessels  along  with  the  skin.  The  flap  is  loose  and  ample,  being 
taken  from  a  part  where  the  skin  is  naturally  redundant  in  order  to  accommodate 
itself  to  the  normal  action  of  flexion.  After  reflexion  of  this  flap — practically  the 
only  one — disarticulation  should  be  performed  from  the  front.  It  will  then  be 
found  that  there  is  a  long  flap  on  the  extensor  and  posterior  asj^ect.  with  practically 
no  flap  upon  the  flexor  aspect.  After  the  blood-vessels  are  secm'ed  and  the  nerves 
cut  short,  this  single  flap  folds  nicely  over  the  condyles,  and  is  easily  secured  by 
sutiires.     Later,  the  appearance  of  the  stump  is  very  satisfactory.     Much  tissue 

1  The  Scottish  Medical  and  SurgicalJ  owned,  Sept.  1904,  p.  193. 

2  See  a  paper  by  Dr.  A.  C.  Wood,  of  Philadelphia  {Ann.  oj  Surg.,  vol.  xhx,  p.  101)  in 
which  he  records  a  case  of  sarcoma  of  the  forearm  treated  in  this  way. 


EXCISION  OF  THE  ET.HOVV 


145 


is  not  roqiiirod.     Tho  <)|)<"r;v1ioii  is,  tlicrefore,  suitable  for  both  primary  and  secondary 
amputations. 

Amputation  by  (5)  by  a  long  postericjr  flaj)  and  (G)  a  long  anterior 
flap  require  no  special  description. 

EXCISION  OF  THE  ELBOW-JOINT  (Fig^.  75-81) 

Practical  points.  These  bear  upon  the  success  of  this  operation. 
(1)  It  is  a  comparatively  simple  joint,  with  small  articular  surfaces 
readily  got  at.  (2)  Its  synovial  membrane  is  simple.  (3)  Its  vascular 
supply  is  abundant.  (4)  The  surrounding  muscles  are  powerful,  ensuring, 
if  they  regain  firm  attachment,  excellent  mobility.  From  the  above 
and  from  the  untoward  effects  of  ankylosis,  a  natural  cure  in  the 
elbow  is  often  not  so  useful  as  that  given  by  excision.  This  operation 
should  be  performed  oftener,  especially  in  the  first  six  of  the  following 
conditions. 

Indications.  (I)  Tuberculous  disease.^  Where  this  has  resisted  treat- 
ment in  a  patient  who  shows  no  sign  of  general  tuberculoss,  lardaceous 
disease,  &e..  where  it  is  the  only  large  joint  affected,  and  where  the  powers 
of  repair  are  sufficient.  If  other  treatment  fails  to  promise  a  sound  and 
useful  joint,  there  is  no  good  losing  more  time  ;  the  muscles  will  only 
be  more  wasted,  sinuses  will  only  form  more  extensively,  and  the 
patient's  health  be  more  impaired.  If  caseation  has  occurred  and, 
still  more,  if  sinuses  and  mixed  infec-  ^^^ 

tion  are  present,  it  will  be  impossible 
to  remove  the  disease  entirely  by 
excision ;  subsequent  troublesome 
curettings  will  be  needed,  and  the  risk 
of  a  stiff  joint  is  enormously  increased. 
The  rule  should  be,  especially  in 
adults,  for  excision  to  antedate  the 
above  complications. 

(2)  Recent  injury  and  its  results. 
A.  Primary  excision.  When  the  joint 
is  much  opened,  the  cartilages  much 
damaged,  when  the  shaft  is  intact  and 
the  tissues  in  front  are  sound,  an  ex- 
cision may  be  preferable  to  expectant 
treatment.  If  aseptic  from  the  first 
the  operation  excludes  the  risk  of 
acute  arthritis,  and  its  certain  sequela, 
a  stiff  joint.  But  here,  as  in  excision 
for    disease,    the    determination    and 

pluck  of  the  patient  will  be  most  im-  ^,     ,     ,   .,,..„    ^    -  • 

^     .       J.    r     .    ^         Ajj.1.  i:.LX.      Fig.  75.  The  hook  m  this  illustration 

portant  factors.     And  the  age  of  the  ^^^^^  ^^g  continuity  of  the  outer  head 

patient's  tissues  and  organs   will   have  of  the  triceps  with  the  fascia  over  the 

much  more  weight  than  the  age  given,  anconeus  (Maunder).    Too  much  of  the 

^1         ^      ■   ■         1     .  p.    '^         J  posterior  aspect  of  the  ulna  has  been 

m  the  decision   between  excision  and  ^  cleared. 

amputation. 

B.  Secondary    excision.     When    acute    arthritis,    not     yielding    to 
incision  and  drainage  of  the  joint,  has  followed  on  an  injury,  and  ankylosis 

1  See  an  interesting  paper  by  J.  Wingate  Todd.      Annals  of  Surgery,  1913,  vol.  Ivii, 
p.  430. 

SURGERY  I  lO 


146        OPERATIONS  ON  THE  UPPER  EXTREMITY 

is  the  best  result  which  can  be  hoped  for  without  operation.  In  such 
cases,  as  the  inflamed  condition  of  the  bones  and  soft  parts  may  produce 
infective  celluUtis  and  osteomvehtis  after  an  operation,  it  will  be  wiser, 
before  excising,  to  wait  till  the  inflammation  has  somewhat  subsided. 
It  must  be  remembered  that,  in  excision  after  injury,  reaction  will 
probably  be  greater,  suppuration  more  certain,  and  a  tendency  to  bony 
ankylosis  more  marked,  especially  if  the  perio.steum  is  preserved. 
Sufficient  drainage  is  absolutely  needful. 

(8)  Old  injuries  to  the  Elbow-Joint,  resulting  in  stiffness,  ankylosis,  or, 
more  rarely,  pressure  on  the  main  vessel  or  nerve-trunks.  Operative 
interference  is  justified  in  such  cases,  where  the  patient  is  otherwise 
healthy,  and  where  his  future  \\'ill  be  seriously  crippled.  The  following 
mode  of  treatment  may  be  employed. 

A.  Forcible  Movement  under  an  AncBsthetic.  This,  often  resulting 
in  the  ''  infraction  "  of  some  American  surgeons,  is  not  to  be  recom- 
mended. The  results  are  rarely  good,  may  be  nil,  and  may  be  followed 
by  serious  damage.  Where  the  needful  forcible  movement  is  painful 
and  followed  con.stantly  by  swelling  and  no  permanent  increase  in  the 
mobility  of  the  joint,  the  patient  must  decide  between  a  complete 
excision,  performed  on  liberal  lines  and  having  the  limb  put  up  in  a 
fixed  position,  at  an  angle  as  acute  as  possible. 

B.  Arthrotomij .  Opening  the  joint,  with  division  of  adhesions,  and 
attempted  reduction  of  the  displaced  bones,  wiW  be  found  a  step  of 
very  limited  usefulness  and  is  not  to  bo  recommended. 

C  Complete  or  partial  excision.  The  former  is  usually  indicated  in 
these  cases.  The  question  of  partial  excision  for  injurv  is  discussed 
at  p.  159. 

The  following  is.  very  briefly  given,  an  interesting  case  of  excision 
of  the  elbow  for  an  old  dislocation  and  fracture  : 

M.  E.  W.,  aged  28,  was  sent  to  Mr.  Jacobscn  in  February  1894,  by  Dr.  E.  Da  vies,  of 
Swansea.  The  injury,  received  the  previous  Xovember  while  he  was  riding  over 
a  sheep-farm  in  Tierra  del  Fuego,  had  never  been  treated.  A  dislocation  back- 
wards of  both  bones  of  the  right  elbow-joint  was  typically  evident,  and.  in  addition, 
there  was  distinct  shortening  of  the  limb,  marked  coldness  and  lividity  of  the  hand, 
and  deficient  radial  pulse.  The  forearm  was  fixed  at  a  very  obtuse  angle,  active 
and  passive  movements  being  almost  completely  abolished.  During  the  excision 
it  was  found  that  a  fracture  ran  obliquely  from  without  inwards  through  the 
lower  third  of  the  humerus.  When  the  limb  was  placed  in  the  extended  position 
after  the  operation,  there  was  still  a  full  one  and  a  quarter  inches  between  the  bone 
ends.  Healing  was  uneventful.  At  the  end  of  four  months  the  patient  could  use 
the  arm  to  play  lawn-temiis.  shoot  rabbits  with  a  rifle,  and  ride.  Five  months  after 
the  operation,  extension  and  pronation  were  practically  complete,  flexion  was  full 
enough  to  allow  of  his  touching  his  right  ear  and  buttoning  his  collar-stud  with 
the  right  hand,  but  not  sufficiently  perfect  for  him  to  touch  his  right  shoulder.  Only 
about  half  the  range  of  supination  was  present.  In  189.5  the  i:)atient  wrote,  sapng  : 
My  right  arm  is  as  useful  to  me  as  it  was  before  the  accident.  I  can  shear  sheep, 
ride,  and  shoot  with  any  man.' 

(4)  Some  rare  cases  of  injury  to  the  Ijywer  Epiphysis  of  the  Humerus. 
In  the  great  majority  of  these  cases,  judicious  treatment,  especially 
early  examination  and  reduction  of  the  disj^lacement  under  an  anaesthetic, 
and  putting  up  the  elbow  fully  flexed  ^^^th  the  hand  on  the  same  shoulder 
will  suffice.  Should  this  not  be  successful,  an  open  operation  with 
fixation  of  the  separated  epiphysis  in  good  position  by  a  wire  or  screw 
may  be  expected  to  yield  good  results.     There  will  however,  occasionally, 


EXCISION  OF  THE  ELBOW  147 

be  cases  where,  some  weeks  or  months  after  the  injury,  the  joint  remains 
stiff,  at  a  useless  angle.  In  some  of  these  cases  the  ankylosis  is  clearly 
intra-articular  and  not  muscular,  and  breaking  down  of  adhesions  is 
constantly  followed  by  recurrent  infiammation,  pain,  swelling,  and  by 
no  permanent  improvement.  The  ankylosis  may  be  due  to  osteoid 
deposit  by  stripped  up  periosteum,  or  to  a  portion  of  detached  epiphysis, 
e.g.  the  epicondyle,  having  been  wedged  in  between  the  trochlea  and 
the  sigmoid  cavity,  thus  rendering  improvement  of  the  position  im- 
possible from  the  first.  In  these  an  excision  may  give  the  best  prospect 
of  a  freelv  movable  and  useful  joint.  Needless  to  say  in  such  cases  a 
careful  and  thorough  radiographic  examination  is  of  the  greatest  help 
in  enabling  the  surgeon  to  decide  upon  the  best  mode  of  treatment. 
The  following  remarks  by  Mr.  Keetley  ^  on  the  diagnosis  of  the  commoner 
injuries  about  the  elbow-joint  in  young  subjects  will  be  useful  to  many. 
""  For  comparison  of  the  two  elbows,  the  patient  should  place  the  two 
hands,  one  on  the  other,  upon  the  top  of  the  head,  and  then  bring  the 
elbows  as  near  each  other  as  possible  in  front  of  the  face.  There  are 
now  two  triangles  to  be  compared.  The  base  of  each  is  formed  by  a  line 
uniting  the  tips  of  the  two  condyles  ;  the  apex  is  at  the  olecranon.  Any 
effusion  into  the  joint  will  cause  a  puffiness  between  the  condyles  and 
the  olecranon.  If  there  be  a  fracture  between  the  condyles  into  the 
joint  there  will  be  an  increase  of  the  distance  between  the  condyles, 
best  measured  by  a  pair  of  calipers.  Fracture  of  either  condyle  will 
disturb  the  relation  of  the  external  or  internal  condyle  to  the  other 
tw^o  points.  If  the  head  of  the  radius  is  dislocated  outwards  or  back- 
w^ards  its  head  will  become  more  prominent  than  on  the  opposite  side. 
A  supra-condylar  fracture  or  separation  of  the  epiphysis  will  be  suspected 
from  the  large  amount  of  swelling  and  the  pain  in  raising  the  injured 
elbow.  The  elbows  should  next  be  flexed  to  a  right  angle  at  the  side, 
and  viewed  from  behind.  A  radiographic  examination  should  in- 
variably be  made,  both  from  the  side  and  in  front ;  both  elbows  should 
be  examined." 

(5)  Ankylosis  in  a  faulty  'position.  The  following  are  the  chief  points 
which  will  present  themselves  for  consideration  :  How  far  the  angle 
is  an  obtuse  one,  and  the  position  of  the  Umb  such  as  to  render  it  use- 
less ;  the  age  and  vitality  of  the  patient,  and  his  interest  in  possessing 
a  mobile  joint ;  the  condition  of  the  muscles  (for  if  the  ankylosis  be  of 
long  standing  these  may  be  so  utterly  atrophied  that  the  usefulness 
of  the  limb  will  be  but  little  increased  by  operation)  ;  the  coexistence 
of  any  cicatricial  bands,  especially  in  front,  which  will  interfere  with 
the  after-result. 

A  bilateral  ankylosis,  especially  at  useless  angles  and  in  young 
subjects,  calls  urgently  for  resection,  the  operations  being  performed 
at  an  interval  of  about  four  weeks,  and  the  limb  in  Avhich  the  muscles 
are  least  wasted  being  taken  first,  so  that  a  good  result  may  encourage 
the  patient.  The  more  complete  the  ankylosis  the  more  the  articular 
surfaces  are  fixed  throughout  {i.e.  not  at  one  spot  only,  e.g.  olecranon 
tip  to  olecranon  fossa),  the  greater  the  thickening  of  the  periosteum, 
the  more  are  osteoid  nodules  or  spicules  found  scattered  about  in  the 
ligaments,  the  more  freely  must  the  bones  be  removed.  Further,  in  all 
cases  of  bony  ankylosis,  the  surgeon  should  examine  into  the  state  of 
the  superior  radio-ulnar  joint,  or  an  ankylosis  here  may  be  overlooked 
1  Clin.Journ.,  Feb.  4,  1903,  p.  247. 


148        OPERATIONS  OX  THE  UPPER  EXTREMITY 

after  the  main  disease  has  been  treated.  Mention  may  be  made  of  the 
method  of  resection  economique  which  the  ingenuity  of  French  surgeons 
has  led  them  to  try  in  cases  of  ankylosis  after  injury.  Here,  after  a 
removal  of  the  bones  less  free  than  that  which  is  ad\'ised  below,  a  flap 
of  muscle — e.g.  the  triceps — is  brought  between  the  resected  ends  and 
attached  to  the  capsule  in  front,  to  prevent  fresh  anks'losis  occurring.^ 
Perusal  of  some  of  the  recorded  cases  conveys  the  impression  that 
the  result,  especially  in  children,  is  not  superior  to  that  of  the  older 
method  of  a  free  resection. 

(6)  Disorganising  arthritis  of  elbow  after  one  of  the  exanthemata, 
pyaemia,  or  rheumatic  fever. 

(7)  Osteo-arthritis.  If  the  patient  is  healthy,  not  advanced  in  years 
{i.e.  not  much  over  forty)  and  not  broken  down,  if  the  muscles  are  likely 
to  recover  their  tone,  and  if  this  is  the  only  joint  attacked.  The  surgeon 
must  be  prepared  for  sawing  very  dense  bones  here.  Dr.  F.  W.  Collinson 
reports  a  most  instructive  case  of  excLsion  of  both  elbow- joints  for 
osteo-arthritis.'-  The  patient,  set.  22,  was  admitted  into  the  Preston 
Royal  Infirmary,  June  30,  1890. 

The  disease  had  begun  when  she  was  eleven.  All  the  joints  were  more  or  less 
affected.  The  right  elbow  was  'absolutely  fixed.  When  attempts  were  made  to 
move  it  under  an  anfesthetic  the  humerus  gave  way  at  its  lower  epiphysial  jimction. 
The  left  elbow-joint  could  only  be  flexed  through  an  angle  from  8  to  10  degrees. 
The  right  joint  was  excised  September  6,  the  left  in  December  1890.  Both  healed 
quickly.  In  August  1891  there  was  on  the  right  side  almost  perfect  flexion  and 
extension  vrith.  practically  no  lateral  movement.  Pronation  and  supination  were 
absent  owing  to  the  absolute  ankj-losis  of  the  -WTist  and  inferior  radio-ulnar  joints. 
On  the  left  side  extension  was  not  quite  so  good,  a  certain  amount  of  lateral  move- 
ment persisting.  Both  hands  were  now  most  useful.  As  an  instance  of  how 
crippled  the  patient  had  been  before  the  operations,  when  eating  she  was  compelled 
to  place  her  plate  on  her  knees,  she  then  lowered  her  head  and  raised  her  knees,  and 
thus  managed  to  get  her  food  into  her  mouth. 

The  following  points  call  for  consideration  in  any  case  where  excision 
of  the  elbow  is  being  discussed  : 

(1)  Age.  This  must  always  have  much  influence.  In  very  young 
children  due  attention  must  be  paid  to  the  naturally  great  power  of 
repair.  After  thirty-five  or  forty  the  surgeon  should  weigh  very  care- 
fully all  the  points  of  the  case,  and  only  excise  where  all  else  is  favour- 
able. From  puberty  to  thirty-five  may  be  regarded  as  the  best  age. 
Those  who  see  much  of  the  surgery  of  childhood  will,  of  course,  be 
called  upon  to  decide  upon  the  operative  treatment  of  tuberculous 
disease  of  the  elbow-joint  at  a  much  earher  date.  During  the  first 
three  or  four  years  of  fife  resection  is  certainly  not  to  be  recommended. 
This  is  partly  due  to  the  fact  that,  owing  to  the  greater  tendency 
to  repair,  less  severe  steps — e.g.  curetting,  removal  of  tuberculous 
foci  of  osteitis  and  caries — will  often  be  sufficient,  but  partly  because 
the  surgeon  will  be  driven  to  hold  his  hand  on  account  of  the  feeble, 
miserable  condition  of  those  patients  with  tuberculous  disease  of  a 
larc^e  joint  so  early  in  fife.  Owing  to  the  difficulties,  ine\4table  during 
the''  after-treatment,  in  carrying  out  active  and  passive  movements, 
the  surgeon  must  be  careful  to  keep  the  fimb,  from  the  first,  at  a  useful, 
i.e.  an  acute,  angle.  After  the  age  of  four  the  patients,  owing  to  their 
increasing  vitafity  and  resisting  power,  are  better  fitted  for  resection, 

1  Quenu,  Bull,  et  Mem.  de  la  Soe.  de  Chir.,  Juin  27,  1905,  p.  622. 

2  Lancet  .1899,  Nov.  4,  p.  1233. 


EXCISION  OF  THE  KLJiOW 


149 


but  the  activity  of  the  periosteum,  together  with  the  fact  that  it  is 
iiiipossibk>  to  rely  upon  the  patients  for  any  lielp  in  active  mobiUsation 
of  the  joint,  calls  for  free  removal  of  bone. 

(2)  Complications.  These  are  most  likely  to  present  themselves  in 
the  shape  of  disease  of  other  bones  and  joints,  for  such  a  complication 
as  phthisis  will  probably  call  for  amputation.  Caries  of  the  meta- 
carpal or  metatarsal  bones  is  not  of  itself  a  contra-indication.  If  a 
diseased  spine  is  present,  the  question  of  excision  will  depend  on  whether 
the  vertebral  caries  is  old,  or  recent,  or  active.  If  old,  is  the  elbow  a 
source    of  much  irritation  ?     Two   large 

joints  are  rarely  diseased  at  the  same 
time.     Mr.  Holmes  ^  has  recorded  a  case  ^^. 

of  a  boy,  aged  5,  where  he  excised,   with  v^  ^» 

excellent  results,  both  elbow-joints — only 
a  few  weeks  intervening  between  the  two 
operations.  Mr.  Clement  Lucas  -  relates 
a  case  in  which  disease  of  the  left  elbow 
came  on  about  two  years  after  excision 
of  the  right  joint,  and  was  also  success- 
fully operated  on.  Since  1886  Mr.  Jacob- 
son  has  excised  the  elbow- joint  with  good 
results  in  four  children,  in  whom  some 
years  before  he  had  successfully  excised 
a  knee-joint.  And  in  one  of  the  four  he 
had,  later  on,  to  remove  a  tuberculous 
tarsus  by  a  Symes  amputation.  When 
this  child  was  seen  a  year  later  all  three 
operations  were  sound.  The  new  elbow- 
joint  was  a  very  useful  one. 

(3)  Question  of  the  Value  of  Preserv- 
ing the  Periosteum.  While  the  perios- 
teum may  be  easily  preserved  in  cases 
where  it  is  swollen  and  loose,  its  preser- 
vation is  in  others  a  matter  of  very  great 
difficulty,  rendering  the  operation  much 
more  laborious  and  prolonged,  and  it  is 
extremely  doubtful  if  it  is  of  any  ad- 
vantage in  this  joint,  where  the  ordinary 
operation  gives  such  excellent  results. ^ 

Some  cases — e.g.  primary  excision  for 
injury — are  unsuited  to  this  method,  as 
the  unaltered  periosteum  is  most  difficult 
to  remove  from  the  irregular  bone  ends. 
In  tuberculous  disease  it  is  often  un- 
desirable on  account  of  the  risk  of  leaving 
mischief  behind. 

Subperiosteal  resection  is  said  to  lead  to  less  haemorrhage,  less  dis- 
turbance of  the  capsule  and  attachments  of  muscles,  mth  greater  lateral 
steadiness  and  completeness  of  the  new  joint.     While  the  last  two  are 

^  Clin.  Soc.  Trans.,  vol.  i,  p.  143. 
2  Brit.  Med.  Journ.,  1881,  vol.  ii,  p.  897. 

'  In  the  case  of  excision    of   the   shoulder-joint  (p.  222)^  the   conditions  are  very 
different. 


Fig.  76.  Right  elbow  after  ex- 
cision of  the  joint  by  the  usual 
posterior  incision.  (Farabeuf.)  1 
and  4,  Gut  edges  of  the  outer  ex- 
pansion of  the  triceps  tendon. 
2,  Ulna.  3,  Humerus.  5,  An- 
coneus, covered  by  6.  Outer 
expansion  of  triceps.  7,  Supi- 
nator longus  and  radial  extensors 
of  the  carpus.  To  the  right  the 
bones  removed  during  the  opera- 
tion are  seen.  The  humerus  has 
been  sawn  through  at  a  point  some- 
what higher  than  usual.  It  will 
also  be  noticed  that  care  has  been 
taken  not  to  unduly  expose  the 
shaft  of  the  ulna. 


150 


OPERATIONS  ON  THE  UPPER  EXTREMITY 


'^^^v=^.*'^ 


undoubted,  this  step  may  bring  about  impaired  movement/  and  the 
surgeon  should  only  trouble  to  preserve  the  periosteum,  while  clearing 
the  lower  end  of  the  humerus  of  its  important  muscular  attachments, 
especially  in  cases  where  an  unusually-  large  amount  of  bone  has  to 
be  removed.  If  the  periosteum  is  kept,  the  removal  of  the  bone  will 
be  additionally  needed. 

Operation.  The  single  vertical  incision  at  the  back  gives  such 
excellent  results  that  this  operation  will  alone  be  fully  described  ;  the 
method  by  two  lateral  and  a  single  bayonet-shaped  incisions  which 
have  the  preference  by  high  authorities  ^^'ill  be  given  later.  As  in  all 
difficult  and  not  very  common  operations,  the  surgeon  will  act  most 
wisely  by  practising  one  operation.  An  Esmarchs  bandage  having 
been  applied  as  high  as  possible  over  the  upper  arm,  which  is  first  well 
elevated,  or  the  whole  limb  being  rendered  evascular  as  far  as  the  above 

point  by  the  use  of  two 
bandages,  the  limb  is  flexed 
and  carried  over  the  front  of 
the  trunk,  so  as  to  present  it 
fairly  to  the  surgeon,  who 
usually  stands  on  the  opposite 
side  of  the  body. 

The  surgeon,  then,  noting 
the  relative  position  of  the 
condyles  and  the  course  of  the 
ulnar  nerve,  makes  a  straight 
incision  of  sufficient  length 
(about  four  inches  in  the  adult) 
with  its  centre  at  the  tip  of 
the  olecranon,  a  little  internal 
to  the  centre  of  the  back  of 
the  joint,  and  parallel  with  the 
ulnar  nerve.  This  incision 
should  begin  above  or  below 
as  is  most  convenient,  and  go  down  to  the  bone  throughout  its  whole 
extent,  splitting  the  triceps,  muscle  and  tendon  and  incising  the 
capsule.  Partly  with  the  point  of  the  knife,  partly  with  a  rugine  or 
elevator-  (Fig.  80).  the  surgeon  then  raises,  as  far  as  possible  in  one 
piece  and  without  tearing  or  jagging,  the  outer  half  of  the  triceps,  which, 
vnih  its  expansion  into  the  deep  fascia  of  the  forearm  over  the  anconeus 
(Figs.  75  and  76  ) — this  latter  muscle  being  drawn  up  at  the  same 
time — is  peeled  up  as  thickly  as  possibly  from  its  insertion  into  the 
ulna.  It  is  on  the  preservation  of  this  expansion  that  the  regaining 
of  active  extension  will  depend.  Resection-knives  and  elevators  of  the 
French  pattern  (Fig.  80)  are  the  best. 

^  A  case  is  given  {Langenbeck,  Arch.,  vol.  viii,  p.  136)  in  which,  after  subperiosteal 
resection,  the  condyles  had  been  very  perfectly  reproduced,  and  the  olecranon  had  been 
reformed  to  even  an  inconvenient  extent,  for  it  was  so  long  and  curved  as  somewhat 
to  limit  extension.  This  method  should  usually  be  rejected  in  children,  and  also  in  cases 
of  ankylosis,  for  fear  of  a  recurrence.  The  candid  Prof.  Oilier,  with  all  his  experience 
wrote  {loc.  supra  cit..  p.  218),  *•  Aussi,  apres  une  resection  sous-periostee,  est-ce  la  roideur 
qui  est  plus  a  craindre  que  la  trop  grande  laxite." 

-  Unless  the  tissues  are  softened  by  mflammation  any  "  blunt  dissectors  "  are  useless. 
Any  periosteal  elevator,  e.g.  the  one  showTi  in  Fig.  80,  should  have  a  distinct  but  not 
sharp  edge.  If  the  knife  be  used  each  cut  should  be  short,  and,  as  it  is  made,  the  edge 
must  ever  be  kept  turned  towards  the  bone. 


/ 


Fig.  77.     To    show    the    level    to    which  tlie 

bones   are    to    be    cleared,    and    the    way  in 

which   the   thumb-nail   is  kept   between  the 

knife  and  the  soft  parts. 


EXCISION  OF  TIIK  KLHOW  151 

The  (It'cpiM-  parts  oti  tlie  outer  ^  side  of  tlie  joint  are  then  separated 
from  the  bones  with  the  elevator  until  tlu;  external  condyle,  and  the 
head  of  the  radius  are  completely  exposed.  The  left  thumb,  all  the  time 
sunk  deeply  into  the  wound,  pushes  the  flap  of  soft  parts,  as  it  is  detached 
towards  and  over  the  external  condyle.  It  is,  finally,  displaced  over 
this,  as  the  joint  is  flexed  strongly.  Next,  the  parts  on  the  inner  side  should 
be  detached  from  the  imier  condyle  and  inner  border  of  the  olecranon, 
great  care  being  taken,  by  the  following  precautions,  to  keep  intact 
the  ulnar  nerve  :  («)  By  keeping  the  knife  or  rugine  parallel  with  the 
nerve  and  close  to  the  bone  ;  here  and  on  the  outer  side  alike  the  instru- 
ment should  follow  closely  the  different  bony  irregularities  around  the 
joint,  (b)  By  the  use  of  the  thumb  which  displaces  the  soft  parts  as 
they  are  separated  by  the  knife.  By  these  means  the  soft  parts  will 
be  satisfactorily  cleared  from  the  bones  ;  retractors  well  applied  will 
be  found  most  useful,  as  the  process  of  peeUng  off  the  soft  parts  is  some- 
what fatiguing  to  the  thumb.  This  is  especially  the  case  in  excision 
for  accidents  or  on  the  dead  body,  and  it  is  in  these  only  that  the  nerve 
may  be  seen,  though  indistinctly.  Where  the  parts  have  been  long 
inflamed,  they  peel  off  much  more  readily,  and  the  nerve  is  buried  in 
the  swelling.  It  is  well  to  remember  that  the  nerve  may  be  injured 
at  three  places:  (1)  Above,  in  the  inner  head  of  the  triceps;  (2)  be- 
hind the  internal  condyle ;  (3)  below,  under  the  extensor  carpi 
ulnaris. 

The  clearing  of  the  soft  parts  off  the  bony  prominences  will  be  much 
facilitated  by  keeping  the  joint  extended  as  much  as  possible,  and  the 
soft  parts  thus  relaxed. 

Each  lateral  ligament,  if  this  has  not  been  already  done,  is  raised, 
together  with  the  periosteum  and  the  group  of  flexors  or  extensors 
respectively,  freed  from  their  bony  attachments  and  pushed  over  them, 
and  there  retained  with  retractors.  The  joint  is  now  strongly  flexed, 
and  the  capsule  opened  just  above  the  olecranon.  The  bone  ends  are 
then  turned  out  and  prepared  for  the  saw  by  passing  the  knife  down  to 
the  bone,  along  the  lines  of  intended  section,  the  soft  parts  being  well 
retracted  beyond  these  lines.  In  turning  out  the  bone  ends  it  is  easy, 
in  patients  where  the  parts  are  delicate  or  softened  by  inflammation, 
to  strip  off  a  needless  amount  of  periosteum,  e.g.  on  the  anterior  aspect 
of  the  shaft  of  the  humerus. 

Site  of  bone  section.-  The  ulna  should  be  sawn  (from  behind  forwards 
with  a  small  Butcher's  saw  set  firmly),  so  as  to  remove  the  greater  and 
lesser  sigmoid  cavities  with  the  olecranon.  The  radius  is  removed  at 
the  same  time  just  below  its  head,  above  the  biceps.  Before  this  is 
done,  the  assistant,  who  is  holding  the  forearm,  should  thrust  the  ends  of 
the  bones  prominently  but  carefully  {vide  supra)  into  the  wound.  The 
section  of  the  humerus  requires  careful  attention.  An  insufficient  amount 
is  usually  removed  here,  and  limitation  of  subsequent  movement  thereby 
invited.  It  is  generally  considered  sufficient  to  remove  all  the  articular 
cartilage,  the  section  being  made  to  pass  through  the  lower  part  of  the 
coronoid  and  olecranon  fossae,  and  below  the  level  of  the  epitrochlea 
on  the  inner,  and  through  the  epicondyle  on  the  outer  side.     This  is  not 

^  For  the  sake  of  practice,  it  is  well  to  take  the  outer  side  first,  before  clearing  the  inner 
with  the  ulnar  nerve  in  proximity  to  it. 
2  Refer  also  on  this  point  to  Fig.  76. 


Fig.  78.     To  show  the  application  of  the 

saw.     The  dotted  line  across  the  humerus 

passes  above  the   articular  cartilage,  but 

is  not  high  enough  (vide  infra). 


152        OPERATIONS  ON  THE  UPPER  EXTREMITY 

enough.^  The  saw  should  pass  at  a  higher  level,  i.e.  above  the  level 
of  the  epicondyle,  and  through  the  highest  part  of  the  epitrochlea, 
removing  quite  the  lower  two-thirds  of  this  process.  This  is  the  very 
lowest  level  at  which  the  surgeon  should  hold  his  hand  if  he  desires  to 
obtain  good  movement.-    And  before  he  is  satisfied  on  this  point  he 

should  place  the  fingers  of  the 
affected  limb  not  only  on  the 
opposite  shoulder  and  the  mouth 
(as  is  often  done),  but  on  the 
shoulder  of  the  same  side,  and 
behind  the  back  to  the  angle  of 
the  opposite  scapula. 

Unless  these  movements  are 
perfectly  free,  he  should  take 
another  thin  slice  off  the  humerus, 
removing  the  whole  of  the  epi- 
trochlea. This  step  may  seem  a 
needless  shortening  of  the  limb, 
and  likely  to  lead  to  a  flail- joint. 
Such,  however,  is  not  the  case. 
As  long  as  the  elbow- joint  is 
freely  movable,  shortening  of  the  bones  matters  very  little.  If  atten- 
tion has  been  paid  to  the  advice  given  at  p.  151,  and  the  soft  parts 
separated  very  carefully  and,  as  far  as  possible,  subperiosteally  from 
the  epicondyle  and  the  epitrochlea,  the  joint  will  become  sufficiently 
steady  laterally  as  well  as  freely  movable  although  these  bony  prominences 
have  been  widely  removed.  Another  test  which  the  surgeon  should 
always  apply  before  considering  the  section  of  the  bones  completed  is 
the  interval  between  the  sawn  ends. 

Professor  Annandale  considers  that  an  inch  and  a  half  should  inter- 
veiie  between  them  when  the  bones  are  extended.  This  will  be  none 
too  much  in  adults,  especially  in  cases  where,  owng  to  the  condition 
of  the  parts,  recurrent  inflammation  is  certain.  Here  two  or  even 
two  and  a  half  inches  separation  is  desirable.^  In  all  cases  (and  this  is 
especially  so  in  those  of  ankylosis  ^  where  a  recurrence  of  the  trouble 
is  to  be  dreaded)  more  bone  must  be  removed  from  the  humerus  than 

^  If  only  half  an  inch  of  humerus  be  removed,  together  with  the  head  of  the  radius 
and  the  olecranon  process — the  la>tter  perhaps  oblic^uely — ankylosis  is  certain. 

2  M.  Oilier  (Traite  des  Besections.  t.  ii,  p.  203)  usually  makes  the  section  at  a  much 
higher  pomt  than  most  surgeons.  He  first  states  that  the  section  of  the  humerus  may  be 
made  at  different  levels:  (1)  That  which  removes  the  articular  surface  only,  the  sub- 
epitrochlear  ;  (2)  That  which  passes  just  above  through  the  substance  of  the  epitrochlea, 
the  intratrochlear ;  (3)  That  which  passes  just  above  the  epitrochlea,  the  supra- 
epitrochlear ;  (4)  That  passing  through  the  shaft.  He  then  goes  on  to  say :  "  The  section 
most  frequently  made — that  which  is  indicated  in  the  majority  of  cases  of  chronic  joint- 
disease,  whether  in  young  or  old  subjects — is  the  section  above  the  ej)! trochlea,"  i.e. 
number  (3). 

3  Mr.  Whitehead  (Brit.  Med.  Journ.,  1872,  vol.  ii,  p.  554)  records  the  case  of  an 
adult  in  which  two  and  a  half  inches  of  the  shaft  of  the  humerus  had  to  be  removed  after 
sawing  off  the  condyles.  The  patient  was  the  subject  of  tertiary  syphilis,  and  the  opera- 
tion was  performed  three  years  after  an  injury  to  the  elbow.  The  joint  is  stated  to 
have  been  completely  disorganised.  Nine  months  she  was  able  to  follow  her  occujiation 
as  charwoman  with  full  use  of  the  joint. 

*  In  cases  of  bony  ankylosis,  it  is  well,  before  attempting  to  make  sections  of  the 
bones,  either  to  break  down  the  union  forcibly  (care  being  taken  not  to  fracture  the  possibly 
atrophied  bones  above  and  below,  or  to  separate  any  of  the  epiphyses) ;  or,  bettei',  to 
divide  the  ankylosis,  with  a  saw,  chisel,  or  osteotome. 


EXCISION  OF  THE  ELBOW  153 

from  those  of  the  forearm,  where  the  section  is  Hmited  by  the  attach- 
ment of  important  muscles.  The  extent  of  bone  to  be  removed  having 
been  detailed,  it  is  well  to  remember  the  advice  of  Professor  Kocher^ 
to  make  the  sawn  section  curved.  It  is  especially  important  to  do  so 
with  the  olecranon,  as  this  step  goes  a  long  way  towards  preventing 
partial  dislocation  of  the  forearm  forwards  and  also  gives  good  leverage 
for  the  triceps.  Mr.  Holmes  has  pointed  out,  long  ago,  that  if,  after 
renio\'ing  as  much  bone  as  is  ^\^se,  disease  is  still  felt  upon  the  anterior 
surface,  it  is  not  necessary  to  make  further  sections  so  as  to  get  beyond 
it ;  thorough  curetting  will  be  sufficient,  and  will  save  any  further  inter- 
ference with  the  attachment  of  muscles. 

Cheyne  and  Burghard-  give  the  following  advice  here,  which  is  one 
recommendation  of  the  method  of  two  lateral  incisions  :  "  The  finger 
can  be  made  to  pass  from  one  incision  to  the  other  between  the  capsule 
and  the  superficial  structures,  amongst  which  will  be  the  brachial 
artery. 

'•  By  passing  the  finger  across  from  one  incision  to  the  other  and 
shifting  the  soft  parts  upwards  and  downwards,  the  entire  front  part 
of  the  capsule  can  be  separated,  and  may  be  cut  across  at  its  attach- 
ments to  the  bones  and  removed  whole."  While  the  bones  are  sawn, 
the  olecranon  and  trochlea  of  the  humerus  may  be  steadied  in  the  grip 
of  a  lion-forceps,  the  soft  parts  being  well  retracted. =*  Any  soft,  caseous 
patches  in  the  bone  ends  are  now  gauged,  any  possible  sequestra  removed. 
In  bad  cases  the  bones  are  liable  to  be  fatty,  with  Uttle  natural  marrow  ; 
such,  however,  are  not  necessarily  irrecoverable.  If  the  bone  above  the 
levels  of  section  appear  roughened,  and  the  site  of  periostitis,  this  need 
not  be  touched  ;  all  will  probably  subside  when  the  cause  of  irritation 
is  removed.  Any  sinuses  or  suppurating  pockets  should  next  be  laid 
open,  with  due  regard  to  the  ulnar  nerve,  and  their  contents  scraped 
out  with  sharp  spoons.  The  extensive  wound  should  then  be  thoroughly 
irrigated  with  sterilised  sahne  solution  (temp.  120  °  Fahr.).  A 
drainage  tube  should  always  be  inserted,  as  considerable  oozing  is 
certain  to  take  place.  If  infected  pockets  or  sinuses  have  been  opened 
and  scraped  a  few  sutures  may  be  used  and  additional  drainage  secured 
by  packing  these  with  sterilised  gauze  soaked  in  iodoform  emulsion.'* 
Very  varied  forms  of  splint  have  been  advised.^  Some  surgeons,  to 
keep  the  bones  apart,  from  the  first  put  the  limb  upon  some  form  of 
right-angled  splint ;  others,  fearing  a  flail-like  condition  of  the  joint, 
prefer  to  begin  with  the  arm  and  forearm  on  a  straight  splint,  or  on 
one  with  an  obtuse  angle  (about  135  degrees)  some  form  of  hinged 
angular  splint,  alloAving  the  degree  of  flexion  of  the  elbow  to  be  altered 
at  each  dressing,  should  be  used.  Cases  may  be  put  up  from  the 
first  on  a  metal  angular  splint,  using  some  such  cheap  form  as  that 

1  Text-book  of  Operative  Surgery,  Stiles's  translation,  third  English  Edition,  p.  317. 

2  Manual  oj Surgical  Treatment,  vol.  iii.  p.  248. 

3  Mr.  Heath  thinks  {loc.  supra  cif.)  that  *'  the  uhiar  nerve  is  in  more  danger  of  being 
cut  with  the  saw  when  the  ulna  is  divided  than  when  the  section  of  the  humerus  is  made, 
it  being  more  difficult  to  clear  the  former  bone." 

i  Farabeuf  {Man.  Opcr.,  p.  710)  points  out  that  if,  owing  to  long-existing  disease 
of  the  elbow,  the  shoulder,  wrist,  or  fingers  are  stiff,  oj^portunity  should  now  be  taken 
to  break  down  adhesions. 

^  By  some  surgeons  a  splint  is  here  dispensed  with.  The  use  of  one  which  is  light  and 
simple  is  strongly  advised  (vide  supra),  especially  in  children,  as  during  the  first  two  weeks, 
where  a  splint  has  been  dispensed  with,  the  bone  ends  have  been  known  to  project  from 
the  wound. 


154        OPERATIONS  ON  THE  UPPER  EXTREMITY 

described  in  the  Brit.  Med.  Journ.,  1877,  vol.  i,  p.  774,  in  which  the 
anterior  metal  bar  supports  the  limb,  while  it  leaves  the  wound  and 
its  vicinity  well  exposed  and  is  easily  kept  clean,  both  parts  being 
readily  boiled  in  a  steriliser  ;  moreover,  the  movable  handpiece  readily 
admits  of  some    early    passive   pronation    and    supination.     The  only 


Fig.  79.     E.smarch's  wire  splint  for  excision  of  left  elbow.     The  supine  position 

of  the  hand,  which  it  is  important  to  preserve,  is  well  maintained  in  this  splint. 

Plaster  of  Paris  bandages  may  be  used.     The  splint  should  be  bent  to  an  acute 

angle.     (MacCormac.) 

objection  to  this  splint  is  that  it  does  not  give  quite  enough  support 
to  the  limb.  Volkmann's  (based  on  that  of  Nathan  Smith  for  the 
lower  extremity),  Esmarch's  (Fig.  79),  and  Olher's,  all  of  wire  and 
easily  bent,  are  better  in  this  respect,  and  all  admit  of  the  limb 
being  slung — a  great  relief  to  many  patients  during  the  first  week  or 
so,  this  position  also  readily  showing  whether  any  discharge  has  made 
its  way  through  the  dressing.  Plaster  of  Paris  bandages  should  not 
be  employed  to  fix  the  splint  owing  to  their  cramping  effect  upon  the 
muscles. 

Passive  movement  of  the  fingers  and  wrist  should  be  begun  on  the 
second  or  third  day.  The  joint  itself  should  be  moved  as  soon  (but 
very  gently  and  slightly)  as  all  irritation  has  subsided — about  seventh 


Fig.  80.     A,  Farabeuf's  rugine.     B,  Ollier's  periosteal  elevator. 


to  tenth  day — this  date  varying  according  to  the  size  of  the  gap  left 
between  the  sawn  bones,  the  probable  condition  of  the  tissues  as  to 
inflammatory  exudation,  &c.  In  children  an  anaesthetic  may  have 
to  be  given  several  times.  The  angle  of  the  splint  should  be  altered  or 
the  limb  put  up  straight  for  a  few  days,  and  then  again  flexed.  Later 
on  weight-extension  should  be  used,  by  securing  a  bag  of  shot,  which 


EXCISION  OF  THE  ELBOW  155 

is  ULlded  to  I loi inlay  to  day.  A  better  method,  especially  with  children, 
because  it  is  gradual  and  gentle,  and  one  that  can  be  made  interesting 
to  them,  is  the  old-fashioned  one  of  weight  and  pulley.  The  patient 
is  seated  with  the  elbow  resting  near  the  edge  of  a  table.  To  a  pulley 
overhead  a  rope  carrying  a  weight  is  attached.  The  patient  grasps 
the  free  end  of  the  rope  with  the  hand  on  the  sound  side,  while  with 
the  other  he  holds  the  rope  a  little  above  the  weight.  The  rope  is  now 
pulled  upon  with  the  hand  on  the  sound  side  ;  this  flexes  the  joint,  and 
when  the  pull  is  relaxed  the  limb  is  extended.  This  should  be  practised 
assiduouslv  until  half  an  hour  a  time  two  or  three  times  a  day  is  attained. 
To  be  of  use  this  method  nuist  be  begun  early.  The  elbow  must  be 
kept  firmly  on  the  table,  or  the  movements  will  be  made  at  the  shoulder- 
joint.  Later,  the  sound  limb  may  be  fastened  up,  so  that  the  child  must 
use  the  excised  joint.  But  when  these  aids  have  to  be  resorted  to,  the 
result  will  often  be  imperfect.  The  surgeon  should  put  himself  on  the 
safe  side  by  ensuring,  originally,  a  sufficient  gap  between  the  bone  ends 
when  he  uses  the  saw.  The  best  test  of  the  future  usefulness  of  the 
limb  is  that  the  first  passive  movements  are  free  and  almost  painless. 
The  getting  of  children  to  use  the  joint  is  often  most  difficult,  as  friends 
are  usually  too  foolish  to  see  that  the  surgeon's  directions  are  carried 
out  daily,  because  they  cause  a  little  brief,  but  most  necessary,  suffering. 
Parents  are  far  too  ready  to  think  that  because  an  operation  has  been 
performed,  and  the  wound  nearly,  if  not  quite,  healed,  no  more  is 
necessary.^  Li  commencing  pronation  and  supination  early  the  ulna 
should  be  steadied  while  the  hand  and  radius  are  very  carefully  moved. 
The  first  attempts  at  passive  movement  should  be  exceedingly  gentle, 
and  too  much  should  not  be  attempted  at  first.  When  the  parts  are 
sufficiently  firm,  usually  at  the  end  of  two  weeks,  the  splint  may  be 
left  off  and  a  sling  substituted. 

Falls  must  be  carefully  avoided,  and  no  liberties  taken  with  the  new 
union,  i.e.  by  a  patient  attempting  to  do  too  much  wdth  the  limb,  as 
in  lifting.  Later  on,  when  an  increasing  range  of  movements  may  be 
allowed,  resort  to  a  gymnasium  vdW  be  very  beneficial.-  Finally,  it 
is  alwavs  to  be  remembered  that  a  twelvemonth  must  elapse  before 
the  full  benefits  of  the  operation — \\z.  a  complete  combination  of  mobility 
and  stability — are  gained.^ 

If,  at  the  end  of  four  weeks,  movement  is  so  free  that  a  flail- joint 
seems  Hkely,  the  limb  should  be  again  immobilised  for  another  month, 
either  on  the  splint  or  by  plaster  of  Paris  bandages.  Should  flail-Hke 
union  still  threaten  the  patient  should  wear  moulded  leather  supports 
for  the  arm  and  the  forearm,  the  two  portions  being  connected  by  two 
jointed  metal  bars  which  permit  of  flexion  and  extension  at  the  elbow, 
but  prevent  all  lateral  mobility. 

Tests  of  success.  In  about  four  months  from  the  operation  the 
patient  should  be  able  to  move  the  new  joint  freely  and  efficiently,  to 
dress  and  feed  himself  easily,  and  to  lift  fairly  heavy  weights.     But  it 

^  Pronation  and  supination  in  a  child  are  often  only  apparent,  the  forearm  and  arm 
being  rotated  together  from  the  shoulder. 

2  In  some  cases  the  regaining  of  only  a  limited  amount  of  movement  is  unavoidable,  e.q. 
where  an  injury  to  the  elbow-joint  requiring  e.Kcision  co-exists  with  a  fracture  of  the 
humerus  necessitating  absolute  rest  of  the  limb.  Here  the  bone  ends  must  be  removed 
very  freely. 

»  See  a  paper  by  Mr.  T.  Wingate  Todd  (Ann.  Surg.,  1913,  vol.  Ivii,  p.  430)  on  "  The 
End  Results  of  Excision  of  the  Elbow  for  Tuberculosis." 


156       OPERATIONS  ON  THE  UPPER  EXTREMITY 

will  be  nine  months  or  a  year  before  the  joint  is  thoroughly  firm  and 
strong. 

Repeated  excision.  Mr.  Jacobson  has  tried  this  in  three  cases,  two  of 
them  instances  of  obstinate  tuberculous  disease ;  in  each  a  very  useful, 
but  much  shortened,  limb  resulted.  In  the  third,  partial  excision  had  been 
performed  at  a  provincial  hospital  for  an  injury  to  the  lower  epiphysis 
of  the  humerus  in  a  boy  of  fourteen.  Great  pains  had  been  taken, 
but  the  limb  was  almost  completely  stift'  and  at  an  obtuse  angle.  After 
re-excising  the  joint  completely,  a  useful  angle  was  secured  admitting  of 
the  hand  being  brought  to  the  mouth,  placed  behind  the  back,  &c., 
so  that  the  boy  could  feed  and  dress  himself.  The  movements  of  the 
joint  ultimately  remained  much  restricted  owing  to  the  absolute  apathy 
and  indifference  of  the  patient.  While  opening  up  the  old  wound  and 
again  separating  the  bone  ends  gives  excellent  access  to  the  remaining 
disease,  this  step  wdll  be  but  seldom  required  if  the  rule  is  followed, 
after  excision  of  such  joints,  to  give  ether  repeatedly  as  soon  as  there 
is  evidence  of  persistent  disease,  and  slit  up  any  sinuses  or  undermined 
tissues,  thoroughly  use  sharp  spoons,  and,  if  needful,  pack  in,  for  a 
few  hours,  strips  of  iodoform  gauze  wrung  out  of  an  emulsion  of  glycerine 
and  iodoform  or  sulphur.  {See  the  remarks  made  on  this  subject  under 
"  Excision  of  the  Wrist  and  Knee.")  Where,  in  cases  of  failed  excision, 
the  tuberculous  mischief  has  burrowed  out  amongst  the  muscles,  where 
osteitis  and  osteo-myelitis  are  also  present,  amputation  is  to  be  pre- 
ferred, especially  if  the  general  condition  of  the  patient  is  not  satisfactory. 

Other  methods.  Excision  by  a  single  posterior  incision  has  been 
describe:!  in  detail  because  this  method  gives  the  best  results 
in  the  largest  number  of  cases,  and  is  best  suited  to  the  majority  of 
operators  who  will  not  perform  this  operation  very  frequently,  and 
who  should,  therefore,  strive  to  perfect  themselves  in  one  method.  The 
above  method  is  very  simple  ;  it  affords,  if  freely  made  and  efficiently 
aided  by  retractors,  ample  exposure  of  the  joint ;  its  limited  interference 
with  the  triceps  does  not  prevent  the  regain  of  complete  extension. 
Therefore  other  methods  will  be  very  briefly  given. 

M.  Oilier,  while  admitting  that  the  single  posterior  incision  allows 
of  the  fulfilment  of  the  essential  conditions  of  the  subperiosteal  method, 
considered  it  inferior  to  his  method  because  it  affords  less  facility  for 
the  different  steps  of  the  operation,  gives  less  room,  and  is,  besides, 
inferior  as  regards  the  after-treatment.  A  final  and  especial  objection 
given  is  that  this  incision  cannot  serve  as  an  exploratory  one  when  the 
surgeon  is  uncertain  whether  he  will  perform  a  complete  or  partial 
resection.  These  objections  are,  however,  not  serious  ones,  and,  with 
regard  to  the  last,  paitial  excisions  are  not  to  be  recommended. 

Ollier's  Method  by  a  Bayonet-shaped  Incision.  This  method,  though  generally 
preferred  by  the  well-known  Lyons  surgeon,  was  introduced  by  him  especially 
for  cases  in  which  ankylosis,  which  could  not  be  broken  down,  was  present  in  an 
extended  position.  An  incision,  vertical  at  first,  made  above,  over  the  external 
supra-condyloid  ridge,  sinking  between  the  triceps  and  supinator  longus  from  a  point 
two  and  a  half  inches  above  the  level  of  the  joint  to  the  top  of  the  external  condyle, 
and  passing  vertically  down  over  this  ;  the  incision  then  passes  obliquely  across 
the  olecranon  between  the  outer  head  of  the  triceps  and  anconeus,  and  below  descends, 
vertically  again,  upon  the  posterior  border  of  the  ulna  for  two  inches.  Through 
this,  the  main  incision,  the  external  condyle,  head  of  radius,  and  olecranon  are  dealt 
with.     To  expose  the  inner  condyle,  make  sure  of  the  ulnar  nerve,  and  to  detach  the 


EXCISION  OF  THE  ELBOW 


157 


soft  parts  and  lateral  ligament,  a  second  small  incision,  about  two  inches  long,  is 
made  internal  to  the  ulnar  nerve  and  parallel  with  the  inner  border  of  the  humerus. 
The  incision  is  at  first  a  superKcial  one.  As  it  is  carefully  deepened,  the  above- 
mentioned  intermuscular  i)lanes  are  identified,  and  along  these  planes  the  bones 
and  joint  are  reached,  by  division  of  the  periosteum  and  capsule.  The  operation 
is  completed  on  the  lines  already  given.  The  following  are  objections  to  the 
above  method.  In  the  first  ])lace,  ankylosis  in  the  extended  position  is  a  rare 
condition.  Further,  the  central  or  oblique  part  of  the  incision  must  surely  divide 
the  very  important  outer  expansion  of  the  triceps.  Finally,  while  the  main 
incision  exposes  fully  the  parts  above  the  external  condyle,  the  small  internal  one, 
wliile  introducing  a  complication,  would  be  inadequate,  with  most  operators,  for 
the  sepaialion  of  parrs  on  the  inner  side  of  the  wound. 

Kocher's  Modification  oi  Ollier's  Incision.'  With  the  elbow  flexed  to  about 
1 50  degrees.an  angular  incision  is  begun  at  the  external  supra -condylar  ridge  one  and 
a  half  to  two  inchesa  bove  the  line  of  the  joint,and  is  carried  downwards,  practically 
j)arallel  to  the  axis  of  the  humerus,  i.e. 
vertically  downwards  to  the  head  of  the 
radius,  and  from  thence  along  the  outer 
border  of  the  anconeus  to  the  posterior 
border  of  the  ulna,  three  inches  below  the 
tip  of  the  olecranon  ;  finally,  the  incision 
termin-.ites  by  curving  inwards  over  the 
inner  surface  of  the  ulna.  This  incision 
falls  in  the  interval  between  those  muscles 
supplied  by  the  musculo-spiral  and  those 
supplied  by  the  posterior  interosseous. 
Subsequent  muscular  atrophy  is  thus 
avoided.  The  external  lateral  Ugament 
with  the  attachments  of  the  extensor  ten- 
dons and  the  capsule  attached  to  the 
external  condyle,  are  separated  by  a  raspa- 
tory. The  forearm  can  now  be  completely 
dislocated  inwards.  If  complete  resection 
is  desired,  the  internal  lateral  ligament  is 
separated  along  with  the  muscles  from  the 
border  of  the  ulna  and  the  internal  condyle, 
and  the  ends  of  the  bones  are  removed. 

Method  by  Two  Lateral  Incisions. 
Both  Oilier  and  Heuter  have  employed  this 
method  largely,  especially  advocating  it  in 
cases  of  ankj'Josis.  It  is  also  sti'ongly  re- 
commended by  ChejTie  and  Burghard  ^  both 
for  excision  and  erasion  of  the  elbow- joint. 

It  is  described  in  the  account  of  the  latter  /  f  |^ 

operation  on  p.  161. 

Treatment  of  Gunshot  Wounds  of 
the  Elbow-joint.  The  structure  of  the 
joint  renders  it  impossible  for  the 
capsule  to  be  injured  without  injury 
to  bone.  As  in  the  case  of  gunshot 
wounds  of  other  bones  and  joints, 
the  experiences  of  the  South  African 
War  differ  considerably  from  those  of 

previous  campaigns,  both  as  regards  the  nature  of  the  injury,  the 
treatment,  and  the  prognosis.  With  modern  high  velocity  projectiles 
a  simple  perforation  of  the  joint  may  occur,  or  there  may  be  exten- 
sive comminution  involving  the  articular  surfaces  with  severe  lacera- 
tion of  adjacent  soft  parts.  The  latter  are  by  far  the  more  serious 
injuries,  especially  as,  in  the  majority  of  instances,  they  are  septic. 

^  Optrative  Surgery,  third  Eng.  Ed.  by  Stiles  and  Paul,  p.  314. 
2  Man.  of  Surg.  Treat.,  pt.  iv,  vol.  iii,  p.  246. 


Fig.  81.     Kocher's  incision  for 
excision  of  the  elbow. 


158        OPERATIONS  ON  THE  UPPER  EXTREMITY 

Lt.-Col.  Hickson  ^  collected  fortj'-nine  cases  of  gunshot  injurj' of  the  elbow-joint, 
thirteen  of  which  Avere  of  the  nature  of  pure  perforations,  the  remaining  thirty-six 
being  either  comminutions  or  fissured  fractures  extending  into  the  articulation.  Of 
the  first  grouji  nine  were  aseptic,  and  of  the  latter  only  three.  Only  one  case 
terminated  fatally,  and  there  amputation  was  performed  for  gangrene,  which 
appears  to  have  been  caused,  or  at  any  rate  contributed  to,  by  the  application  of  a 
plaster  of  Paris  casing. 

Treatment.  '•  In  the  aseptic  and  in  the  less  serious  septic  cases  the  treatment 
was  directed  to  keeping  the  wound  as  free  from  infection  as  possible  and  placing 
the  limb  on  suitable  splints.  The  total  number  of  comminuted  fractures  which 
recovered  \\-ithout  recourse  to  oj^erative  measures  was  only  eight.  The  remainder 
were  subjected  to  operative  interference  of  some  sort  :  thus,  in  seventeen,  fragments 
of  the  various  bones  were  removed,  of  which  number  fifteen  were  septic,  one  aseptic, 
and  one  doubtful.  Incision  for  the  evacuation  of  pus,  without  further  measures 
being  required,  was  performed,  and  was  followed  by  recovery  in  one  case.  Excision 
of  the  elbow-joint  has  been  reported  in  seven  cases,  but  in  two  of  these  amputation 
was  subsequently  carried  out  on  account  of  necrosis  and  suj^puration.  Amputation 
of  the  arm  was  required  in  seven  cases,  in  two  of  which  an  unsuccessful  excision  had 
previously  been  performed,  and  one  died." 

Mr.  G.  H.  Makins^  does  not  mention  any  cases  in  which  excision  of  the  elbow- 
joint  was  performed.  He  ^^Tites  :  "  Injuries  to  this  joint  ^  came  second  in  frequency 
in  my  experience  to  those  of  the  knee.  Thej-  were,  in  fact,  comparatively  common 
especially  in  conjunction  with  fractures  of  the  various  bony  prominences  sur- 
rounding the  articulation.  Fractures  of  the  lower  end  of  the  humerus  were  of  worse 
prognostic  signiiicance  than  those  of  the  ulna,  on  account  of  the  greater  tendency 
to  splintering  of  the  bone.  I  saw  several  cases  of  pure  perforation  of  the  olecranon 
without  any  signs  of  implication  of  the  elbow-joint.  Several  cases  of  suppuration 
which  came  under  my  notice  did  well.  I  saw  one  of  them,  six  months  after  the 
injury,  with  perfect  movement." 

Partial  Excision.  The  value  of  this  operation  has  been  disputed. 
In  cases  of  disease  it  should  not  be  employed  as,  in  addition  to  the 
probability  of  ankylosis,  it  is  likely  that  the  parts  affected  will  be  im- 
perfectly removed.  It  should  also  be  rejected  for  the  treatment  of 
ankylosis  at  an  unsatisfactory  angle,  for  excision  of  the  lower  end  of  the 
humerus  alone  will  not  permit  of  pronation  or  supination  afterwards, 
as  the  radius  and  ulna  are  firmly  united  at  their  upper  ends. 

In  excision  for  injury  it  might  be  permissible  to  leave  the  bones 
of  the  forearm  untouched  when  it  had  been  needful  to  remove  the  ends 
of  the  humerus  very  freely.  The  importance  of  securing  free  mobility 
must  always  be  borne  in  mind.  The  same  conditions,  which,  after  an 
injury  to  the  elbow- joint,  may  interfere  with  a  good  result 
from  forcible  movement,  will  also  interfere  with  success  after  partial 
excision.  Thus  osteoid  masses  may  be  formed  by  stripped-up  periosteum, 
a  torn  part  of  the  capsule  may  be  displaced  between  the  joint  surfaces, 
the  articular  surfaces  or  the  radial^  olecranon  or  coronoid  fossae  may 
become  filled  with  fibrous  tissue,  or  ankylosis  develop  at  the  superior 
radio-ulnar  joint.  Some  of  the  above — e.g.  the  formation  of  osteoid 
deposits — will  be  especially  marked  in  young  patients.  Partial  excision 
thus  risks  a  result  of  incomplete  value,  i.e.  a  joint  of  limited  mobility, 
though  one.  perhaps,  with  a  useful  angle. 

The  only  cases  in  which  partial  excision  of  the  elbow-joint  for  injury 
is  to  be  recommended  are  :  (1)  Cases  where  it  is  necessary  to  excise 
a  large  amount  of  bone  from  the  humerus.  (2)  Excision  of  a  fractured 
epicondyle  or  epitrochlea,  or  fracture  of  the  head  of  the  radius.     Removal 

^  Bepf.  on  Surgical  Cases  in  the  South  African  War. 

2  Surg.  Experiences  in  South  Africa,  1899-1900,  p.  23(3. 

'  Apparently  all  the  injuries  were  from  bullet  and  not  shell. 


EXCISION  OF  THE  ELBOW  159 

of  this  process  will  be  specially  indicated  when  it  is  made  out,  at  once 
or  later  on,  to  be  the  cause  of  limited  movement  in  the  joint,  or  when 
it  is  the  cause  of  pressure  upon  the  ulnar  nerve.  (3)  Some  gunshot 
injuries  {vide  supra). 

Excision  of  the  Superior  Radio-ulnar  Joint.  Indications.  Thisopera- 
sion  may  be,  very  occasionally,  made  us(^  of,  with  every  precaution, 
in  old  cases  of  dislocation  of  the  head  of  the  radius,  where  reduction 
has  not  been  effected  owing  to  the  amount  of  swelling,  &c.,  and  where 
the  movements  of  the  forearm  are  much  hampered,  especially  in  a 
young  and  healthy  adult. 

Operation.  An  incision  about  two  inches  long  is  made  over  the 
projecting  head  of  the  bone  behind  or  through  the  posterior  part  of  the 
supinator  longus. 

The  soft  parts  having  been  separated  with  a  blunt  dissector  and  held 
aside  with  retractors,  the  neck  of  the  radius  is  carefully  divided  with 
a  fine  saw  or  cutting  bone-forceps.  Sufficient  bone  must  be  removed 
here  or  from  the  external  condyle  to  leave  a  gap  that  will  avoid  the 
risk  of  fresh  ankylosis.  The  musculo-spiral  nerve  lies  to  the  inner  side, 
and  great  care  nmst  be  taken  not  to  interfere  with  this  or  the  biceps 
tendon.  The  forearm  should  be  put  through  its  movements  {see  p.  152) 
freely  but  carefully,  while  the  patient  is  under  the  anaesthetic,  so  as  to 
break  down  adhesions.  Any  needful  drainage  should  be  provided, 
and  every  care  taken,  by  not  interfering  with  the  soft  parts  more  than 
is  absolutely  needful,  and  by  keeping  the  wound  aseptic,  to  secure 
primary  union,  and  thus  avoid  the  risk  of  stiffness  again  occurring. 
After  a  few  days  a  sling  may  be  substituted  for  a  splint,  and,  ten  to 
fourteen  days  later  {see  p.  155),  passive  movements  made  use  of  daily, 
with  the  aid  of  an  ansesthetic  if  needful.  In  October  1894  Mr.  Jacobson 
excised  the  head  of  the  radius  in  the  following  obscure  and  instructive 
case  : 

In  the  previous  August  the  lad,  aged  12,  had  fallen  from  a  ladder  on  to  his 
feet,' partly  on  his  right  elbow,  not  on  the  hand.  Much  swelling  of  the  joint  had 
followed,  with  subsequent  stiffness,  rendering  the  limb  very  useless.  The  forearm 
was  fixed  in  a  position  midway  between  pronation  and  supination,  and  flexed  at  a  right 
angle.  No  flexion  was  possible  beyond  this.  Passive  extension  possible  to  about 
120  degrees.  Pronation  and  supination,  passive  and  active,  quite  abolished.  A  pro- 
minence— ?  the  head  of  the  radius — to  be  felt  below  the  external  condyle,  but  not 
admitting  of  rotation  :  there  was  no  crepitus.  A  diagnosis  of  dislocation  of  the  head 
of  the  radius  was  made,  though  against  it  were  the  history  of  direct  violence  and  the 
absence  of  any  rotation  in  the  swelling.  On  exploration  of  the  injury  by  a  free  lateral 
incision,  it  turned  out  to  be  one'  of  those  rare  cases  of  fracture  through  the  neck  of 
the  radius.  Just  below  the  external  condyle  the  head  of  the  radius  was  found 
separated  from  the  shaft  by  a  fracture  through  the  upper  part  of  the  neck,  and 
lying  with  its  articular  surface  turned  directly  outwards.  On  removal  of  this  there 
was  distinct  improvement  in  pronation,  but  little  in  supination.  Flexion  was  now 
possible  to  40  degrees,  and  extension  to  almost  the  complete  range,  but  only  on 
forcible  movement.  As  the  movements  were  stiU  incomijlete,  and  certainly  would 
not  be  retained,  I  removed  the  capiteUum  of  the  humerus  from  the  same  incision 
with  a  narrow  osteotome.  The  forearm  could  now  be  put  through  its  full  range 
of  movements.  The  wound  healed  under  an  aseptic  clot,  and  the  patient,  on  leav- 
ing the  hospital  five  weeks  later,  had  recovered  almost  complete  active  movements 
of  the  joint,  though  the  whole  limb  was  still  weak.  Three  months  later  he  could 
"  do  everything  nearly  as  before  the  accident,  and  he  could  also  carry  considerable 
weights." 

Unfavourable  Results  and  Sequelae  of  Elbow- joint  Excision.  (1)  Per- 
sistence of  tuberculous  disease.     This  is  especially  likely  when,  previous 


160        OPERATIONS  ON  THE  UPPER  EXTREMITY 

to   the   operation,    the   capsule   has   been   perforated   and   disease   has 
burrowed  out  amongst  the  origins  of  the  flexors  or  extensors. 

(2)  Caries  and  chronic  osteo-myelitis.  These  are  not  unlikely  to 
supervene  when  the  reparative  power  is  poor  and  the  wound  becomes 
infected. 

(3)  Ankylosis.  This  is  not  uncommon  in  children,  owing  to  the 
great  tendency  of  inflammatory  products  to  organise  quickly  in  early 
life.  Furthermore,  there  is  the  difficulty  of  getting  them  to  use  the 
joint  or  submit  to  passive  movement ;  all  they  will  do  is  to  move  their 
arm  and  forearm  from  the  shoulder-joint.  But  thorough  persevering 
treatment  will  secure  a  sound,  though  stiff,  joint,  with  a  very  useful 
hand. 

(4)  A  flail-like  joint.  A  limb  may  remain  weak  for  some  time,  owing 
to  the  muscles  not  taking  on  firm  attachments.  Friction  and  galvanism 
should  be  used  perseveringly.  If  there  is  too  much  separation  between 
the  ends,  the  patient  should  wear  a  well-moulded  support ;  the  use 
of  the  hand  and  fingers  will  thus  be  retained  and,  if  the  patient  is  young, 
gradual  and  great  improvement  will  very  likely  take  place  in  the  elbow. 
Re-excision  and  wiring  may  be  tried  in  some  cases  with  healthy  patients. 
Most  of  the  flail- joints  follow  the  extensive  removal  of  the  lower  end 
of  the  humerus,  especially  in  cases  of  injury.  In  such  cases  the  perios- 
teum of  the  condyles  and  the  muscular  attachments  should  be  as  little 
interfered  with  as  possible.  Flail- joints  are  of  two  kinds  :  (1)  Active 
flail-joints,  in  which  the  muscles  are  strong  and  exercise  control.  These 
may  be  very  useful,  especially  when  aided  by  a  support  to  the  elbow. 
(2)  Passive  flail-joints,  where  the  muscles  are  wasted,  and  the  hand 
only  can  be  used  by  the  employment  of  a  supporting  splint. 

(5)  Infection  of  the  wound. 

(6)  A  useless  limb,  owing  to  the  muscles  being  utterly  wasted  from 
long  disease  and  disuse.  > 

(7)  Injury  to  the  ulnar  nerve,  with  its  resulting  interference  with 
motion,  sensation,  and  nutrition.  A  few  days  after  the  excision  the 
nerve  should  be  found  by  a  second  incision  below  and  in  front,  traced 
upwards  and  the  divided  ends  united. 

(8)  An  adherent  scar. 

ERASION  OF  THE  ELBOW-JOINT 

This  operation  has  not  been  extensively  practised,  partly  on  account 
of  the  good  results  given  by  a  carefully  performed  excision  and  partly 
because  this  joint  does  not  lend  itself  to  free  exposure  by  so  simple  an 
incision  as  in  the  case  of  the  knee-joint.  Erasion  is  especially  indicated 
in  children,  but  in  the  elbow,  as  in  other  joints,  it  can  only  be  perfectly 
satisfactory  if  performed  in  suitable,  i.e.  early,  cases.  Where  the  bones 
themselves  are  not  diseased,  erasion  will  give  better  results  than  excision, 
but  tuberculous  disease  of  the  joints,  and  among  them  the  elbow,  does 
not  always  come  before  the  surgeon  in  its  early  stage. 

Mr.  Glutton,  at  a  meeting  of  the  Medico-Chirurgical  Society  ^  advo- 
cated early  erasion  of  the  elbow-joint  in  place  of  late  excision.  He 
exposed  the  joint  by  dividing  the  olecranon.  Nine  cases  were  thus 
treated.  Of  these  the  first  two  had  ankylosed  joints,  but  very  service- 
able limbs.     Six  cases  resulted  in  more  or  less  movement  in  the  joint, 

1  Brit.  Med.  Journ.,  Dec.  16,  1893. 


ERASION  OF  TlIK  KL1?0W  101 

with  cessation  of  the  disease.  The  niiitli  and  hist  case  was  subsofjuently 
excised.  After  erasion  there  is  always  a  tendency  to  fibrous  ankylosis 
between  the  ends  of  the  bones  which  are  left.  Now  this  is  not  a  matter 
of  nuich  importance  in  the  lower  extremity  where  a  firm  support,  as 
little  shortened  as  possible,  is  the  chief  point  to  be  attained.  In  the 
case  of  the  elbow-joint,  on  the  other  hand,  complete  removal  of  the 
disease  and  free  mobility  should  be  our  aim.  The  latter  certainly — 
and  the  former  also  with  the  majority  of  operators — will  be  best 
attained  by  excision  with  free  removal  of  the  ends  of  the  bones.  Next 
to  thorough  exposure  and  complete  removal  of  the  disease,  a  freely 
movable  joint  is  what  we  reipiire  here  and,  if  this  be  attained,  it  matters 
very  little  if  the  liml)  is  shortened. 

Operation.  The  following  account  is  taken  fiom  the  "  Manual  of 
Surgical  Treatjuent,"  vol.  iii,  p.  246,  by  Cheyne  and  Burghard.  It  will 
be  noticed  that  these  writers  speak  guardedly  of  the  amount  of  move- 
ment which  may  be  expected  afterwards.  "  Arthrectomy  in  children 
is  an  extremely  satisfactory  operation,  which  generally  leaves  a  certain 
amount  of  movement,  although  the  restoration  of  function  is  not  com- 
plete. The  operation  is  best  performed  through  two  long  lateral  incisions, 
one  on  either  side  of  the  joint.  On  the  inner  side  the  incision  should 
reach  from  just  below  the  point  at  which  the  ulnar  nerve  pierces  the 
internal  intermuscular  septum  downwards  to  about  two  or  three  inches 
below  the  level  of  the  joint.  On  the  outer  side,  the  incision  may  extend 
slightly  higher  up  the  arm,  but  must  not  reach  as  low  down  on  the 
forearm  for  fear  of  injuring  the  posterior  interosseous  nerve  just  opposite 
the  neck  of  the  radius.  It  is  as  well  to  make  the  incisions  as  free  as 
possible  because  plenty  of  room  is  required  to  enable  the  surgeon  to 
see  clearly  what  he  is  doing.  The  incisions  are  carried  down  to  the 
condyles  of  the  humerus,  and  the  removal  of  the  synovial  membrane 
from  the  back  of  the  joint  is  proceeded  with.  The  capsule  can  usually 
be  readily  defined  especially  upon  the  outer  side,  and  the  skin  and 
subcutaneous  tissues  are  raised  from  it  by  a  blunt  dissector.  The  whole 
of  the  capsule  over  the  radio-ulnar  and  radio-humeral  articulations 
is  thus  gradually  separated  as  far  as  the  edge  of  the  olecranon.  The 
triceps  is  also  raised  from  the  capsule  as  far  as  the  middle  line  of  the 
joint,  when  a  similar  procedure  is  adopted  on  the  inner  side,  care  being 
taken  to  raise  the  ulnar  nerve  from  its  groove  behind  the  internal  condyle 
along  with  the  soft  parts  and  not  to  injure  it.  The  fingers  can  then  be 
made  to  meet  across  between  the  triceps  and  the  capsule,  and  thus  the 
whole  of  the  upper  part  of  the  synovial  membrane  is  easily  separated 
and  can  be  divided  by  a  knife  just  at  its  reflection  on  to  the  bone,  and 
peeled  carefully  downwards  ;  it  is  also  divided  on  each  side  in  the  line 
of  the  incisions,  and  is  cut  away  below  at  its  attachments  to  the  ole- 
cranon, and  to  the  radius  and  ulna.  The  entire  posterior  portion  of  the 
synovial  membrane  is  thus  removed,  and  the  next  step  is  to  deal  with 
the  anterior  portion.  In  order  to  do  this  satisfactorily  it  is  generally 
advisable  partially  to  detach  the  tendinous  origins  of  the  muscles  from 
the  condyles  of  the  humerus,  beginning  over  the  outer  one.  The 
periosteum  is  incised  and  stripped  forwards  together  with  the  muscles  ; 
these  structures  are  pulled  forcibly  forwards,  an  assistant  holds  the 
limb  flexed  to  a  right  angle,  and  the  anterior  surface  of  the  capsule  is 
defined  and  separated  by  a  blunt  dissector  and  the  fingers.  Special 
care  must  be  taken  not  to  damage  the  posterior  interosseous  nerve 

SURGERY   I  II 


162        OPERATIONS  ON  THE  UPPER  EXTREMITY 

in  the  lower  part  of  the  incision.  The  structures  on  the  inner  side  are 
then  dealt  with  in  a  similar  manner,  the  periosteum  and  the  tendinous 
origins  of  the  muscles  being  separated  from  the  internal  epicondyle 
and  the  capsule  defined  and  separated  from  them.  The  finger  can 
soon  be  made  to  pass  across  from  one  incision  to  the  other  between  the 
capsule  and  the  superficial  structures,  amongst  which  will  be  the  brachial 
artery.  The  entire  front  portion  of  the  capsule  can  now  be  separated 
and  may  be  cut  across  at  its  attachment  to  the  bones  and  can  be  removed 
whole.  The  lateral  ligaments  are  divided  in  doing  this,  and  the  ends 
of  the  bones  can  then  be  easily  protruded  through  the  wound  ;  the 
olecranon  is  first  pushed  through  whichever  incision  it  can  be  made 
to  project  from  more  easily — generally  the  outer — and  the  synovial 
membrane  of  the  radio-ulnar  articulation  is  completely  removed.  The 
orbicular  ligament  will  also  require  careful  inspection,  for  it  is  often 
diseased.  After  all  the  synovial  membrane  has  been  removed  from 
its  attachment  to  the  bone,  and  after  any  portions  of  cartilage  or  bone 
that  are  affected  have  been  shaved  ofF  with  a  knife  or  freely  gouged 
out,  the  humerus  is  protruded  through  one  of  the  wounds — generally 
the  inner — and  examined.  Special  attention  must  be  paid  to  the 
olecranon  and  coronoid  fossae,  and  the  articular  surface  must  be  treated 
in  a  manner  similar  to  that  adopted  for  the  bones  of  the  forearm.  After 
the  disease  has  been  thoroughly  removed,  the  bones  are  replaced,  the 
wounds  stitched  up  without  a  drainage  tube,  the  usual  antiseptic  dressings 
applied,  and  the  limb  placed  upon  an  intornal  angular  splint." 

"  After-treatment.  The  splints  should  be  retained  for  three  or  four 
weeks,  after  which  the  arm  should  be  kept  in  a  shng  for  another  two 
or  three  weeks,  and  the  patient  encouraged  to  move  it  freely.  There  is 
no  particular  advantage  in  performing  passive  movement.  The  only 
form  of  passive  movement  that  is  really  desirable  is  rotation  of  the 
hand,  and  this  may  be  practised  diligently,  both  actively  and  passively." 

OPERATION  FOR  FRACTURE  OF  THE  OLECRANON 

A.  Simple  fractures.  Operation  should  be  the  rule,  a  few  days  after 
the  injury,  unless  contra-indicated  by  the  want  of  any  separation  between 
the  fragments,  by  some  constitutional  condition  or  by  the  age  of  the 
patient.  In  the  first  case  the  diagnosis  may  be  only  possible  after  a 
radiographic  examination.  Otherwise  firm  bony  union  is  very  im- 
probable owing  to  (a)  the  wide  separation  of  the  fragments  brought 
about  by  the  triceps  ;  (b)  the  interposition  of  torn  portions  of  the 
aponeurosis  of  this  muscle  between  the  fragments  ;  and  (r)  tilting  to 
the  upper  fragment.  The  subsequent  fibrous  union  leads  to  considerable 
deficiency  in  the  power  of  extension  of  the  joint  and  consequently  of 
serious  disability.  It  is  especially  indicated  when  both  olecranon  processes 
have  been  fractured,  or  when  a  patient,  in  addition  to  a  fracture  of  one 
olecranon  has  a  fracture  anywhere  in  the  other  upper  extremity,  thus 
rendering  him  very  helpless. 

B.  Coni'pound  fractures.  Here  the  operation  is  distinctly  indicated. 
The  free  incision  required  will  relieve  the  tension  of  the  ecchymosed 
soft  parts,  it  will  aid  the  neefled  asepsis,  it  will  admit  of  the  removal 
of  any  detached  fragments,  it  will  enable  the  surgeon  to  empty  the 
joint  of  clot,  which,  even  if  it  do  not  suppurate,  will  persist  tediously 
and  impair  future  movements. 


FRACTURE  OF  THE  OLECRANON       163 

C.  //(  some  old-standing  fractures,  originally  treated  by  sj)lints,  where 
treatment  is  sought  on  account  of  the  resulting  weakness. 

It  may  here  be  mentioned  that,  when  for  any  reason,  operation  is 
not  performed,  no  time  should  be  wasted  by  attempts,  usually  futile, 
to  draw  down  the  upper  fragment  with  strapping.  The  case  should  be 
assiduously  treated  from  the  first  with  we]l-a])])lied  massage.  If  this 
be  intelligently  carried  out,  the  w^asting  of  the  triceps  and  other  muscles 
does  not  take  place,  the  effused  products  are  c^uickly  absorbed,  and 
the  adhesions  in  and  about  the  joint  are  prevented.  The  splint  is  left 
off  after  a  few'  days,  the  patient  then  carries  his  arm  in  a  sling  and  begins 
to  use  it  cautiously.  The  result  is  excellent  with  far  less  irksomeness 
to  the  patient,  and  trouble  on  the  part  of  the  surgeon. 

Operation.  The  parts  having  been  most  carefully  cleaned,  the 
surgeon  raises  a  convex  flap,  including  the  skin,  subcutaneous  tissue 
and  the  olecranon  bursa.  The  incision  begins  a  little  above  the  level 
of  the  fracture,  about  one  inch  to  one  side  of  it,  and  is  then  carried 
downwards  and  curved  across  the  back  of  the  elbow  about  one  inch 
below  the  lower  extent  of  the  olecranon,  and  then  finally  carried  up 
upon  the  opposite  side  to  a  point  opposite  to  where  it  began.  The 
convexity  of  the  flap  is  thus  directed  downwards ;  care  must  be  taken 
that  it  is  of  even  thickness  throughout. 

The  line  of  fracture  is  then  made  out,^  any  torn  edges  of  fascia  which 
may  lie  between  the  fragments  are  turned  aside  and  trimmed  clean, 
but  not  removed  ;  the  joint  is  fully  flexed,  and  any  clots  picked  out 
or  washed  away  with  sterile  saline  solution.  To  carry  out  the  wiring, 
a  small  incision  is  made  vertically  down  to  the  ulna,  a  full  half-inch 
below  the  line  of  fracture.  The  cut  edges  of  the  periosteum  are  at  once 
seized  with  small  clip  forceps,  to  mark  the  spot  and  to  obviate  one 
difficulty  in  passing  the  wire.  The  bone  is  then  drilled  obliquely  with 
a  drill  of  suitable  size,  the  point  emerging  on  the  articular  surface  just 
behind  the  articular  cartilage.  A  second  small  vertical  incision  is  then 
made  with  the  same  precautions  through  the  periosteum  of  the  upper 
fragment,  and  its  edges  seized  with  forceps.  The  drill  is  then  again  intro- 
duced obliquely  so  as  to  make  a  passage  for  the  wire  exactly  opposite  to 
the  first.  The  greatest  care  must  be  taken  in  drilling  these  holes  that 
they  exactly  correspond  on  the  fractured  surfaces,  other\vise  exact  apposi- 
tion w'ill  not  be  secured.  Sterilised  silver  ware  is  then  insinuated  through 
the  openings  in  the  fragments,  and  the  forceps  which  act  as  guides  are 
not  removed  until  this  is  done.  Full  flexion  of  the  joint  facilitates  the 
passage  of  the  wdre.  The  joint  is  now  finally  washed  out  with  hot 
sterilised  saline  solution,  the  forearm  is  extended,  and  an  assistant 
brings  the  fragments  accurately  together  by  pressure  with  a  piece  of 
sterilised  gauze  in  each  hand.  The  surgeon,  grasping  the  ends  of  the 
wire  in  strong  forceps,  straightens  them,  and  keeping  his  hands  low 
makes  a  small,  neat  twist  of  about  four  half  turns.  The  ends,  cut  short, 
are  then  hammered  down  into  the  periosteum  and  bone.  The  ends 
should  be  completely  buried  by  suturing  over  them  with  catgut  any 
fascia  or  periosteum  that  is  to  hand.  Any  lateral  gaps  in  the  capsule 
are  closed  in  the  same  way.  The  skin  is  then  sutured  and,  as  a  rule, 
no  drainage  is  required.      An  ample  dressing  should  be  applied,  but  no 

^  This  may  be  in  one  of  three  places  :  (a)  The  tip  of  the  olecranon  may  be  broken  off; 
(b)  fracture  may  occur  at  the  narrowest  part  of  the  sigmoid  cavity  ;  (c)  the  process  may 
be  detached  at  its  junction  with  the  shaft  of  the  ulna. 

SURGERY  I  ll' 


164        OPERATIONS  ON  THE  UPPER  EXTREMITY 


splint  is  necessary.    Passive  movements  should  be  commenced  in  about 
a  week,  and  massage  as  soon  as  the  stitches  have  been  removed.     The 
patient  may  be  allowed  to  move  the  joint   himself  at  the  end   of  a 
fortnight,  but  free  use  should  not  be  permitted  for  five  or  six  weeks. 
In  old-standing  cases  the  operation   will  be  upon  similar  lines,  but 

owing  to  adhesions  having  formed 
between     the     upper    fragment 
and  the   olecranon  fossa  of   the 
humerus,    and     owing    to     the 
great   separation  brought  about 
by    the    action   of    the    triceps, 
great     difficulty    may    be     ex- 
perienced in  drawing  the    frag- 
ments   together.     This   may  be 
overcome    by    lengthening    the 
triceps.    The  method  of  effecting 
this  is  indicated  in  Fig.  82. 
Mr.  Walton^  suggests  as   an 
mipro\enient  a  method  similar  to   that 
advocated  by  Lord  Lister  for  old-stand- 
iiig  fractures  of  the  patella." 

Fractures  of  the  Condyles  of  the 
Humerus.  These  injuries,  which  always 
involve  the  articular  surface,  are,  unless 
the  fiagments  are  accurately  replaced, 
very  hkely  to  be  followed  by  serious 
disability  Either  condyle  may  be  frac- 
tuied  or  there  may  be  a  T-shaped 
fiactuie,  in  which  the  lower  extremity  of 
the  humerus  is  separated  while  a  vertical 
line  of  fracture  extends  from  the  trans- 
verse line  to  the  articular  surface.  The 
tip  of  the  epicondyle  may  also  alone  be 
fractured,  in  which  case  the  joint  is  not 
opened.  A  thorough  and  careful  radio- 
graphic examination  is  essential  for  the 
diagnosis  of  these  injuries,  and  also  to 
guide  the  surgeon  in  the  treatment  to 
be  adopted. 

An  attempt  may  at  first  be  made  to 
manipulate  the  fragments  into  position, 
the  patient  being  anaesthetised. 

The  arm  should  then  be  put  up  in 
the    fully    flexed    position.     A    second 


Fig.  82.  Method  of  lengthening 
the  triceps  in  the  operation  for 
wiring  long-standing  cases  of  frac- 
ture of  the  olecranon.  The  larger 
figure  shows  the  long  flap  re- 
quired for  exposure  of  the  triceps, 
and  the  serrated  division  of  the 
muscle  described  in  the  text.  The 
smaller  figure  shows  the  method 
of  approximating  the  serrations 
above  and  below,  and  how  the 
muscle  is  elongated.  The  apices 
of  the  serrations  arc  made  blunt 
in  order  to  secure  a  larger  surface 
for  union.  (Cheyne  and  Burghard. ) 


radiographic  examination  should  always 
be  made  and  if  the  position  is  not  satisfactory,  open  operation,  if  not 
contra-indicated  by  age,  or  by  some  constitutional  condition,  should 
certainly  be  advised.  It  must  be  remembered  that  in  an  important 
joint,  such  as  the  elbow,  a  very  trifling  irregularity  of  the  articular 
surface  may  cause  much  limitation  of  movement,  and  also  that  callus 


^  Fractures  and  Separated  Epiphyscf!,  1910,  p.  155. 
2  See  Operations  for  Fracture  of  the  Patella. 


FRACTURE  OF  THF  OLECRANON  165 

or  osteoid  masses  foinied  by  stripped-np  ])eriosteum  may  subsequently 
seriously  interfere  with  the  inobility  of  the  joint. 

Operation.  The  fracture  nuist  be  freely  exposed  either  by  a  lon<; 
vertical  median  incision  over  the  back  of  the  joint,  or  by  a  lateral  incision 
along  the  supra-condylar  ridges  of  the  humerus.  The  former  incision 
is  best  for  dealing  with  a  T-shaped  fracture,  while  in  separation  of  one 
condyle  a  lateral  incision  may  be  employed.  Two  lateral  incisions 
may  be  made  if  necessary,  when  the  soft  parts  may  be  separated  from 
the  capsule  in  front  and  behind  (as  described  for  Erasion,  see  p.  101). 
Care  must  be  taken  to  avoid  injury  to  the  ulnar  or  musculo-spiral  nerves. 
In  this  way  a  free  exposure  of  the  fracture  and  of  the  joint  may  be 
obtained.  With  either  incision,  after  the  soft  parts  have  been  reflected, 
the  joint  is  opened  and  all  blood  clot  washed  away  with  sterile  saline 
solution.  The  fragments  are  now  manipulated  into  good  position  and 
secured  by  a  screw  or  by  a  small  Lane's  plate.  Li  the  case  of  a  T-shaped 
fracture  the  two  small  fragments  should  first  be  accurately  fitted  together, 
while  the  lower  extremity  should  be  fixed  to  the  shaft  by  means  of  a 
small  plate.  One  of  Lane's  three-limbed  plates  may  be  employed  for 
this  purpose. 

The  rent  in  the  capsule  is  then  closed  by  a  few  catgut  sutures  and  the 
wound  closed.  An  internal  angular  splint  should  be  applied,  care  being 
taken  that  the  vessels  in  front  of  the  elbow  are  not  constricted  by  too 
tight  bandaging. 

Cautious  passive  movements  may  be  started  in  a  week,  while  gentle 
massage  should  be  commencedas  soon  as  the  stitches  have  been  removed. 

Separation  of  the  Lower  Epiphysis  of  the  Humerus.  In  certain  cases, 
where  reduction  of  the  deformity  is  impossible  or  in  some  old- standing 
cases  where  the  mobility  of  the  joint  is  seriously  affected,  operation 
may  be  called  for.  It  is  carried  out  on  the  lines  described  above.  The 
epiphysis  is  exposed  through  one  of  the  above-described  incisions, 
manipulated  into  position,  and  secured  by  a  plate,  wire,  or  staple. 

The  after-treatment  is  also  similar.  Sir  A.  Lane  advises  removal  of 
the  plate  as  soon  as  union  has  occurred  in  all  cases  of  mechanical  fixa- 
tion of  epiphyses ;  otherwise  interference  with  growth,  leading  to 
subsequent  deformity,  is  likely  to  occur. 

Dr.  G.  E.  Davies,  of  Philadelphia,  advises  osteotomy  of  the  humerus  for  cubitus 
varus,  the  deformity  which  may  follow  a  fracture  of  the  internal  condyle  not  corrected 
at  the  time  of  the  accident.  He  looks  upon  this  as  the  most  common  of  fractures 
about  the  elbow-joint. 

Technique.  An  incision  is  made  over  the  internal  condyle  and  prolonged  up- 
wards, and  the  bone  exposed  by  careful  dissection.  The  brachial  artery  and  the 
median  nerve  he  to  the  outer  side  and  in  front  of  the  ulnar  nerve  to  the  inner  side 
and  behind  this  incision.  The  edges  of  the  wound  having  been  well  retracted,  a 
narrow  osteotome  is  introduced  and  the  bone  divided,  but  not  completely.  The 
remainder  is  then  fractured  or  bent  until  the  desired  position  is  attained.  The 
Hmb  is  kept  extended  in  plaster  of  Paris  for  six  weeks  ;  after  the  removal  of  this, 
massage  and  movement  restore  the  mobihty  of  the  joint  in  two  weeks.  Three  cases 
are  given  with  successful  results.^ 

Arthrotomy.  Opening  the  elbow- joint  may  be  called  for  in  the 
following  conditions:  (1)  For  drainage  in  cases  of  acute  suppurative 
arthritis.  This  may  be  the  result  of  a  punctured  wound  or  be  pysemic 
in  origin.  (2)  For  the  removal  of  loose  bodies.  These  are  usually  small 
pieces  chipped  from  the  articular  surface,  the  result  of  injury.  In  the 
1  Ann.  of  Surg.,  January  1899. 
SURGERY  I  1 1 


166        OPERATIONS  OX  THE  UPPER  EXTREMITY 

former  case  drainage  may  be  effected  by  two  incisions,  one  on  each 
side  of  the  olecranon.  The  proximity  of  the  uhiar  nerve  must  be  remem- 
bered when  making  the  inner  incision.  Frequent  free  irrigation  with 
sterile  saline  solution  should  be  carried  out,  or  immersion  of  the  elbow 
in  an  arm-bath  containing  hot  boracic  lotion  or  saline  solution  may  be 
tried. 

The  elbow  should  be  flexed  to  a  right  angle  and  the  forearm  kept 
midway  between  full  pronation  and  supination.  Passive  movements 
should  be  commenced  early,  as  ankylosis  is  very  likely  to  follow.  Not 
infrequently  however  in  pysemic  cases,  especially  in  children,  surprisingly 
good  movement  is  obtained.  For  the  removal  of  loose  bodies  an  incision 
on  the  outer  side,  over  the  head  of  the  radius,  is  recommended.  A 
fragment  detached  from  the  articular  surface  of  this  bone  is  one  of  the 
commonest  loose  bodies  in  the  elbow-joint. 

VENESECTION 

Indications.  Though  not  very  frequently  performed,  there  are  a 
number  of  conditions  in  which  this  operation  is  strongly  indicated. 
Generally  speaking,  these  are  characterised  by  a  rapid,  weak,  often 
irregular  pulse  of  low  tension,  a  labouring  and  dilated  right  ventricle, 
and  backward  pressure  along  the  systemic  veins.  Dr.  Beddard  says  : 
"  In  extreme  cases  of  cardiac  dilatation  venesection  may  be  an  almost 
necessary  preliminary  to  enable  the  overstretched  muscle  to  respond  to 
digitalis,  strychnine,  and  other  cardiac  stimulants." 

The  following  are  the  chief  indications  :  (1)  In  some  cases  of  chronic 
bronchitis,  especially  when  an  acute  attack  exaggerates  the  chronic 
trouble  leading  to  rapidly  increasing  cyanosis  and  cardiac  failure  from 
over-distension  of  the  right  side  of  the  heart. ^ 

(2)  In  some  cases  of  injury  to  the  lung  and  pleura  and  of  traumatic 
pneumonia.  Captain  F.  J.  Porter.  R.A.M.C.,  relates  a  case-  which 
illustrates  the  truth  of  the  above  remarks : 

"  A  lieutenant  was  shot  through  the  chest  in  a  Boer  ambush.  He  was  picked 
up  four  hours  later  in  a  critical  condition,  o^\-ing  to  dyspnoea  from  a  large  effusion  of 
blood  into  the  right  pleura.  Twenty-four  hours  later,  while  the  patient  was  being 
taken  across  countn,-  to  Heilbron.  the  lividity  became  so  great  and  the  pulse  failed  so 
much  that  ten  ounces  of  verj'  dark  blood  were  taken  from  the  median  basihc  vein. 
The  patient  immediately  turned  on  his  wounded  side  and  went  to  sleep.  Next 
morning  he  was  quite  rational.  Fifty  miles  were  trekked  in  twenty-eight  and  a  half 
hours.     The  recovery  was  uninterrupted." 

In  cases  of  acute  lobar  pneumonia,  owing  to  the  tendency  to  cardiac 
failure,  venesection  will  be  very  seldom  indicated  and  should  only  be 
done  after  consultation  with  a  physician. 

(3)  In  severe  cases  of  cardiac  valvular  disease,  when  the  heart  is  so 
dilated  and  engorged  that  the  right  ventricle  can  with  difficulty  contract 
upon  its  contents. 

(4)  In  some  severe  epileptic  attacks,  especially  the  status  epilepticus, 
a  moderate  venesection  is  of  service.  In  severe  ursemic  con\Tilsions 
the  fits  may  be  arrested  in  this  way.  though  care  must  be  taken  not  to 
draw  off  too  much  blood.  It  has  also  been  employed  with  advantage 
in  the  treatment  of  puerperal  eclampsia.-^ 

^  Very  interesting  papers  (with  casos)  will  be  found  by  Dr.  Pye  Smith  {Med.  Chir. 
Trans.,  vol.  Ixxiv,  p.  14),  Dr.  Qfile  and  Sir  S.  Wilks  (Lancet,  vol.  i.  1891,  pp.  1029,  1139). 
2   Brit.  Med.  Journ.,  vol.  i,  1901,  p.  9.54. 
2  Dr.  Thomas  [Brit.  Med,  Journ,,  1898,  vol.  i,  p.  400). 


VENESECTION  107 

(5)  111  aiioiirysiiis,  ospecially  thoracic.  Only  a  small  amount  of 
l)loo(l  should  he  withdrawn,  though  the  treatment  may,  if  necessary, 
he  repeated.  Venesection  here  undoubtedly  relieves  certain  very 
troublesome  symptoms,  viz.  dyspnoea  and  pain. 

Operation,  liie  skin  having  been  cleansed,  the  patient  being  usually 
in  a  sitting  ])osition,  and  a  bandage  tied  round  the  middle  of  the  arm 
with  sufHcient  tightness  to  retard  the  venous  circulation  without  arresting 
that  in  the  arteries,^  the  surgeon  selects  the  median  cephalic  or  the 
median  basilic,  whichever  is  more  prominent.-  Steadying  this  vein  by 
placing  his  left  thumb  upon  it  just  below  the  point  of  intended  puncture 
and  with  his  right  hand  resting  steadily  upon  its  ulnar  margin,  he  opens 
the  vein  with  a  small,  sharp  scalpel,  scrupulously  clean,  making  with, 
a  gentle  sweep  of  his  wrist  a  small  incision,  and  not  a  mere  puncture, 
into  the  vein.  The  anterior  wall  of  this  being  divided,  the  joint,  without 
penetrating  any  deeper,  is  thrust  onwards,  first  increasing  the  slit  in  the 
vein,  and  then  being  cut  vertically,  care  being  taken  to  make  the  skin 
wound  larger  than  that  in  the  vein.  The  thumb  is  now  raised  and  the 
stream  directed  into  the  measuring  vessel.^  While  the  blood  is  escaping 
the  limb  should  be  kept  in  the  same  position,  lest,  by  the  skin  slipping 
over  the  wound  in  the  vein,  the  blood  should  be  prevented  from  escaping 
freely  and  thus  make  its  way  into  the  cellular  tissue. 

The  required  amount  of  blood  having  been  withdrawn,  a  sterilised 
thumb  is  placed  on  the  wound  w^hile  the  bandage  is  removed.  A  small 
pad  of  aseptic  gauze  is  then  placed  on  the  puncture,  and  secured  with 
a  bandage  applied  in  the  figure  of  8.  This  pad  may  be  removed  in 
about  forty- eight  hours,  and  for  a  day  or  two  the  patient  should  use  a 
sling. 

Difficulties  during  and  complications  after  Venesection.  (1)  Difficulty 
in  finding  a  vein.  This  may  be  due  to  their  small  size,  the  feebleness 
of  the  circulation,  or  the  abundance  of  fat.  If  a  vein  cannot  be  made 
sufficiently  distinct  by  hanging  down  the  limb,  putting  it  in  warm  water, 
flexing  and  extending  the  wrist  and  fingers,  and  chafing  the  limb,  one 
should  be  opened  on  the  back  of  the  hand,  or  blood  withdrawn  from  the 
external  jugular  or  internal  saphena  at  the  ankle.  (2)  In  other  cases, 
where  the  patient  is  much  emaciated,  owing  to  the  absence  of  steadying 
fat  the  mobility  of  a  vein  may  enable  it  to  avoid  puncture,  unless  a 
very  sharp  instrument  be  used  and  the  vein  well  steadied.  (3)  When 
the  vein  has  been  opened,  sufficient  blood  may  not  escape  owing  to  : 
(a)  The  opening  may  be  a  mere  puncture,  (6)  The  skin  opening  may 
be  insufficient  in  size,  or  not  parallel  in  position  to  that  in  the  vein. 
These  impediments  are  removed  by  a  freer  use  of  the  knife,  carefully 
made,  or  by  bringing  the  wound  in  the  vein  parallel  with  that  in  the 
skin,  (c)  A  pellet  of  fat  may  block  the  opening  in  the  vein.  This 
should  be  snipped  away,  (d)  The  patient  may  faint,  (e)  A  thrombus 
may  form.  This  will  disappear  when  the  venous  current  becomes  more 
active.  (/)  The  bandage  may  be  tied  too  tightly  round  the  arm. 
(4)  Wound    of    the    brachial    or  some  other  artery,  e.g.  an  abnormal 

^  The  surgeon  makes  use  of  the  pulsation  in  the  arteries  to  tell  the  relation  of  the 
brachial,  or  one  of  its  branches  given  oflE  abnormally  high  up  and  running  superficially 
to  the  veins  at  the  bend  of  the  elbow. 

2  If  the  patient  is  nervous,  or  if  the  veins  are  small,  he  should  be  told  to  hold  a  walking- 
stick  or  book.  This  steadies  his  arm,  distracts  his  thoughts,  and,  by  producing  muscular 
contraction,  supports  and  fills  the  veins. 

^  Not  a  drop  of  blood  should  be  allowed  to  go  on  the  bed  or  the  patient's  linen. 


168       OPERATIONS  ON  THE  UPPER  EXTREMITY 

ulnar.  TJiis  can  always  be  avoided  by  a  careful  use  of  the  scalpel,  and 
by  noting  beforehand  the  existence  of  any  pulsation.  The  force  of  the 
jet  and  the  mixture  of  bright  with  dark  blood  will  tell  of  this  accident. 
Pressure  should  be  carefully  applied  and  maintained,  and  blood 
taken  from  the  opposite  arm  if  required.  (5)  Escape  of  blood  into  the 
cellular  tissue.  This  will  lead  to  ecchymosis,  and  perhaps  formation 
of  a  thrombus,  which  may  be  absorbed,  but  which  also  may  suppurate. 
(6)  Phlebitis  or  inflammation  of  the  lymphatics.  These  may  be  caused 
by  the  use  of  infected  instruments.  Every  precaution  must  be  taken 
to  secure  asepsis,  as  any  failure  is  likely  to  lead  to  the  following  two 
most  grave  results.  (7)  Cellulitis  and  septicaemia.  (8)  Intense  pain 
in  the  limb,  with  gradual  flexion  of  the  elbow-joint.  This  is  due  to 
puncture  of  the  external  or  internal  cutaneous  nerves,  which  are  con- 
nected through  the  brachial  plexus  with  the  motor  nerves  to  the  brachialis 
anticus  and  biceps,  which  flex  the  elbow-joint.  The  injured  nerve 
should  be  divided,  subcutaneously  if  possible,  or  the  scar  excised. 

LIGATURE  OF  THE  BRACHIAL  ARTERY  AT  THE  BEND  OF  THE 
ELBOW  (Figs.  64  and  83) 

This  operation,  common  enough  fifty  years  ago  owing  to  the 
frequency  of  venesection  and  the  facility  with  which  the  brachial  artery 
was  wounded,  will  be  briefly  described  here. 

Indications.  (1)  Wound  of  the  artery,  especially  after  venesection 
or  tenotomy  of  the  biceps  tendon  (here  a  ligature  above  and  below  the 
wound  will  be  required),  or  a  punctured  wound  from  any  other  cause. 
(2)  Traumatic  aneurysm,  whether  arterio- venous  or  not,  occurring  after 
accidents  such  as  the  above. 

The  late  campaign  in  South  Africa  saw  a  great  increase  in  the  occurrence  of 
arterio-venous  aneurysms  from  the  passage  of  high  velocity  bullets  of  a  small 
calibre  through  adjacent  arteries  and  veins.  This  subject  will  be  referred  to  at 
p  190  in  the  account  of  ligature  of  the  axillary  artery,  the  vessel  of  the  upper 
extremity  in  which,  according  to  Mr.  G.  H.  Makins,  operative  interference  is  most 
likely  to  be  useful. 

Guide.     The  inner  side  of  the  biceps  tendon. 
Relations. 

hi  Front 
Skin ;      fasciae ;      bicipital    fascia;       median 
basilic   vein.     Branches   of   internal   and 
external  cutaneous  nerve. 
Outside  Inside 

Biceps  tendon.  Brachial  artery  Median  nerve 

Vena  comes.  at  bend  of  elbow  Vena  comes. 

Behind 
Brachialis  anticus. 

Operation  ^Figs.  64  and  83).  The  hmb  being  steadied,  with  the 
elbow  slightly  flexed,  the  site  of  the  biceps  tendon  should  be  defined, 
and  also  that  of  any  large  veins,  by  making  pressure  a  little  above  the 
proposed  site  of  the  ligature.  An  incision  about  two  and  a  half  inches 
long  is  then  made,  a  little  to  the  inner  side  of  the  biceps  tendon,  through 
the  superficial  fascia,  carefully,  so  as  to  avoid  the  median  basilic  vein 
and  its  companion,  the  internal  cutaneous  nerve.  If  these  are  seen, 
they  must  be  drawn  inwards.     The  deep  fascia  is  then  divided,  but  this 


LIGATURE  OF  THE  BRACHIAL  ARTERY 


169 


and  the  semi-lunar  fascia  of  the  biceps,  which  strengthens  it,  should  be 
interfered  with  as  little  as  possible.  The  artery,  with  its  vena;  comites, 
lies  directly  underneath.  The  needle  should  be  passed,  after  the  veins 
are  separated  and  the  artery  cleaned,  from  within  outwards,  so  as  to 
avoid  the  median  nerve,  which  lies  more  deeply  and  to  the  inner  side.^ 
In  the  case  of  traumatic  aneurysm,  arterio-venous  or  not,  resisting  other 
treatment,  a  proximal  ligature  placed  as  near  as  possible  above  the  sac, 
or  the  old  operation  of  placing  double  ligatures,-  will  be  preferable  to 
the  Hunterian  one,  which  runs  the  risk  of  overlooking  the  possibility 
of  a  rather  higher  division  than  usual  of  the  brachial  into  radial  and 


TENDON    OF  BICEPS 


I    BRACHJAL 


MEDIAN  N. 


MED.  BASILIC    K 


MED.   CEPHALIC    W. 


Fio.  83.     Ligature  of  the  brachial  artery  at  the  bend  of  the  elbow. 


ulnar.  If  much  haemorrhage  is  expected,  the  brachial  should  be  com- 
pressed about  the  middle  of  the  arm  with  an  Esmarch's  bandage  or  a 
tourniquet. 

The    median    basilic    vein    will,    in    many    cases    of   arterio-venous 

^  If  it  be  needful  to  prolong  the  incision  downwards  so  as  to  secure  the  upper  end  of 
the  radial  or  ulnar,  the  bicipital  fascia  must  be  divided  more  freely,  and  the  median 
basilic  vein  secured  if  it  cannot  be  drawn  to  one  side. 

2  On  this  and  all  other  arterio-venous  aneurysms  the  advice  of  Mr.  Makins,  p.  190, 
should  be  studied.  It  will  be  seen  that  he  prefers  trial  of  a  proximal  ligature  first.  If  a 
local  operation  is  found  to  be  needful,  ligatures  will  be  required  above  and  below  the 
communication  with  the  vein  in  the  case  of  aneurysmal  varix,  and  above  and  below  the 
sac  if  the  surgeon  is  dealing  with  a  varicose  aneurysm.  It  may  be  better  (the  artery 
being  commanded  above)  to  open  the  sac,  and  thus  find  the  apertures  into  the  artery 
by  the  aid  of  a  small  bougie.  As  Mr.  Holmes  {Syst.  of  Sunj.,  vol.  iii,  p.  92)  points  out, 
the  other  plan  of  attempting  to  find  and  tie  the  artery  without  opening  the  sac  presents 
these  difficulties,  viz.  that  the  artery  is  surrounded  by  dilated  and  closely  packed  veins, 
and  that  below  the  sac  it  is  of  small  size.  Every  precaution  should  be  taken  to  spare 
the  main  vein.  If  haemorrhage  from  it,  uncontrollable  by  pressure,  be  present,  a  lateral 
ligature  should  be  attempted.  Only,  if  it  be  absolutely  unavoidable,  should  the  vein  be 
tied  above  and  below. 


170        OPERATIONS  ON  THE  UPPER  EXTREMITY 

aneurysm,  be  found  much  dilated  by  the  entrance  of  arterial  blood. 
Occasionally  it  has  been  obliterated.  In  ordinary  traumatic  aneurysm 
the  sac  should  be  cut  away  with  scissors  after  the  artery  above  and 
below  has  been  secured. 

This  operation  at  the  bend  of  the  elbow  should  always  be  performed 
with  the  utmost  carefulness  at  the  time,  and  pains  taken  with  the  after- 
treatment,  so  as  to  ensure  the  minimum  of  disturbance  and  the  smallest 
amount  of  cicatrix,  and  thus  to  interfere  as  little  as  possible  with  the 
movements  of  the  elbow-joint. 


CHAPTER  VIII 
OPERATIONS  ON  THE  ARM 

LIGATURE  OF  BRACHIAL  ARTERY  (Figs.  84,  85  and  86) 

This   is  performed    {a)  in    the   middle   of    the    arm   and,    much    more 
rarely,  (h)  at  the  bend  of  the  elbow,  the  operation  last  described. 

(a)  In  the  middle  oJ  the  Arm  (Fig.  85).  Indicatiuns.  (1)  Chiefly 
wounds  of  the  palmar  arch,  resisting  pressure  {see  p.  89). 

(2)  Wound  of  the  artery  itself  by  a  penknife,  bayonet,  bullet,  &c. 

(3)  Gunshot  wound  of  the  elbow,  leading  to  secondary  haemorrhage 
resisting  other  treatment. 

(4)  Angeioma  of  hand. 

In  March  1891  Mr.  Jacobson  tied  first  the  brachial,  and,  five  months  later,  the 
radial  and  ulnar  arteries  for  a  congenital  angeioma  with  much  erectile  tissue 
affecting  all  the  fingers  and  the  palm  of  the  hand  in  a  girl  aged  18.     By  the  first 


Fig.  84.     Incision  for  Hgature  of  the  brachial  artery. 

operation  the  vascularity  was  quickly  reduced  ;  the  second,  aided  by  catgut  setons, 
was  followed  by  very  marked  skrinking,  and,  ultimately,  a  complete  cure.  A  full 
account  of  the  case  with  the  result  ten  years  after  the  operation,  is  given  in  the 
Guy's  Hospital  Reports,  vol.  Ivi. 

(5)  Wound  of  one  of  the  arteries  of  the  forearm,  followed  by  severe 
haemorrhage,  a  sloughy  condition  of  the  parts  preventing  ligature  of 
the  vessel  above  and  below  the  wound. 

In  the  year  1882  a  patient  came  under  the  care  of  Mr.  Jacobson  for  secondary 
hannorrhage  from  a  wound  of  the  forearm,  infiicted  by  the  bursting  of  a  gun  in 
rook-shooting.  The  parts  were  much  swollen  and  sloughy  :  the  ulnar  artery  in 
its  middle  third,  from  which  the  hamiorrhage  was  coming,  was  greenish  in  colour, 
and  apparently  not  in  a  condition  to  hold  a  ligature.  A  good  recovery,  with  no 
further  haemorrhage,  took  place  after  ligature  of  the  brachial  in  the  middle  of  the 
arm.  In  1885  it  was  found  necessary  again  to  tie  this  artery,  for  ha?morrhage 
occurring  repeatedly  a  few  days  after  a  suppurating  palmar  bursa  had  been  opened 
in  the  usual  way,  above  and  below  the  anterior  annular  ligament.  The  patient 
recovered  with  a  weakened  limb. 

(6)  Traumatic  and  spontaneous  aneurysm.     In  traumatic  aneurysm, 

171 


172        OPERATIONS  ON  THE  UPPER  EXTREMITY 

whether  of  the  brachial  or  the  arteries  of  the  forearm,  the  old  operation 
is  preferable  to  the  Hunterian,  as  the  sac  is  often  imperfect  {see  also 
remarks  on  p.  173  on  ••Abnormalities  of  the  Brachial  Artery"). 

Dr.  H.  Bousquet  records  ^  a  case  of  traumatic  aneurysm  ^  of  the 
forearm,  dating  to  a  gunshot  injury,  cured  by  excision  of  the  sac. 

A  labourer,  while  poaching,  received  a  charge  of  No.  6  shot,  which,  entering  in 
the  lower  third  of  the  forearm,  passed  obliquely  upwards  almost  as  high  as  the 
elbow.  The  wound  healed  up  in  about  six  weeks.  Evidence  of  an  aneurysm  became 
manifest  thirteen  days  after  the  injury,  but  operative  treatment  was  refused.  Six 
months  after  the  accident,  an  Esmarch's  bandage  having  been  apphed,  an  incision 
was  made  over  the  swelling,  which  was  now  of  a  pyriform  shape,  and  reached 
from  the  middle  of  the  arm  to  the  lower  third  of  the  forearm.  The  brachial  arterv 
having  been  tied  as  low  down  as  possible,  the  aneurysm  was  separated  from  the 


Fig.  85.     Ligature  of  the  brachial  artery  in  the  middle  of  the  arm. 

adjacent  structures.  In  spite  of  much  care,  its  walls,  which  were  very  thin,  gave 
way  at  several  spots.  Its  interior  was  iilled  with  passive  clot.  Its  lower  extremity 
was  embedded  in  the  cicatrix  of  the  wound.  The  aneun'sm  probably  sprang  from 
the  arteries  of  the  forearm  near  their  origin,  jx'rhaps  also  from  the  brachial.  The 
removal  of  the  aneurysm  left  a  large  cavity,  of  which  the  floor  was  formed  by  the 
interosseous  membrane,  and  the  sides  by  muscles  of  the  forearm.  Several  vessels 
were  tied  before  and  after  the  removal  of  the  Esmarch's  bandage.  As  it  was  im- 
possible to  bring  so  large  a  wound  together,  it  was  plugged  with  iodoform  gauze.  The 
patient  recovered  with  a  useful  limb. 

With  regard  to  spontaneous  aneurysms,  it  is  well  known  that  these 
are  very  rare  in  the  upper  extremity,  and  usually  associated  with  cardiac 
disease.  When  this  complication  is  present,  ligature  will  only  be  thought 
of  when  the  aneurysm  is  rapidly  increasing,  or  causing  painful  pressure 
upon  a  nerve. 

Local  anaesthesia  mav  be  useful  here. 


1  Congres  Fran,  de  Chir..  1895.  p.  741. 

-  The  aneurysm  is  also  described  as  arterio- venous,  but  no  evidence  of  this  is  given. 
The  account  of  the  vessels  affected  is  practically  nil, 


LIGATURE  OF  THE  BRACHIAL  ARTERY  173 

Line.  From  the  junction  of  the  middle  and  anterior  thirds  of  the 
axilla,  along  the  inner  edge  of  the  coraco-brachialis  and  biceps,  to  the 
middle  of  the  elbow-triangle.  This  line  is  of  especial  importance,  when, 
owing  to  the  swelling,  &c.,  the  edge  of  the  biceps  is  difficult  to  make 
out. 

Guide.     The  above  line  and  the  inner  edge  of  the  biceps. 

Relations  in  arm. 

In  Front 

Skin ;     fasciae ;     branches    of    internal    and 

external  cutaneous  nerves. 
Median  nerve  ^  (about  the  centre  of  the  arm). 


Outside 

Inside 

Coraco-brachialis  (above). 
Biceps. 

Brachial 
artery 

Ulnar  nerve. 

Internal  cutaneous  nerve. 

Vena  comes. 

in  arm. 

Vena  comes. 

Basilic  vein  superficial  to 
deep  fascia  in  lower  half, 
beneath  it  above,  usually. 

Behind 
Triceps  (middle  and  inner  heads)  ;    coraco- 
brachialis  ;   brachialis  anticus. 
Musculo-spiral  nerve  and  superior  profunda 
artery  (above). 
Collateral  circulation.     («)  If  the  ligature  be  placed  above  origin  of  the 
superior  profunda,  the  vessels  chiefly  concerned  will.be  : 

Above  Below 

The  subscapular  ^^^^  rj,^^  -^^^  profunda. 

Ihe  circumflex 

(6)  If  the  ligature  be  placed  below  origin  of  the  superior  profunda  : 

Above  Below 

The  radial  recurrent. 
^,  •  r      1  i.!  The  posterior  ulnar  recurrent. 

The  superior  profunda  with         ^j^^  interosseous  recurrent. 

The  anastomotica  magna, 
(c)  If  the  ligature  be  placed  below  the  inferior  profunda  : 

Above  Beloiv 

The  radial  recurrent. 
^,  .  .      T  The    anterior    and    posterior 

The  superior  profunda  ^,^^^  ^^j^^^^  recurrents. 

The  inferior  profunda  ^j^^  interosseous  recurrent. 

The  anastomotica  magna. 
Abnormalities.     These  are  so  far  from  infrequent  that  the  surgeon 
must  be  prepared  for  the  following  : 

(1)  The  artery  being  in  front  of  the  nerve. 

(2)  A  high  division  of  the  artery.  According  to  Quain,  in  one  out  of  every  five 
cases  there  were  two  arteries  instead  of  one  in  some  part,  or  in  the  whole,  of  the  arm. 
The  point  of  bifurcation  is  thus  described  by  Gray  :  "  It  is  most  frequent  in  the 
upper  part,  less  so  in  the  lower  part,  and  least  so  in  the  middle,  the  most  usual  point 
for  the  apphcation  of  a  ligature  ;    under  any  of  these  circumstances,   two  large 

1  The  median  nerve  is  to  the  outer  side  of  the  artery  at  its  commencement,  crosses  it 
Buperficially  about  the  middle  of  the  arm  and  is  to  the  inner  side  in  the  lower  third. 


174        OPERATIONS  ON  THE  UPPER  EXTREMITY 

arteries  would  be  found  in  the  arm  instead  of  one.  The  most  frequent  (in  three 
out  of  four)  of  these  pecuharities  is  the  high  origin  of  the  radial.  That  artery  often 
arises  from  the  inner  side  of  the  brachial,  and  runs  parallel  with  the  main  trunk 
to  the  elbow,  where  it  crosses  it.  lying  beneath  the  fascia ;  or  it  ma}^  perforate  the 
fascia,  and  pass  over  the  artery  immediately  beneath  the  integument."  ^ 

(3)  The  artery  may  be  partially  covered  by  a  muscular  slip  given  off  from  the 
pectoralis  major,  biceps,  coraco-brachialis,  or  brachialis  anticus. 

(4)  Instead  of  following  its  usual  course  along  the  brachial  anticus,  the  brachial 
artery  may  accompany  the  median  nerve,  behind  an  epicondylic  process  or  liga- 
ment, as  in  many  carnivora. 

(5)  It  may  also  give  off  a  vas  aberrans  or  a  median  artery,  and  any  of  its  ordinary 
branches  may  be  absent.  The  vas  aberrans  usually  ends  in  the  radial,  sometimes 
in  the  radial  recurrent  and  rarely  in  the  ulnar  artery  (Cunningham). 

Operation  (Fig.  85).  The  arm  being  extended  and  abducted  from 
the  side,  with  the  elbow-joint  flexed  and  supported  -  by  an  assistant, 
the  surgeon,  sitting  between  the  limb  and  the  trunk, ^  makes  an  incision 
three  inches  in  length  along  the  inner  border  of  the  biceps,  beginning 
from  below  or  above  as  is  most  convenient,  going  through  the  skin  and 
fascise.  and  exposing  just  the  innermost  fibres  of  the  muscle.^  This  is 
then  drawn  outwards  with  a  retractor,  the  median  nerve  next  found 
and  drawn  inwards  or  outwards  with  an  aneurysm-needle.  and  the 
artery  defined  and  sufficiently  cleaned,  when  the  ligature  is  passed  from 
the  nerve.  In  doing  this  the  basilic  vein  and  the  venae  comites,  which 
increase  in  size  as  they  ascend,  must  be  carefully  avoided. 

It  may  be  here  pointed  out  that  the  brachial  artery  is  by  no  means 
so  easy  a  Vessel  to  tie  as  might  be  supposed  from  its  superficial  position. 
This  is  especially  the  case  when  the  artery  is  concealed  by  the  median 
nerve  at  the  point  where  it  is  sought,  and  when  its  beat  is  feeble  and  the 
vessel  itself  small  and  but  little  distended  after  repeated  haemorrhage 
lower  down.^ 

AMPUTATIONS  OF  THE  ARM  (Figs.  87-90) 

Indications.     Amongst  these  are  : 

(!)  Accidents,  e.g.  compound  fractures,  machinery  accidents.  &c., 
which  do  not  admit  of  any  part  of  the  forearm  being  saved  or  of  amputa- 
tion at  the  elbow. 

(2)  New  growths  involving  the  forearm  and  not  admitting  of  extirpa- 
tion. 

(3)  Disease  of  the  elbow- joint  not  admitting  of  excision,  or  in  which 
this  operation  has  failed  {see  pp.  156,  160). 

(4)  Gunshot  injuries  of  the  upper  part  of  the  forearm,  elbow,  and 
arm  not  admitting  of  conservative  treatment  or  excision. 

1  The  possibility  of  this  superficial  position  of  the  radial  or  ulnar  should  alwaj^s  be 
remembered  when  venesection,  or  Ugature  of  the  brachial,  at  the  elbow  is  about  to  be 
performed. 

2  Mr.  Heath  has  pointed  out  (Oper.  Surg.,  p.  18)  that  if  the  arm,  when  at  right 
angles  to  the  bod  v.  be  allowed  to  rest  upon  the  table  the  triceps  is  pushed  up,  and  displacing 
the  parts,  may  bring  into  view  the  inferior  profunda  and  the  ulnar  nerve  instead  of  the 
brachial  and  the  median  nerve. 

3  This  is  a  much  more  comfortable  position  than  standing  on  the  outer  side  and 
looking  over. 

*  Authorities  differ  as  to  this  step.  The  operator  is  strongly  advised  to  avail  himself  of 
this  guide.  If  it  can  be  done  carefully,  and"  the  wound  kept  aseptic  afterwards,  it  can  do 
no  harm.  The  fibres  of  the  muscle  aire  a  distinct  help,  and  (as  stated  above)  ligature  of 
this  arterv  is  not  so  easy  a  one  as  it  would  appear. 

1  This^was  so  marked  in  the  latter  of  the  two  cases  mentioned  at  p.  171,  that,  when 
the  vessel  was  exposed,  several  bystanders  felt  certain  that  it  was  not  the  brachial,  but 
one  of  its  branches. 


INFERIOR    THYROID  A:- 
THrROID     AXIS  A. 

SUPRASC/^PULAR   A. 


ACROWO-THORACIC  A 


ANTERIOR    CIRCUMFLEX  A. 
POSTERIOR  CIRCUMFLEX  A 


SUPERIOR      PROFUNDA     A.      t- 


POSTERIOR 
^SCAPULAR  A. 


DORS  A  LIS 
SCAPULAE  A. 


DESCENDING    ARTICULAR 

BRANCHES    OF 

SUPERIOR    PROFUNDA  A    ^-k 


POSTERIOR  1 

INTEROSSEOUS  I 

RECURRENT  A.        > 


RADIAL   RECURRENT  A 


POSTER. 

INTER 
P ECU PRE 


I  OP  \       \.fPt\ 

OSSEOUS  >'        I    f  liW 
lENT    A.   )  \    I  f\     \\\ 


ANASrOMOTICA     MAGNA    A. 


--{posterior    branches     of 

XANASTOHOriCy^        MAGNA     ^. 

\ {ANTERIOR      BRANCHES     OF 

"^         \ANASrOMOTICA      MAGNA     /4 . 

^  *9 


POSTERIOR       ULNAR.      RECURRENT  A. 

ANTERIOR        ULNAR       RECURRENT    A. 

POSTERIOR      ULNAR      RECURRENT   A. 


Fig.  86.     Anastomosing  branches  of  subclavian,  axillary  and  brachial  arteries. 


176       OPERATIONS  ON  THE  UPPER  EXTREMITY 

Amongst  the  special  conditions  which  will  have  to  be  considered 
here  are  the  size  and  character  of  the  projectile,  the  gravity  of  the 
laceration  of  the  soft  parts,  the  amount  of  longitudinal  splintering  of 
the  bones,  the  extent  of  lesions  to  the  vessels  and  nerves  and  the  degree 
to  which  conservative  measures  can  be  adopted  in  the  absence  of  hospital 
facilities  or  of  easy  transportation. 

If  the  surroundings  of  the  surgeon  and  patient  admit  of  it,  attempts 
will,  nowadays,  be  made  to  suture  the  nerve  ends,  especially  when  only 
one  or  two  of  the  chief  trunks  are  involved.  Reference  has  already 
been  made  to  the  infrequency  of  severe  gunshot  injuries  to  the  elbow- 
joint  in  the  South  African  War. 

It  is  noteworthy  here  that  Mr.  Makins  writes  i^ 

"  I  am  unable  to  say  what  was  the  proportional  number  of  shell  wounds  among 
the  men  hit,  but  I  can  say  with  some  confidence  that  it  was  not  as  great  as  10  per 
cent.  I  should  be  inclined  to  place  it  as  low  as  5  per  cent.  Again.  I  cannot  fix 
The  proportionate  occurrence  of  wounds  from  bullets  of  large  calibre,  such  as  the 
Martini  Henry,  but  this  was  certainly  not  large.  I  think  if  lU  per  cent,  is  deducted 
to  repiesent  the  number  of  hits  from  either  of  these  forms  of  projectiles,  that  we 
may  fairly  assume  the  remaining  90  per  cent,  of  the  wounds  to  have  been  produced 
by  bullets  of  small  calibre."  With  regard  to  treatment  of  wounded  jo'nts 
Mr.  Makins  states  (p.  235)  that  this  was  generally  simple.  "  The  old  difficulties 
of  deciding  on  partial  as  against  complete  excision  or  amputation  was  never  met 
with  by  us.  We  had  merely  to  do  our  first  dressing  with  care,  fix  the  joint  for  a 
short  period,  and  be  careful  to  commence  passive  movement  as  soon  as  the  joints 
were  properly  healed,  to  obtain  in  the  great  majority  of  cases  perfect  results.  If 
suppuration  occurred,  the  choice  between  incision  and  amputation  had  to  be  con- 
siclered.  In  the  early  stages  this  choice  depended  entirely  on  the  nature  of  the 
injury  to  the  bones.  If  this  were  slight,  incision  was  the  best  course  to  adopt.  I 
saw  several  cases  so  treated  which  did  well,  although  convalescence  was  often  pro- 
longed, and  only  a  small  amount  of  movement  was  regained.  Amputation  was 
sometimes  indicated  in  cases  of  severe  bone-splintering  when  the  shafts  were  impli- 
cated, but  as  a  rule  only  performed  after  an  ineffectual  trial  to  cut  short  general 
infection  of  the  septic:emic  type  by  incision.  I  should  add  that,  on  the  whole, 
suppuration  of  the  joints  was  uncommon,  except  in  the  case  o'  injuries  far  exceeding 
the  average  in  primary  severity."^ 

(5)  In  some  cases  of  acute  septic  infection  of  the  forearm,  when 
septicaemia  or  toxic  absorption  threatens  the  patient's  life. 

So  inestimable  is  the  value,  even  when  only  partial,  of  the  hand, 
and  so  good  are  the  results  of  conservative  treatment  and  secondary 
amputation,  that  the  tissues  must  be  almost  disorganised  for  the  surgeon 
to  think  of  primary  amputation  here. 

The  following  case  illustrates  the  power  of  recovery  after  very 
extensive  injury  to  soft  parts  : 

A  man,  set.  22,  was  admitted  into  Guy's  Hospital  in  November  1911  with  a 
large  transverse  gash  just  below  the  right  elbow-joint,  caused  by  a  fall  through  a 
glass  window.  The  severe  haemorrhage  was  checked  by  a  tourniquet  applied  at 
once  by  a  policeman,  but  on  arrival  at  the  hospital  he  was  almost  pulseless.  The 
whole  of  the  soft  structures  were  divided  down  to  the  bones,  the  elbow- joint  being 
opened  and  the  head  of  the  radius  exposed  on  the  outer  side.  All  the  superficial 
flexors  of  the  forearm  were  divided  just  below  the  internal  condyl  •,  and  also  the 
supinator  longus  and  the  tendon  of  the  biceps.  The  radial  and  ulnar  arteries 
were  divided  at  their  commencement  and  also  the  common  interosseous.  The 
median,  radial,  and  posterior  interosseous  nerves  were  severed,  the  latter,  just  at  its 
passage  through  the  supinator  brevis.  The  tendon  of  the  bicejis  and  the  muscles  were 
sutured,  though  it  was  impossible  to  identify  the  various  muscular  bellies.     The 

1  Surgicnl  Experiences  in  South  Africa,  1899-1900,  p.  11. 

-  In  the  present  war  the  proportion  of  shell  wounds  is  certainly  much  greater  than  in 
the  South  African  War.  Owing  to  the  conditions  of  trench  warfare,  too,  infection  and 
supiJuration  are  almost  certain  to  occur. 


AMPUTATION  OF  TIIK  AKM  177 

nuMlian  iiiul  radial  nerves  wore  also  identified  and  sutured,  hut  oonsideral)le  diffi- 
cuity  was  experienced  in  identifying  the  ])()steri()r  interosseous  as  it  was  liere  giving 
ofT  a  number  of  imiscular  branches.  The  injincd  arteries  were  hgatured.  Kxcept 
for  the  sloughing  of  a  large  lacerated  area  of  skin  on  the  forearm  below  the  elbow, 
the  wound  healed  well.  The  function  of  the  median  and  radial  -nerves  was  recovered 
and  there  was  good  movement,  and  sensation  in  the  fingers,  but  owing  to  the 
scarrhig  in  front  of  the  forearm,  though  this  was  minimised  as  far  as  possibh^  by  skin- 
grafting,  full  extension  of  the  elbow  was  impossible.  Owing  to  the  ])ersistence  of 
paralysis  of  the  extensors  the  posterior  interosseous  nerve  was  subsequently  exposed, 
dissected  free  from  the  scar  tissue  and  sutured. 


A.  B. 

Fig.  87.  A.  Amputation  through  shoulder  joint  by  deltoid  flap.  Amputation 
through  arm  by  long  anterior  and  short  posterior  flaps.  B.  Amputation  through 
arm  by  the  circulai-  method.     Spence's  method  of  amputating  at  the  shoulder. 

A  compound  fracture,  especially  when  comminuted  and  associated 
with  severe  laceration  of  the  soft  parts  and  division  of  the  main  vessels 
or  nerves  will  probably  require  a  primary  amputation,  though  even  in 
some  of  these  cases  conservative  treatment  may  be  tried. 

Methods.  ( 1 )  Circular.  (2)  Skin  flaps  with  circular  division  of  muscles 
— (a)  antero-posterior ;  (b)  lateral  flaps.  (3)  Antero-posterior  flaps, 
usually  cut  by  transfixion.  (4)  Skin  and  transfixion  flaps  combined. 
(5)  Single  flap. 

( 1 )  Circular  method  (Fig.  88) .  Owing  to  the  moderate  size  of  the  limb, 
its  cylindrical  shape,  and  its  single  centrally  situated  bone,  this  is  the 
place,  above  all  others,  where  this  method  can  be  employed,  especially 


SURGERY  I 


12 


178        OPERATIONS  ON  THE  UPPER  EXTREMITY 

in  limbs  which  are  not  very  bulky.  Whether  he  make  use  of  it  in  after 
life  or  not,  the  student  should  always  practise  circular  amputation  here 
on  the  dead  subject. 

Standing  on  the  outer  side  of  either  limb,  the  brachial  artery  having 
been  controlled  by  a  tourniquet  placed  as  high  as  possible,  the  surgeon 
with  his  left  hand  draws  the  skin  up  strongly  and  passes  his  knife  under 
the  arm,  then  above,  and  so  around  it,  till,  by  dropping  the  point  verti- 
cally, the  back  of  the  knife  looks  towards  him,  and  the  heel  rests  on 
the  part  of  the  arm  nearest  to  him.  A  circular  sweep  is  then  made 
round  the  limb,  the  completion  of  this  being  aided  by  the  assistant  in 
charge  of  the  limb,  who  should  rotate  it  so  as  to  make  the  tissues 
meet  the  knife.  A  cuff-like  flap  of  skin  and  fasciae  is  then  raised, 
for  about  three  inches,  with  light  touches  of  the  knife,  these  being 
especially  needed  along  the  lines  of  the  intermuscular  septa.  In  a  very 
muscular  arm  it  may  be  difficult  to  raise  the  skin  as  directed,  and  it 
will  be  sufficient  here  for  an  assistant  to  retract  it  evenly  all  round  a? 


.  Fig.  88. 

it  is  freed  by  the  knife.  When  the  skin  has  been  sufficiently  folded 
back  and  retracted  the  muscles  are  cut  through  close  to  the  reflected 
skin,  the  biceps  being  cut  rather  longer  than  the  rest,  as,  owing  to  its 
having  no  attachment  to  the  humerus,  it  retracts  more.  The  cut  muscles 
are  next  retracted  by  the  operator's  left  hand,  and  the  remaining  soft 
parts,  with  the  main  vessels  and  nerves,  are  severed  clean  and  square.^ 
The  bone  is  then  cleared  for  three-quarters  of  an  inch  and,  the  periosteum 
having  been  divided,  is  sawn  through  as  high  as  possible. 

The  modified  circular  method  (Fig.  89),  as  described  for  the  forearm 
on  p.  140,  may  also  be  employed. 

The  vessels  to  be  secured  vAW  be  the  brachial  upon  the  inner  side, 
the  superior  profunda  in  the  musculo- spiral  groove  and  the  inferior 
profunda  to  the  inner  side  of  the  brachial  close  to  the  ulnar  nerve.  The 
wound  should  be  sutured  so  that  the  resulting  scar  is  in  the  antero- 
posterior plane. 

(2)  Skin  Flaps  with  Circular  Division  of  Muscles.  This  method  should 
be  made  use  of  for  bulky  muscular  arms. 

(a)  Antero-posterior  Flaps.  The  brachial  having  been  controlled,^ 
and  the  arm  supported,  at  a  right  angle  to  the  body,  the  surgeon  stands 

^  In  an  amputation  which  passes  through  the  musculo-spiral  groove,  great  care  must 
be  taken  to  divide  completely  the  nerve  lying  in  this  before  the  bone  is  sawn.  The  depth 
of  this  groove  varies  much.  When  it  is  considerable,  the  nerve  may  easily  escape  division 
and  be  frayed  by  the  saw.  giving  rise,  if  overlooked,  to  a  most  painful  bulbous  end. 

2  In  amputation  high  up  the  application  of  a  tourniquet  may  be  impossible.  The 
axillary  must  then  be  controlled  by  clastic  tubing  as  described  on  p.  201,  or  the  subclavian 


AMPUTATION  OF  THE  ARM 


171) 


outside  the  right  and  inside  the  left  limb,  with  the  forefinger  and  thumb 
of  his  left  hand  marking  the  site  of  the  iiiteiulcd  bone-section  (Fig.  90). 
He  then  enters  the  knife  on  the  side  of  the  limb  farthest  from  him, 
carries  it  first  down  three,  three  and  a  half,  or  four  inches,  according 
as  he  is  going  to  make  this  flap  longer  than  the  other  or  not,^  next  across 


c    A 


Fig.  89.  Amputation  of  the  arm  by  the  modified  circular  method.  The  dotted 
line  rt  c  in  A  is  the  ordinary  incision  in  the  circular  method,  while  the  thick  line 
a  b  c  shows  the  modified  circular  incision.  The  skin  flaps  are  shown  in  B  as 
well  as  the  circular  division  of  the  muscles. 

Two  equal  flaps  of  skin  and  subcutaneous  tissue  are  cut,  their  lower  limit 
being,  in  the  case  of  an  ordinary  forearm,  about  1^  inches  below  the  seat  of  the 
circular  division  of  the  muscles,  and  then  again  about  Ih  inches  below  the  point 
of  section  of  the  bones.  In  the  arm  each  of  these  measurements  will  be  increased 
to  2h  inches  or  more.  After  the  flaps  are  raised,  the  muscles  are  divided  by  a 
series  of  circular  sweeps  of  the  knife.  After  each  cut  they  are  firmly  retracted 
until  the  bone  is  exposed  at  the  2:)roposed  point  of  division.  The  periosteum 
having  been  divided  circularly,  it  is  strijiped  up  with  a  rugino  along  with  the 
muscles.  Thus,  when  the  bone  has  been  sawn,  a  cap  of  periosteum  fall's  over  the 
cut  end.  The  muscles  and  periosteum  must  be  stripped  off  the  bone  together, 
not  separately.     (Cheyne  and  Burghard.) 


the  limb,  with  square  edges,  and  up  the  side  nearest  to  him,  to  the 
point  opposite  to  that  from  which  the  incision  started.  Then  passing 
the  knife  under  the  limb,  he  marks  out  a  posterior  flap,  usually  somewhat 
shorter  than  the  anterior.  These  flaps,  consisting  of  skin  and  fasciae, 
are  now  dissected  up,  the  muscles  cut  through  at  the  flap-base  with  a 

must  be  controlled  by  a  reliable  assistant,  or  the  vessels  secured  by  Spence's  method.  The 
latter  w"hich  is  described  on  p.  206,  is,  owing  to  its  simplicity  and  reliability,  strongly 
recommended. 

^  Long  anterior  and  short  posterior  flaps  are  preferable:  if  equal,  the  cicatrix  will  be 
opposite,  and  perhaps  adherent  to,  the  bone.  This  is  undesirable,  though  of  less  im- 
portance than  in  the  lower  extremity. 


180       OPERATIONS  ON  THE  UPPER  EXTREMITY 

circular  sweep,  and  the  bone  sawn  through  as  high  as  possible.  The 
biceps  should  be  cut  rather  longer  than  the  other  muscles,  and  especial 
care  should  be  taken  here  to  divide  the  nerve-trunks  cleanly  and  as 
high  as  possible.  In  tying  the  arteries  each  must  be  thoroughly 
separated  from  its  accompanying  nerve. 

(&)  Lateral  Flaps.  This  method  may  be  employed,  one  flap  being 
cut  longer  than  the  other,  when  the  skin  is  more  damaged  on  one  side. 

The  surgeon,  standing  as  before,  marks  the  site  of  bone-section  by 
placing  his  left  forefinger  and  thumb,  not  now  on  the  two  borders  ot  the 
arm,  both  on  the  middle  of  the  anterior  and  posterior  surfaces  of  the 
limb.  Looking  over,  he  enters  his  knife  at  the  latter  spot,  and  cuts 
a  well-rounded  flap,  ending  on  the  middle  of  the  anterior  aspect,  and 
then  from  this  point,  without  removing  the  knife,  another  flap  is  marked 
out  by  a  similar  incision  ending  at  the  middle  of  the  back  of  the  arm. 
The  flaps  are  then  dissected  up,  and  the  operation  completed  as  before. 

(3)  Transfixion  Flaps,  usually  antero-posterior.  In  an  arm  of 
moderate  size,  or  where  rapidity  is  required,  as  in  warfare  or  in  cases 
of  double  amputation,  this  method  may  be  made  use  of.  The  objection 
to  it  is  that  it  involves  the  removal  of  an  undue  amount  of  bone  and, 
where  the  amputation  is  high  up,  interferes  with  the  preliminary  securing 
of  the  brachial  artery  by  Spence's  method.  The  surgeon,  standing  as 
before,  and  with  his  left  hand  marking  the  flap-base,  and  lifting  up  the 
soft  parts  anterior  to  the  humerus  so  as  to  get  in  front  of  the  brachial 
vessels,  and  thus  avoid  splitting  them,  sends  his  knife  across  the  bone 
and  in  front  of  the  above  vessels,  and  makes  it  emerge  at  a  point  exactly 
opposite  ;  he  then  cuts  a  well-rounded  flap,  about  three  inches  long, 
with  a  quick  sawing  movement,  taking  care,  after  he  feels  the  muscular 
resistance  cease,  to  carry  his  knife  on  a  little,  so  as  to  cut  the  skin 
longer  than  the  muscles,  the  knife  being  finally  brought  out  quickly  and 
perpendicularly  to  the  skin.  The  flap  being  lightly  raised,  without 
forcible  retraction,  the  knife  is  passed  behind  the  bone  at  the  base  of 
the  wound  already  made,  and  a  posterior  flap  cut  similar  to  the  anterior, 
but  somewhat  shorter.  Both  flaps  are  then  retracted,  any  remaining 
muscular  fibres  divided  with  circular  sweeps  of  the  knife,  and  the  bone 
exposed  a  little  above  the  junction  of  the  flaps.  The  saw  is  then  applied 
after  careful  division  of  the  periosteum.  The  brachial  artery  will 
either  be  found  in  the  posterior  flap,  or  if,  as  both  flaps  are  made,  the 
soft  parts  are  drawn  a  little  from  the  humerus,  the  main  artery  and 
nerves  will  be  left,  and  must  be  cut  square  with  the  circular  sweeps  of 
the  knife. 

If  it  be  preferred,  lateral  flaps  can  be  made  by  transfixion,  one,  of 
course,  being  cut  longer  than  the  other  if  this  is  rendered  desirable  by 
the  condition  of  the  soft  parts. 

(4)  Combined  Skin  and  Transfixion  Flaps  (Fig.  90).  This,  a  speedy 
and  efficient  method,  may  be  made  use  of  here.  An  anterior  flap  of 
skin  and  fascia;,  about  three  inches  long,  having  been  marked  out  and 
dissected  up,  the  bulk  of  the  soft  parts  behind  the  bone  are  drawn  a 
little  away  from  it,  the  knife  passed  behind  the  humerus,  and  a  posterior 
flap,  somewhat  shorter,  cut  by  transfixion.  The  operation  is  completed 
as  described  above. 

(5)  Single  Flap.  The  condition  of  the  soft  parts  may  render  tliis  method 
advisable.  If  possible  an  anterior  flap  is  cut  by  transfixion  and  so  arranged  as 
not  to  include  the  large  nerves.  ; 


FRACTURE  OF  THE  HUMERUS  181 

In  all  cases  of  amputation  high  up  in  the  arm  some  part  of  the  inser- 
tion of  the  pectoralis  major  should  be  preserved  in  order  to  counteract 
the  tendency  to  abduction  of  the  stump. 

EXCISION  IN  CONTINUITY  OF  THE  SHAFT  OF  THE  HUMERUS 

Bv  the  term  "  excision  in  continuity,  "  deliberate  removal  of  portions 
of  the  shaft  of  the  humerus— c.r/.  two  to  six  inches — the  periosteum 
being  preserved  as  far  as  possible,  is  meant.  If  such  operations  as 
incision  and  removal  of  spHnters,  for  necrosis,  and  for  pseudo-arthrosis 
be  excluded  the  indications  are  very  few.  It  has  been  performed  for 
gunshot  injuries  and  possibly  might  be  required  for  a  localised  growth 
such  as  a  chondroma  and  in  some  cases  of  necrosis.  In  the  latter  the 
surgeon  will,  in  the  great  majority  of  cases,  wait  for  the  sequestrum 


Fig.  90. 

to  separate  and   then   remove   the   necrosed   portion   of  the   shaft   by 
sequestrotomy  {q.v.). 

With  regard  to  its  employment  for  gunshot  wounds,^  Dr.  Otis  thus 
wrote  in  1883  : 

"  I  cannot  discern  that  the  experience  of  the  war  lends  any  support  to  the 
doctrine  of  the  justifiability  of  operations  of  this  nature  except  in  very  exceptional 
cases.  The  numerical  returns,  and  the  necessarily  abbreviated  summaries,  may 
appear,  at  first  glance,  to  represent  the  results  in  a  favourable  light,  but  a  more 
precise  analysis  reveals  most  lamentable  conclusions.  .  .  .  The  mortality  rate  is 
nearly  double  that  observed  in  the  cases  treated  by  expectant  measures,  and  more 
than  12  per  cent,  higher  than  the  fatality  in  a  larger  series  of  primary  amputations  in 
the  upper  third  of  the  arm." 

Free  exposure  of  the  shalt  of  the  humerus  is  not  easy,  owing  to  the 
important  vessels  and  nerves  in  more  or  less  close  relationship  with 
it.  It  is  best  exposed  by  an  incision  commencing  in  the  interval  between 
the  deltoid  and  the  pectoralis  major  and  continued  downwards  along 
the  groove  to  the  outer  side  of  the  biceps  as  low,  if  necessary,  as  the 
level  of  the  external  condyle.  The  bone  is  reached  to  the  outer  side 
of  the  coraco-brachialis  and  the  brachialis  anticus.  Care  must  be  taken 
to  avoid  injury  to  the  circumflex  vessels  in  the  upper  part  of  the  incision, 

^  See  also  the  remarks  on  gunshot  wounds  of  the  radius  and  ulna,  p.  134. 
SURGERY    I  12' 


182        OPERATIONS  ON  THE  UPPER  EXTREMITY 

while  towards  its  lower  end  the  musculo -spiral  nerve  should  be  identified 
and  be  drawn,  together  with  the  superior  profunda  artery,  the  supinator 
longus,  and  triceps,  to  the  outer  side.  The  periosteum  should  be  care- 
fully peeled  off  the  bone  with  the  help  of  a  sharp  periosteal  elevator. 
The  requisite  quantity  of  bone  is  then  removed,  the  shaft  of  the  bone 
being  divided  by  a  fine  saw. 

Another  incision  sometimes  employed  commences,  as  described 
above,  in  the  interval  between  the  deltoid  and  the  pectoralis  major. 
Below  the  insertion  of  the  deltoid  it  is  carried  more  superficially  (so 
as  not  to  injure  the  musculo-spiral  nerve)  till  it  gets  into  the  interval 
between  the  triceps  behind  and  the  brachialis  anticus  and  supinator 
longus  in  front,  whence  it  is  carried  down  to  a  point  just  above  the 
external  condyle.  The  nerve  is  made  sure  of  by  opening  the  inter- 
muscular septum  and  drawing  the  triceps  backwards  and  the  brachialis 
anticus  forwards,  and  then  held  carefully  aside  with  an  aneurysm-needle. 
The  shaft  is  exposed  and  the  necessary  amount  of  bone  removed,  as 
described  above. 

Causes  of  Failure  after  Excision  of  the  Humerus  in  Continuity. 
Amongst  these  are  :  (1)  Osteo-myelitis  and  pyemia.  (2)  Secondary 
haemorrhage.  (3)  Secondary  necrosis.  (4)  Non-union,  leading  to  a 
limb  which  dangles  or  is  fiail-like,  and  is  more  or  less  useless  in  spite  of 
a  support. 

Operative  Treatment  of  Acute  Infective  Periostitis.  This  disease  may 
commence  either  at  the  upper  or  the  lower  epiphyseal  line.  The  pus 
collects  beneath,  and  strips  up,  the  periosteum  from  the  shaft.  Acute 
osteo-myelitis  always  occurs  at  the  same  time.  Necrosis  of  a  part  of 
the  shaft  is  an  inevitable  sequela.  In  the  acute  stage  one  or  more 
incisions,  according  to  the  extent  of  the  abscess,  must  be  made,  care 
being  taken  to  avoid  the  important  vessels  and  nerves.  The  medullary 
cavity  should  be  freely  gouged  open  in  all  cases.  No  attempt  should 
be  made  to  remove  the  necrosed  portion  of  the  bone  until  the  sequestrum 
is  separated.  This  will  occur  in  from  ten  to  twelve  weeks.  The  opera- 
tion of  sequestrotomy  is  then  required.  A  free  incision  is  made,  if 
possible,  on  the  outer  aspect  of  the  limb,  but  this  will  depend  upon  the 
situation  of  the  sinuses.  The  bone  is  exposed,  the  soft  involucrum, 
consisting  of  newly  formed  soft  periosteal  bone,  is  freely  gouged  away 
until  the  sequestrum  is  thoroughly  exposed.  This  is  removed,  and  the 
cavity,  often  of  considerable  extent,  is  washed  out  with  lot.  hydrogen 
peroxide.  A  few  stitches  are  inserted,  but  free  drainage  must  be  pro- 
vided and  the  wound  allowed  to  heal  by  granulation — a  long  and  tedious 
process.  Methods  for  filling  up  the  cavity  and  thus  hastening  the 
healing  of  the  wound  will  be  given  below.  Occasionally  the  periosteum 
of  the  entire  shaft  may  be  separated,  which  then  is  certain  to  necrose. 
Should  this  condition  be  found  the  diaphysis  should  be  removed,  but, 
unless  separation  has  occurred,  a  small  piece  of  the  shaft  adjoining 
the  epiphysis  should  be  left,  to  avoid  injuring  the  cartilage  at  the 
epiphyseal  line. 

Operative  Treatment  of  Fracture  of  the  Humerus.  This  will  be  required 
in  some  cases  when  it  is  impossible  to  get  the  fragments  into  apposition 
by  manipulation,  and  in  those  cases  where  non-union  occurs  or  where 
there  is  injury  to  the  musculo-spiral  or  other  nerves.  The  fracture  is 
best  exposed  by  a  long  vertical  incision  between  the  triceps  and  the 
brachialis  anticus  on  the  outer  aspect  of  the  arm. 


FRACTITUK  OF  THE  HUMERUS  183 

Any  inteiveiiing  portions  ol  muscle  or  fascia  are  removed,  the  frag- 
ments are  brought  into  position  by  extension  and  are  secured  by  a  plate. 
An  internal  angle  s})lint  is  applied  ;  massage  is  started  as  soon  as  the 
wound  is  healed  and  the  stitches  are  removed. 

Operation  for  Psendo-arthrosis.  A  false  joint  is  not  an  uncommon  sequela  to  a 
fracture  neai'  the  centre  of  the  shaft  of  the  huuKMiis.  Jt  probably  depends  upon 
imperfect  immobilisation.  Operative  treatment  is  always  required.  The  fracture 
is  exposed  freely  throufih  the  long  external  incision  described  above.  A  portion  of 
each  fraf^ment  nnist  be  icmoved  l)y  a  tine  saw  so  that  the  section  ])assfs  through 
healthy  bone.  The  refreshed  surfaces  are  then  brought  together  and  secured  by  a 
yjlate.  Where  there  is  much  s(>paration  this  may  be  impossible.  An  attempt  may 
then  be  made  to  till  up  this  syiace  by  bone-grafting  {vide  infra). 

In  any  of  the  above  operations,  the  treatment  of  the  periosteum 
will  be  of  \'ery  great  importance.  Professor  Oilier  warns  those  who 
would  expect  that  periosteum  methodically  detached  from  the  bone 
will  always  and  completely  reproduce  the  bone  that  it  normally  covered, 
that  they  are  under  a  dangerous  illusion.  It  can  only  be  relied  upon 
to  do  so  in  early  life  in  young  subjects,  and  when  there  has  been  no 
infective  suppuration  destructive  to  the  bone-producing  cells  and 
when  some  longitudinal  splinters  have  been  left  attached  within  the 
periosteal  sheath.  If  detached  with  a  blunt  elevator,  the  outer  elastic 
tissue  of  the  periosteum  is  alone  detached.  When  separated  w^ith  a 
knife  or  a  sharp  periosteal  elevator  or  rugine,  however,  the  inner  bone- 
forming  layer  and  attached  spicules  of  bone  are  preserved.  When  it 
is  desired  that  new  bone  should  be  developed  this  method  of  separation 
should  always  be  adopted. 

In  these,  and  in  similar  operations  on  the  other  long  bones,  a  con- 
siderable gap  in  the  continuity  of  the  shaft  resulting  in  non-union  and 
a  useless  limb,  or  a  large  cavity  in  the  bone  which  will  only  slowly  heal 
by  granulation,  may  have  to  be  treated.  The  following  methods  have 
been  employed. 

(1)  Bone- grafting.  The  bone  required  to  fill  up  the  gap  may  be 
obtained  from  the  patient  himself  by  chiselling  away  portions  of  the 
same  or  another  bone  (auto-plastic  method),  or  by  taking  portions  of 
bone  from  a  freshly  amputated  limb,  or  by  making  use  of  a  bone  taken 
from  one  of  the  lower  animals  (hetero-plastic  method).  The  former  is 
naturally  of  very  limited  use. 

Sir  W.  McEwen  ^  records  a  successful  case  in  which  a  boy  who  had  necrosis  of  the 
entire  shaft  of  the  humerus  after  acute  infective  periostitis  with  a  useless  dangling 
limb,  in  which  he  grafted  portions  of  bone  derived  from  cases  of  cuneiform  osteotomy 
of  the  tibia  between  the  widely  separated  extremities.  These  tilled  up  the  gap  to 
the  extent  of  four  and  a  quarter  inches,  the  arm  then  measuring  six  inches  in  length. 
Seven  years  afterwards  the  shaft  of  the  humerus  was  found  to  have  increased  to 
seven  and  three-quarter  inches.  The  2)atient  could  use  his  arm  for  a  great  many 
purposes — taking  his  iood,  adjusting  his  clothes,  and  in  many  games. 

Sir  A.  Lane  has  recorded  two  cases  in  which  he  restored  the  shaft 
of  the  ulna  by  grafting  bone  from  a  rabbit. 

One  case  was  that  of  a  child  with  congenital  maldevelopment  of  the  bone. 
The  ulna  consisted  of  two  separate  portions,  whose  pointed  extremities  overlapped, 
and  whose  axes  varied  considerably  in  direction.  Both  were  freely  exposed  and 
separated  from  the  adjacent  parts.  Extension  was  then  made  on  the  lower  one 
until  the  hand  was  in  normal  position.  The  femur  of  a  rabbit  was  then  split  longi- 
tudinally, and  its  halves  wired  to  the  fragments  of  the  ulna  so  as  to  bring  their 

^  Ann.  of  Surg.,  vol.  vi,  p.  .301. 
SURGERY  I  12" 


184        OPERATIONS  ON  THE  UPPER  EXTREMITY 

axes  into  the  normal  line  and  to  retain  the  lower  one  on  a  level  with  the  radius. 
The  result  was  most  satisfactory,  not  only  as  to  the  deformity,  but  also  because  of 
the  marked  and  progressive  improvement  in  the  usefulness  of  the  limb. 

The- second  case  was  that  of  a  man,  set.  19,  who  had  lost  the  shaft  of  one  ulna 
two  years  before.  Radiographic  examination  showed  the  existence  of  a  line  spicu- 
lum  between  the  two  extremities.  An  incision  exposed  the  two  ends  of  the  ulna  and 
the  spicule,  and  freed  them  from  the  adjacent  parts.  The  femur  of  a  very  large 
rabbit  was  then  securely  wired  to  the  ends  of  the  ulna.  The  resulting  limb  was 
much  stronger  than  it  was  before  the  operation.  It  is  pointed  out  that  in  such  a 
case  the  presence  of  new  bone  thrown  out  at  the  upper  extremity  of  the  ulna,  as  a 
result  of  the  original  inflammation,  and  some  ankylosis  of  joints  may  interfere  with 
a  perfect  result. 

In  the  latter  of  the  two  cases,  however,  a  sarcoma  subsequently  developed  about 
the  grafted  bone. 

As  regards  the  technique  of  the  operation  the  greatest  care  must  be 
taken  to  secure  the  most  rigid  asepsis.  The  grafts  in  the  auto-plastic 
method,  and,  unless  there  is  a  very  large  gap  to  be  filled,  in  the  hetero- 
plastic also,  must  be  broken  up  into  small  pieces  and  placed  accurately 
in  the  axis  of  the  bone.  Any  periosteum  must  be  carefully  preserved. 
Where  no  connecting  periosteum  is  present,  as  was  the  case  in  Sir  W. 
McEwen's  patient,  a  groove  must  be  made  between  the  muslces  for 
the  reception  of  the  grafts.  An  interesting  case,  quoted  from  the 
German  Surgical  Congress  Transactions,  1906,^  shows  that  a  large  graft 
may  be  employed  and  that  living  bone  is  not  essential. 

Rausch,  of  Schoneberg.  filled  a  gap  9  cm.  long  in  the  shaft  of  the  tibia,  the 
result  of  the  excision  of  a  portion  of  the  bone  for  a  myeloid  growth,  by  grafting  a 
portion  of  tibia  of  sufficient  length  taken  from  an  amputated  limb.  Before  this 
was  secured  in  its  new  position  by  ivory  pegs,  it  was  boiled  to  ensure  sterilisation. 
Nine  months  later  the  leg  was  amputated  for  reciurence  of  the  growth,  and  examina- 
tion then  showed  that  the  grafted  portion  had  firmly  united  at  each  end  and  that  it 
was  covered  by  new  periosteum. 

(2)  The  use  of  Decalcified  Bone.  This  is  sometimes  employed  for 
filling  cavities  in  bone,  such  as  are  left  after  removal  of  a  sequestrum. 
Though  occasionally  successful  the  results  are  usually  disappointing. 
This  is  owing  to  the  septic  condition  of  the  cavities,  the  foreign  sub- 
stance being  usually  disintegrated  and  discharged. 

(3)  The  Iodoform  Bone-filling  of  Moestig  and  Moorhof.  This  also  may 
be  used  for  filling  cavities  in  bone.  The  material  consists  of  :  Finely 
powdered  iodoform  60  parts,  spermaceti  oil  40  parts,  oil  of  sesam♦^ 
40  parts.  The  cavity  must  be  aseptic  and  should  be  thoroughly  dried 
preferably  by  means  of  a  hot-air  blast.  The  iodoform  wax  is  melted, 
shaken  up,  and  then  poured  into  the  cavity  which  it  completely  fills 
to  the  normal  surface  of  the  bone.  The  soft  parts  are  then  brought 
together  without  drainage  and  the  wound  completely  closed.  The 
chief  objection  to  this  method  is  that  mentioned  for  decalcified  bone, 
viz.  the  difficulty  in  ensuring  the  asepsis  of  the  cavity.  It  is  stated 
that  the  best  results  are  obtained  when  tuberculous  cavities  are  treated 
in  this  way. 


Ann.  of  Surg.,  vol.  xliv,  p.  792. 


MUSCULO-SPIRAL  NERVE 


185 


OPERATIONS  ON  THE  MUSCULO-SPIRAL  NERVE 

(Figs.  91  and  1)2) 

Owing  to  its  proximity  to  the  humerus  as  it  lies  in  the  nmscuhj- 
spiral  groove,  this  nerve  is  Uable  to  injury  in  fractures  about  the  middle 
of  the  shaft/  either  by  laceration  by  the  fractured  ends  of  the  bone  or  by 
subsequently  becoming  involved  in  the  callus.      In  either  case  operation 


Fig.  91.  A,  Deltoid.  B,  Outer  head  of  triceps.  C.  Long  head.  D,  Inner 
head.  E,  Supinator  longus  and  extensor.  C,  Radialis  longior.  F,  Latissimus 
dorsi.  a.  Superficial  branch  of  posterior  circumflex,  h.  Anastomotica.  1,  ], 
Cutaneous  branches  of  circumflex.  2,  Intercosto-humeral.  .3.  Internal 
cutaneous  of  musculo-spiral.  4,  Nerve  of  Wrisberg.  5,  Posterior  branch 
of  internal  cutaneous.  6.  External  cutaneous  branches  of  musculo-spiral. 
*  Acromion,     f  Internal  condyle.     (Godlee.) 


will  be  required.     Occasionally  the  nerve   is  divided  by  a   stab.     Mr 
Lucas  •^  has  recorded  two  such  cases. 

In  one  case,  a  lad  set.  16,  the  axillary  vein  and  superior  profunda  artery  were 
wounded,  as  well  as  the  musculo-spiral  nerve,  which  was  divided,  and  its  lower  part 
torn  and  notched.  The  damaged  part  was  cut  away  and  the  ends  united  by  catgut 
sutures.  Complete  recovery  followed,  about  three  months  after  the  injury.  The 
other  case  was  seen  two  months  after  the  injury.  The  scar  was  five  inches  from 
the  acromion,  opposite  the  insertion  of  the  deltoid,  behind  and  to  the  outer  side 
of  the  humerus.  On  laying  bare  the  nerve  it  was  found  that  there  was  a  high 
division  into  radial  and  posterior  interosseous,  the  latter  being  severed  just  after  its 
origin.  The  musculo-spiral  just  befoie  its  division,  and  the  radial  ai,  its  commence- 
ment, were  involved  in  dense  scar  tissue.  They  were  freed  from  this,  and  the  ends 
of  the  posterior  interosseous,  after  resection,  were  united  by  fine  catgut.  The  arm 
gradually  improved  with  three  months'  galvanism  and  a  complete  cure  followed. 

1  Much  interesting  information  on  this  subject  is  contained  in  a  paper  by  Dr.  Charke 
Scudder  and  Dr.  Walter  Paul  on  "  Muscular  Spiral  Paralysis  Complicating  Fracture  of 
the  Humerus."     {Ayin.  of  Surg.,  1909,  vol.  1,  p.  1118.) 

2  Guy's  Hospital  Reports,  vol.  xlvi,  p.  1. 


186       OPERATIONS  ON  THE  UPPER  EXTREMITY 


Relations  (Fig.  92).  In  the  upper  third  of  the  arm  the  nerve  runs 
vertically  downwards,  behind  the  brachial  artery,  to  the  inner  side  of 
the  humerus,  resting  upon  the  long  head  of  the  triceps.  In  the  middle 
third  it  passes  obliquely  downwards  and  outwards,  with  the  superior 
profunda  artery,  close  to  the  bone  in  the  musculo-spiral  groove,  at  first 
between  the  long  and  outer,  and  then  between  the  outer  and  inner 
heads  of  the  triceps.  In  the  lower  third  it  pierces  the  external  inter- 
muscular septum  and  passes  to  the  bend  of  the  elbow  in  front  of  the 
external  condyle,  between  the  brachialis  anticus  and  the  supinator 
longus. 

Operation.  It  will  most  frequently  have  to  be  exposed  in  its  middle 
third;  as  it  here  lies  close  to  the  bone  in  the  groove  and  is  especially 


J 


N^^^^ky  Fig.  92.     A,  Deltoid  cut  and  partlj'  turned  forwards.     B,  In- 

'  ".'Mj  fraspinatus.    C,  Teres  minor.     D,  D,  Teres  Major.     F,  F,  Outer 

■  head  of  triceps,  part  of  which  has  been  removed.     G,  Middle 

head.  H,  Inner  head  of  triceps.  I,  I,  Supinator  longus,  cut, 
and  the  upper  part  reflected.  J.  Extensor  C.  radialis  longior. 
K,  Anconeus.  L,  Common  origin  of  extensors.  M,  Brachialis 
anticus.  a.  Posterior  circumflex.  h.  Branch  of  dorsalis 
scapulae,  c.  Superior  profunda.  1,  2,  2,  Branches  of  circum- 
flex to  deltoid.  3,  Cutaneous  branches  of  circumflex.  4,  Branch  to  T.  minor. 
5,  Musculo-spiral.  G,  6,  Branches  to  outer  head  of  triceps.  7  and  8,  External 
cutaneous  branches  of  musculo-spiral.  the  former  supplying  outt-r  head  of 
triceps.  9,  Branch  to  long  head  of  triceps.  10,  10,  Branches  of  musculo- 
spiral  to  brachialis  anticus.  11,  11,  Branches  to  supinator  longus.  12,  Branch 
of  extensor  carpi  radialis  longior.     (Godlee.) 

liable  to  injury  by  fractures  in  this  situation.  An  incision,  four  inches 
in  length,  should  be  made  in  the  axis  of  the  humerus  on  the  posterior 
aspect  of  the  arm.  The  centre  of  the  incision  is  opposite  the  insertion 
of  the  deltoid.  The  posterior  border  of  the  latter  muscle  is  identified, 
and  then  on  separation  of  the  long  and  inner  heads  of  the  triceps  the 
nerve  comes  into  ^^ew.  For  free  exposure  it  is  however  necessary  to 
incise  and  separate  the  fibres  of  the  inner  head  in  the  vertical  direction. 
If  required,  the  nerve  may  be  exposed  in  its  upper  third  bj'  an  incision 
along  the  internal  bicipital  ridge  opposite  the  lower  extent  of  the 
posterior  fold  of  the  axilla.  It  will  here  be  found  resting  on  the  latis- 
simus  dorsi  behind  the  brachial  artery  close  to  the  inner  aspect  of  the 
humerus.  In  the  lower  third  it  may  be  readily  exposed  by  an  oblique 
incision  in  the  interval  between  the  supinator  longus  and  the  brachialis 
anticus.  The  median  cephalic  vein  should  be  drawn  aside  and,  on 
separation  of  the  above-mentioned  muscles,  the  nerve  comes  into  view. 


CHAPTER  IX 
OPERATIONS  ON  THE  AXILLx^  AND  THE  SHOULDER 

LIGATURE  OF  THE  AXILLARY  ARTERY  (Figs.   93-96) 

Indications.     (I)  Wound  of  the  artery.^ 

(2)  Aneurysm  of  the  brachial  high  up.  The  following  instructive 
case  2  will  repay  perusal.  It  (1)  enforces  the  importance  of  exploring 
at  once  a  wound  near  a  large  artery  that  has  bled  "  profusely  "  ;  (2)  it 
proves,  if  this  step  be  not  taken  and  a  traumatic  aneurysm  arise,  how 
much  the  old  operation  of  tying  the  vessel  above  and  below  the  aneurysm 
and  emptying  the  latter  of  clot  is  to  be  preferred  to  the  Hunterian 
method ;  ^  and  (3)  it  is  an  inter- 
esting instance  that  gangrene, 
which  is  by  no  means  unknown  in 
the  lower  limb  after  ligature  of  the 
external  iliac  {q.v.),  may  also  occur 
in  the  upper  extremity  with  its 
better  collateral  supply. 


A  man,  set.  30,  accidentally  stabbed 
himself  in  the  outer  aspect  of  the  right 
arm,  in  its  middle  third.  Profuse 
haemorrhage  followed.  The  woiuid  was 
cleansed  and  dressed  antiseptically,  and 
the  arm  was  bandaged  from  the  hand 
upwards.  The  patient  was  sent  home, 
but  at  night  severe  bleeding  again  set  in. 
This  was  aiTCsted  by  "  plugging."'  The 
following  night  haemorrhage  recurred, 
and  was  again  arrested  by  plugging.  The  Fig.  93.  Incisions  for  ligature  of  the 
wound  gradually  healed,  and,  three  weeks  first  part  of  the  axillary  artery  and  the 
later,  a   circumscribed  traumatic  aneur-  third  part  of  the  subclavian, 

ysm   of    the   brachial    artery   developed 

at  "  the  seat  of  the  original  wound,  but  on  a  higher  level."  The  aneurv'sm  increased 
rapidly,  soon  occupying  the  whole  of  the  inner  and  anterior  aspect  of  the  upper  arm, 
causing  oedema  and  loss  of  sensation  of  the  hand  and  fingers.  About  fourteen 
days  later,  pressure  having  failed,  it  was  decided  to  tie  the  axillary  artery  in  its 
third  part.     This  cured  the  aneurysm,  but  gangrene  ^  of  the  thumb,  together  with 

1  In  some  wounds  of  the  artery,  the  surrounding  parts,  e.g.  veins  and  nerves,  may  be 
so  injured,  that  the  vitaHty  of  the  hmb  is  impaired  beyond  what  ligature  and  nerve  suture 
can  do,  and  the  advisability  of  amputating  at  the  shoulder-joint  must  be  considered. 

-  Lancet.  1895,  vol.  i,  p.  92. 

3  It  is  always  invidious  to  criticise  cases,  especially  those  which  the  writer  has  not 
seen,  and  it  is  only  fair  to  the  surgeon  who  publishes  this  to  quote  his  words.  "  The 
only  alternative  would  have  been  to  open  the  aneurysm,  turn  out  the  contents,  and 
attempt  to  tie  both  ends  of  the  artery,  an  operation  fraught  with  great  danger  to  the  hmb 
and  to  the  patient  in  his  then  weakened  condition." 

*  In  this  case  the  repeated  bleeding  had  reduced  the  size  of  the  main  vessel  (as  in  the 
case  mentioned  at  p.  152)  and  its  anastomoses.     Ligature  of  the  axillary  artery,  very 

187 


188        OPERATIONS  ON  THE  UPPER  EXTREMITY 

sloughing  of  the  tendons  of  the  forefinger,  commenced  thirty  hours  afterwards. 
Amputation  of  the  tnumb  at  the  metacarpo-phalangcal  joint  was  required  later  on, 
and  the  index  finger  remained  stiff. 

More  rarely  still  :  (3)  As  a  distal  operation  for  aneurysm  of  the  sub- 
clavian. 

(4)  In  some  cases  of  axillary  aneurysm. 

(5)  For  haemorrhage  from  malignant  disease  in  the  axilla.  This  last 
is  extremely  rare,  but  a  good  instance,  and  one  showing  the  difficulties 
which  may  be  present,  was  published  by  Sir  W.  Savory.^     Injury  to 


CO^y4CO/D  PRO. 

.C£PHAiL/c  a:. 


MUSCULO- 

■CUTAHE.OUSN. 


MEDIAN  N/ 
/iX/LLARY  A 

'^JC/LLAR.Y     V.' 


BR/!CHI/JL  PLEXUS 


,-  INNER  HEAP 
OF  MEDI/tN  //. 


ULNAR    N. 


-PECTORy^JUS    MIHOR 


^LESSSR      /HT.     CUTANEOUS     N. 


Fig.  94.     Anatoiiiy  of  the  parts  concerned  in  ligature  of  the  axillary  artery. 

the  axillary  vessels  during  removal  of  the  breast  is  dealt  with  under  this 
heading. 

Results  of  injuries  from  modern  bullets  to  the  axillary  artery,-  trau- 
matic aneurysm,  varicose  aneurysm,  and  aneurysmal  varix. 

These  are  given  by  Mr.  G.  H.  Makins  :  ^ 

External  i)r{mary  hcvmnrrhage  from  the  great  vessels  of  the  limbs  or  even  of  the 
neck  proved  responsible  for  a  remarkably  small  proportion  of  the  deaths  on  the 
battlefield.  Only  one  case  of  rapid  death  due  to  bleeding  from  a  limb  artery 
was  recomited  to  Mr.  Makins.  In  this  a  wound  of  the  first  part  of  the  axillary 
artery  proved  fatal  in  the  twenty  minutes  occupied  by  the  removal  of  the  patient 
to  the  dressing  station.     With  regard  to  the  treatment  of  primary  haemorrhage 

probabh%  further  cut  off  the  blood-supply  through  one  of  the  most  important  collaterals, 
viz.  the  superior  profunda  (p.  150). 

1  Med.  Chir.  Trans.,  vol.  Ixix,  p.  157. 

2  Reference  may  be  made  to  an  interesting  cure  of  a  wound  of  the  axillary  artery  by 
a  pistol  bullet  recorded  by  Dr.  F.  W.  Murray  (Ann-  of  Sur(j.,  1909,  vol.  1,  p.  .448). 
The  first  part  of  the  artery  was  ligatured  and  the  patient  made  an  excellent  recovery. 

3  Surgical  Experiences  in  South  Africa,  1899-1900. 


LIGATURE  OF  THE  AXILLARY  ARTERY  180 

while  tlu'  roadincss  with  which  sponlanoous  cessation  of  lia'inorrliage  from  small 
calibre  wounds  was  secured  was  very  marked,  tlie  fre(|uenev  witli  which  tra\imatic 
aneurysms  of  every  variety  followed  shows  that  tlie  ultimate  result  is  in  many  such 
cases  by  no  means  satisfactory.  "  Under  the  circumstances  it  may  be  said  that  the 
classical  rule  of  ligation  at  the  j)oint  of  injury  should  never  be  disregarded.  Against 
this,  however,  certain  objections  may  be  at  on(^e  raised  ;  thus  in  many  cases  both 
artery  and  vein  need  ligature,  a  consideration  of  much  imjuntance  in  the  case  of 
such  vessels  as  the  carotid  and  femoral  arteries.  .  .  .  On  t  he  whole  it  seems  clear  that 
the  military  surgeon  must  be  guided  by  circumstances,  since  it  may  be  far  better  to 
risk  the  chances  of  recurrent  ha'morrhage  or  the  develo])ment  of  an  aneurysm  or  a 
varix,  than  those  of  gangrene  of  a  limb,  or  softening  of  the  brain.  As  a  general  rule, 
therefore,  on  the  field  or  in  a  lield-hospital,  primary  ligature  of  the  great  vessel  is 
best  reserved  for  those  cases  only  in  which  haemorrhage  persists,  while  in  those  in 
which  si>ontaneous  cessation  has  occurred,  or  in  which  bleeding  is  readily  controlled 
by  pressure,  rest  and  an  expectant  attitude  are  to  be  preferred." 

Secnndarif  hannorrhage  in  simple  wounds  by  small  calibre  bullets  was  decidedly 
rare:  in  compound  fractures,  especially  of  the  "explosive"  kind,  it  was  not  un- 
common. Lesions  of  vessels  short  of  jxnforation,  but  causing  devitalization  of  the 
walls,  perforation  by  a  sharp  spicule  of  bone,  and,  in  the  large  majority,  sepsis  and 
suppuration  were  the  chief  causes.  The  treatment  to  be  adopted  depends  on  the 
nature  of  the  case.  \Yhen  tlie  wound  is  aseptic  and  bleeding,  the  result  of  separa- 
tion of  sloughs  (this  was  found  to  be  very  tardy  in  aseptic  wounds),  local  ligature  is 
the  proper  treatment.  In  septic  cases,  on  the  other  hand,  it  is  usually  far  better  to 
amputate,  unless  the  general  state  of  the  patient  and  the  local  conditions  are 
especially  favourable.-  When  neither  amputation  nor  local  ligature  is  practicable. 
proximal  ligature  may  be  of  use.  Thus  one  case  is  given  in  w'hich  ligature  of 
the  common  carotid  was  successful  for  hemorrhage  from  an  arterial  hsematoma  in 
connection  with  the  internal  maxillary  arter^'. 

Traumntic  aneurysms.  The  experience  of  the  campaign  fully  bears  out  that  of 
the  past  as  to  the  steady  increase  of  the  number  of  aneurj^sms  from  gunshot  wounds 
in  direct  ratio  to  diminution  in  the  size  of  the  projectiles  employed.  Every  variety 
was  met  with,  and  most  frequently  of  all,  perhaps,  aneuiysmal  varices  and  varicose 
aneurysms.     The  following  are  instances  of  traumatic  aneurysms  of  this  region. 

False  traumatic  aneurysms  or  aneurj'smal  haematoma  of  the  axillaiy  artery. 
Entrance  wound  in  posterior  fold  of  axilla,  exit  one  and  a  half  inches  below  the 
junction  of  the  anterior  fold  with  the  arm.  The  man  rode  four  miles  after  being 
hit,  but  the  horse  then  fell  and  rolled  over  him  twice.  The  wound  healed,  but  the 
whole  upper  arm  was  swollen  and  discoloured,  while  an  indurated  mass  extended 
along  the  vessels  into  the  axilla.  This  was  not  obviously  distensile.  and  pulsation 
was  very  slight.  The  pulses  below  were  absent.  A  fluctuating  swelling  w-as  present 
along  the  anterior  border  of  the  deltoid.  Tactile  anaesthesia  existed  in  the  area  of 
the  median  nerve.  On  the  thirty-first  day  considerable  enlargement  was  noticed 
This,  together  w'ith  continued  rise  of  temperature,  aroused  suspicion  of  suppura- 
tion, and  an  exploratory  punctuie  was  made  by  Major  Longhead.  R.A.M.C..  after 
consultation  with  Prof.  Chiene.  Clot  escaped,  followed  by  profuse  haemorrhage. 
The  incision  was  enlarged,  while  compression  of  the  third  part  of  the  subclavian  was 
maintained,  and  an  oval  wound  half  an  inch  long  was  found  in  the  axillary  artery. 
Ligatures  were  applied  above  and  below  the  opening  between  the  converging  heads 
of  the  median  nerve.  All  the  swelling  disappeared  with  the  healing  of  the  wound, 
but  the  diminished  median  tactile  sensation  persisted.  A  somewhat  similar  case, 
but  one  of  true  traumatic  aneurysm,  treated  by  double  ligature  of  third  part  of  the 
axillary  artery,  came  under  Mr.  Jacobson's  care  in  the  spring  of  1902,  at  Guys 
Hospital.  The  patient  had  been  shot  through  the  inner  and  upper  part  of  the 
pectoral  region,  the  wound  of  exit  being  in  the  posterior  fold.  He  received  the 
wound  in  one  of  the  night  attacks  on  our  camps,  and  his  assailant  was  so  close 
that  he  killed  him  by  a  snapshot  with  his  rifle  resting  on  his  thigh.  Both  wounds 
healed  by  first  intention,  and  he  was  admitted  for  diminished  tactile  sensation 
over  the  area  of  the  musculo-spiral. 

The  radial  pulse  was  normal,  and  there  was  nothing  to  call  attention  to  the 
existence  of  an  aneurv'sm.  A  bruit  was  not,  however,  listened  for.  The  musculo- 
spiral  nerve,  which  alone  appeared  damaged,  was  explored  by  an  incision  along 
the  axillary  vessels,  with  partial  division  of  the  great  pectoral.  Xo  damage  could 
be  found  in  the  course  of  the  nerve,  but,  as  it  was  traced  upwards,  a  small  ovoid 
sac  of  a  traumatic  aneurysm  was  found  between  the  two  heads  of  the  median 
nerve.     Ligatures  were  placed  above  and  below,  the  aneurj'sm  opened,  and  some 


190       OPERATIONS  ON  THE  UPPER  EXTREMITY 

old  clot  turned  out.  Owng  to  the  intimate  association  of  the  nerve  it  seemed 
wiser  not  to  try  and  remove  the  aneurysm.  It  was  hoped  that  any  pressure  which 
the  aneurysm  might  be  making  on  the  nerve  would  gradually  diminish  with  the 
shrinking  of  the  ojiened  sac.  This,  however,  was  not  reahzed.  When  the  patient 
left  the  hospital  there  was  no  evidence  of  recovery  of  the  diminished  tactile  sensation 
over  the  musculo-spiral  area.  A  very  similar  case  is  given  by  Mr.  Makins.^  The 
Mauser  bullet  entered  two  and  a  half  inches  below  the  acromial  end  of  the  right 
clavicle,  and  emerged  over  the  ninth  rib  in  the  posterior  axillary  line. 

Three' weeks  later  the  wound  being  healed,  a  large  pulsating  hajmatoma  was 
noted  in  the  axilla.  Signs  of  injury  to  the  musculo-spiral  were  also  observed.  The 
swelling  altering  little,  Major  Burton,  R.A.M.C,  cut  down  upon  it  through  the 
pectorals  a  fortnight  later.  The  aneurysm  was  of  the  third  jiart  of  the  axillary,  and 
a  ligatiu-e  was  applied  at  the  lower  margin  of  the  pectoralis  minor.  The  wound 
healed  by  primary  union,  and  when  the  man  left  for  England  a  month  later,  the 
musculo-spiral  paralysis  was  improving. 

Aneurysmal  Varix  and  Varicose  Aneurysm.  The  frequency  with  which  these 
occuri  ed  and  the  larger  proportion  of  the  latter  has  already  been  alluded  to.  With 
regard  to  treatment  Mr.  Makins  (p.  145)  warns  us  that  "  while  modern  surgery  has 
lightened  the  difficulties  under  which  our  predecessors  approached  these  operations, 
none  the  less  the  experience  of  this  campaign  fully  supports  the  objection  to  indis- 
criminate and  ill-timed  surgical  interference,  as  accidents  have  followed  both  direct 
local  and  proximal  ligature."  ThefollowingareMr.Makins's  chief  conclusions:  (1)  In 
aneurysmal  varix  there  should  be  no  interference  in  the  early  stage,  in  the  absence  of 
symptoms.  "  In  many  cases  an  expectant  attitude  may  lead  to  the  conviction  that 
no  interference  is  necessary,  especially  in  certain  situations  where  the  danger  of 
gangrene  has  been  fully  demonstrated.  In  connection  with  this  subject  Mr.  Makins 
relates  two  cases  in  which  an  aneurj^smal  varix,  in  one  patient  of  the  femoral  vessels, 
in  the  other  of  the  axillary,  had  existed  for  years,  and  had  not  interfered  with  the 
patient "s  work.  In  the  second  case,  after  twenty  years'  existence  of  the  varix,  the 
patient  as  a  combatant  in  South  Africa  was  subjected  to  very  hard  manual  work. 
This  brought  about  increase  in  size,  cervico-brachial  neuralgia,  &c.,  and  in  con- 
sequence, the  man  was  invalided.  (2)  The  arteries  of  the  upper  extremity  are  the 
most  suitable  for  operation,  and  the  axillary  may,  perhaps,  be  the  vessel  in  which 
interference  is  most  likely  to  be  useful.  The  vessels  of  the  arm  and  forearm  may  in 
almost  all  cases  be  interfered  with,  but  in  many  instances  the  absence  of  any  serious 
symptoms  renders  operation  unnecessary.  (3)  The  operation  most  in  favour 
consists  in  ligature  of  ihe  artery  above  and  below  the  varix,  the  vein  remaining  un- 
touched. .  .  .  Failure  is  due  to  the  presence  of  collateral  branches,  which  are 
not  easy  of  detection.  Even  when  the  vessels  lie  exposed,  the  even  distribution 
of  the  thrill  renders  determination  of  the  exact  point  of  communication  difficult,  and 
the  difficulty  is  augmented  bj^  the  t-  mporary  arrest  of  the  thrill  following  the  applica- 
tion of  a  proximal  ligature.  ...  If  the  vein  cannot  be  spared,  excision  of  a  limited 
part  of  both  vessels  may  be  preferable,  especially  in  those  of  the  upper  extremity." 
Single  ligature  or  proximal  ligature  is  useless  in  aneurysmal  varix.  (4)  "  Given 
suitable  surroundings  and  certain  diagnosis,  the  ideal  treatment  of  this  condition, 
as  of  the  next,  is  preventive — i.e.  primary  ligature  of  the  wounded  artery.  Many 
difficulties,  however,  lie  in  the  way  of  this  beyond  mere  unsatisfactory  surroundings 
It  suffices  to  mention  the  two  chief  :  uncertainty  as  to  the  vessel  wounded,  and  the 
necessity  of  always  ligaturing  the  vein  as  well  as  the  artery  in  a  limb  often  dis- 
sected up  by  extravasated  blood,  to  show  that  this  will  never  be  resorted  to  as  a 
routine  treatment." 

(5)  Arterio-venous  aneurysm.  Many  of  the  above  remarks  find  equal  application 
here,  but  in  the  presence  of  an  aneurysmal  sac  non-intervention  is  rarely  possible 
or  advisable.  .  ..  In  the  early  stages  the  proper  treatment  in  any  ca.se  consists  in  as 
complete  a  position  of  rest  as  possible,  and  affording  local  support  to  a  limb  by  a 
splint,  preferably  a  removable  jilaster  of  Paris  case.  Should  no  further  extension,  or 
what  is  more  likely,  should  contraction  and  diminution  occur,  it  will  be  well  to 
continue  this  treatment  for  some  weeks  at  least.  When  the  aneurysm  has  reached 
a  quiescent  stage,  the  question  of  further  treatment  arises,  and  whether  this  should 
consist  in  local  interference  or  proximal  ligature.  ...  In  the  case  of  arterio-venous 
aneurysms  in  the  limbs  the  possibilities  of  treatment  are  enlarged,  and  here  the 
alternatives  of  («)  local  interference  with  the  sac  and  direct  ligature  of  the  wounded 
point  ;  (6)  simple  ligature  above  and  below  the  sac  ;  (c)  proximal  ligature  (Hunterian 
operation)  present  themselves. 

^  Loc.  supra  ciL,  p.  129. 


LIGATURE  OF  THE  AXILLARY  ARTERY  191 

Mr.  Makins's  opinion  is  strongly  "  to  the  effect  that  none  of  these  operations 
should  be  undertaken  before  a  period  of  from  two  to  three  months  after  the  injury, 
unless  there  is  evidence  of  progressive  enlargement.  In  every  case  which  came 
under  my  own  observation,  ])rogressive  contraction  and  consolidation  took  place 
up  to  a  certain  point  luider  the  influence  of  rest.  When  this  process  has  become 
stationary,  and  the  surroiniding  tissues  have  regained  to  a  great  extent  their  normal 
condition,  the  operations  are  far  easier,  and  beyond  this  more  likely  to  be  followed 
by  success." 

Writing  five  years  later  in  a  paper,  in  which  a  later  history  of  several 
of  his  cases  of  arterio- venous  aneurysm  are  given,  Mr.  Makins,  speaking 
of  operative  treatment  generally,  says  :  "  A  ligature  placed  as  near  as 
possible  above  the  aneurysmal  sac  has  been  shown  to  be  safe,  to  afford 
a  reasonable  prospect  of  cure,  and  not  to  prejudice  a  further  operation, 
should  this  become  necessary."  And  with  more  especial  reference  to 
the  arteries  of  the  upper  extremity,  the  same  authority  writes  :  "  My 
personal  experience  of  published  cases  shows  that  a  proximal  ligature 
may  with  safety  and  a  good  chance  of  success  be  applied  to  the  vessels 
above  the  elbow,  and  for  wounds  at  the  elbow  itself,  this  procedure  is 
to  be  generally  preferred.  In  the  midarm  a  local  operation  is  simple, 
and  in  the  forearm  the  same  may  be  said.  In  either  of  the  latter  situa- 
tions a  local  is  to  be  preferred  to  a  proximal  operation,  as  more  nearly 
approaching  the  ideal  and  necessitating  no  obvious  risks." 

LIGATURE  OF  THE  FIRST  PART 

Collateral  circulation  (Fig.  86).  (a)  If  the  artery  be  tied  in  its 
first  part,  and  the  ligature  be  placed  above  the  acromio-thoracic,  the 
vessels  concerned  will  be  the  same  as  those  which  carry  on  the  blood- 
supply  after  ligature  of  the  third  part  of  the  subclavian  {q.v.). 

(b)  If  the  artery  be  tied  in  its  third  part,  and  the  ligature  be  placed 
below  the  circumflex  arteries,  the  anastomosing  vessel  will  be  the  same 
as  after  ligature  of  the  brachial  above  the  superior  profunda  {see  p.  173). 

(c)  If  the  artery  be  tied  in  its  third  part,  and  the  ligature  be  placed 
between  the  subscapular  and  the  circumflex  arteries,  the  chief  vessels 
concerned  are  : 

Above  Beloiv 

The  supra-scapular  ^^j^         ^^^^  posterior  circumflex. 

i  he  acromio-thoracic  ^ 

(d)  If  in  tying  the  third  part  of  the  artery  the  ligature  be  placed 
above  the  subscapular,  the  anastomoses  are  more  numerous,  viz.  in 
addition  to  those  just  given  : 

Above  Below 

The  supra-scapular  ^.^^        rj,^^  subscapular, 

ihe  posterior  scapular 

Operations.  Ligature  of  the  first  and  the  third  parts  of  the  artery 
will  be  first  described,  and  then  the  old  operation. 

(1)  Ligature  of  the  first  part  (Figs.  93  and  94).  This  operation  is 
very  rarely  performed  on  the  living  subject.  Owing  to  the  depth  of 
the  vessel  here,  its  most  important  and  intimate  surroundings,  and  the 
risk  of  secondary  haemorrhage  from  the  vessels  which  lie  so  close  to 
the  knot,  ligature  of  the  third  part  of  the  subclavian  is  preferred  if 
ligature  be  required  for  axillary  aneurysm.     On  the  dead  subject  the 


192        OPERATIONS  OX  THE  UPPER  EXTREMITY 

student  should  always  take  the  opportunity  of  tying  the  first  part  of 
the  axillary,  as  it  is  an  excellent  test  of  anatomical  knowledge  and  skill. 
Line.     From  the  centre  of  the  clavicle  (with  the  arm  drawn  from 
the  side)  to  the  inner  margin  of  the  coraco-brachialis. 

Guide.     The  above  line,  the  coracoid  process,  and  the  inner  margin 
of  the  coraco-brachialis. 
Relations. 

In  Front 
Skin ;    fasciae ;    fibres  of  platysma.     Supra- 

cla\'icular  nerve. 
Pectoralis  major  with   the   external  anterior 

thoracic  nerve. 
Costo-coracoid  membrane. 
Cephalic  vein. 
Acromio-thoracic  vessels. 
Ouiside  Inside 

Outer  and  inner  cords  of         Axillary  artery      Axillary  vein, 
brachial  plexus.  first  part. 

Beh  ind 
First  digitation  of  serratus  magnus. 
First  intercostal  space  and  muscle. 
Posterior  thoracic  nerve. 
Operation.     The  vessel  may  be  secured  in  the  following  ways  : 

A.  Bij  a  curved  incision  beloiv  the  clavicle.  This  gives  the  necessary 
room,  but  has  the  disadvantage  of  dividing  the  pectoralis  major  and 
its  large  muscular  nerve. 

B.  By  an  incision  in  the  interval  between  the  fectoralis  major  and 
deltoid.  This  method  scarcely  gives  room,  especially  if  the  parts  are 
displaced  by  effused  blood,  &c.,  and  it  is  well  to  supplement  the  incision 
in  the  interval  by  one  partly  detaching  the  pectoralis  from  the  cla\ncle. 
While  this  plan  involves  less  haemorrhage  from  the  pectoralis  major, 
care  must  be  taken  to  avoid  the  cephalic  vein  and  acromio-thoracic 
branches  which  lie  in  this  interval.  This  end  is  best  secured,  whichever 
method  be  adopted,  by  going  down  on  the  artery  as  close  to  the 
cla\acle  as  possible,  the  sheath  of  the  subclavian  being  opened,  and 
some  of  its  fibres  detached,  if  needful. 

C  By  an  incision  in  the  line  of  the  artery,  viz.  one  three  and  a  halj 
to  four  inches  long,  starting  from  just  outside  the  centre  of  the  clavicle  and 
fussing  dmvmvards  and  outwards.  This  has  the  disadvantage  of  cutting 
the  muscular  branches  to  the  pectoralis  major,  and  gives  less  space 
than  the  first  two. 

A.  The  limb  being  at  first  abducted,  the  surgeon,  standing  between 
it  and  the  body,  which  is  brought  to  the  edge  of  the  table,  makes  a 
curved  incision,  with  its  convexity  downwards  and  about  half  an  inch 
from  the  clavicle,  reaching  from  just  outside  the  sterno-cla\acular  joint 
to  the  coracoid  process,  the  knife  being  used  lightly  at  the  outer  end 
of  the  incision,  so  as  to  avoid  wounding  the  cephalic  vein  and  branches 
of  the  acromic-thoracic  vessels.  The  cla\acular  origin  of  the  pectoralis 
major  is  then  di\'ided  in  the  whole  extent  of  the  wound,  and  any  muscular 
branches  which  require  it  tied  or  twisted  at  once.  The  arm  should 
now  be  brought  down  to  the  side  to  relax  the  parts.  The  cellular  tissue 
beneath  the  muscle  being  next  explored  \nth  the  tip  of  the  finger  and 


TJGATITRK  OF  THE  AXILLARY  ARTEUY 


193 


lUrector,  the  upper  border  of  the  pectoralis  minor  is  defined,  and  this 
imisck^  drawn  downwards.  'JMie  costo-coracoid  niendjrane  must  next 
be  most  carefully  divided  in  the  vertical  direction,  the  acromio-thoracic 
vessels  and  the  cephalic  vein  being  most  scrupulously  avoided.  Tiie 
latter  forms  a  useful  guide  to  the  position  of  the  axillary  vein.  The 
wound  all  this  time  must  be  kept  dry,  and,  if  needful,  a  large  laryngeal 
mirror  or  an  electric  head  lamp  may  be  usefully  employed  in  throwing 
light  into  the  bottom  of  tiie  deep  wound.      The  pulsation  of  the  artery 


CORDS     OF  BRACHIAL      PLEXUS 

H.  TO    PE.CTORALIS    M'AJOR. 


PFXTORALIS       t^AJOP 
_     \-    SUBCLAI^IUS 


~AXILLAR.Y  A. 


CEPHALIC    y. 


CORA  CO  ID      PRO. 


AXILL-APY    V. 


^CUT    EDGE    OF 
COSTO-  CORACOID 

MEMBRANE 


Fig.  95.     Ligature  of  the  first  part  of  the  right  axillary  artery. 

being  felt  for  in  the  living,  and  its  flattened  cord- like  feel  made  out  in  the 
dead  subject,  the  sheath  is  exposed,  and  the  vessel  itself  carefully  cleaned 
and  separated  from  the  vein,  which  lies  below  and  in  front,  and  from 
the  brachial  cords,  which  are  above  the  artery.  The  needle  should  be 
passed  from  below  so  as  to  avoid  the  vein. 

B.  By  an  incision  made  between  the  pectoralis  major  and  the 
deltoid.  The  limb  and  the  surgeon  being  in  the  same  position  as  in 
the  operation  just  given,  an  incision  is  made  obliquely  downwards  and 
outwards  between  the  above  muscles,  commencing  at  the  clavicle 
opposite  to  the  coracoid  process.  Care  being  taken  to  avoid  the  cephalic 
vein  and  branches  of  the  acromio-thoracic  vessels,  the  muscles  are 
separated  and,  to  gain  more  room,  a  transverse  incision  is  made  running 
inwards  along  the  lower  border  of  the  clavicle,  and  detaching  as  much 
as  is  required  of  the  clavicular  origin  of  the  pectoralis  major.  This 
flap  can  be  turned  inwards  and  downwards  without  any  interference 
with  the  nerve- supply  of  the  muscle,  and,  owing  to  its  division  high 
up,  less  hgemorrhage  is  met  w^ith  by  this  method.  The  deltoid  being 
strongly  drawn  outwards  with  a  retractor,  the  upper  border  of  the 
pectoralis  minor  is  defined,  and  the  operation  completed  as  in  the 
account  already  given,  the  parts  being  relaxed  at  this  stage  by  abduction 
of  the  arm. 


SURGERY  I 


13 


194        OPERATIONS  ON  THE  UPPER  EXTREMITY 


(1)  Ligature  of  the  third  part  o£  the  axillary  artery  (Fig.  96).  Line. 
From  the  centre  of  the  clavicle,  with  the  arm  in  the  abducted  position, 
to  the  inner  margin  of  the  coraco-brachialis. 

Guide.  (1)  The  above  line.  (2)  A  line  drawn  from  the  junction 
of  the  middle  and  anterior  thirds  of  the  axilla,  along  the  inner  border 
of  the  coraco-brachialis. 


C  OR/i  CO-  BRA  CHMUi 
,^  MED  IAN  N. 


AX/LLAHy  A.  ^ 
-/NT.     CUTANEOUS  n} 

ULNAR     N. 


l£:SS£R    /A'; 


TANEOUS  N. 


AXILLARY 


Fig.  96.     Ligature  of  third  part  of  the  left  axillary  artery. 


Relations. 

In  Front 
Skin  ;  fasciae. 
Pectoralis  major  (at  first). 

Outside 

Musculo-cutaneous,  median.  Axillary 

Inner  border  of  artery 

coraco-brachialis.  third  part 

Behind 
Subscapularis.  Latissimus  dorsi. 

Circumflex  nerve. 


Inside 
Internal  cutaneous  ;  ulnar. 
Axillary  vein  or  vense 
comites. 


Teres  major. 
Musculo-spiral. 

somewhat    that    for    ligature 
As  with  the  brachial,  so  with 


Operation  (Fig.  96).  This  resembles 
of  the  brachial  in  the  middle  of  the  arm. 
the  axillary  here  ;  though  the  vessel  is  comparatively  superficial,  it  is 
not  an  easy  one  to  hit  off  at  once,  owing  to  the  numerous  surrounding 
nerves,  which  may  resemble  the  artery  closely,  especially  if  blood- 
stained.     The   axilla    having   been   shaved   and   thoroughly  cleansed. 


LIGATURE  OF  THE  AXILLARY  ARTERY  195 

the  arm  being  extended  from  the  side  and  rotated  sHghtly  outwards 
(not  too  forcibly,  as  this  will  alter  the  relations),  the  surgeon,  sitting 
between  the  limb  and  the  trunk,  makes  an  incision  three  inches  long 
at  the  junction  of  the  anterior  and  middle  thirds  of  the  space  along 
the  inner  border  of  the  coraco-brachialis  (Fig.  9G).  The  incision  may 
be  begun  above  or  below,  as  is  most  convenient.  Skin  and  fascia)  being 
divided,  and  the  point  of  a  director  used  more  deeply,  the  coraco- 
brachialis  is  identified,  and  the  axillary  vein  and  the  median  nerve  are 
distinguished  from  the  artery,  the  former  drawn  inwards,  and  the  latter, 
together  with  the  coraco-brachialis,  outwards.^  The  artery  is  then  clearly 
defined,  the  sheath  opened,  and  the  needle  passed  from  within  outwards, 
the  neighbourhood  of  any  large  branch,  such  as  the  subscapular  or  the 
circumflex,  being  avoided,  and  the  needle  being  kept  very  close  to  the 
artery.  Instead  of  one  axillary  vein,  two  venae  comites  and  the  basilic 
as  well  may  bo  present. 

(3)  "  Old  "  operation  of  ligature  of  the  axillary  artery  ("  OperatioD 
of  Antyllus  ")  for  some  cases  of  axillary  aneurysm  and  injured  axillary 
artery.  This  method  may  be  called  for  (1)  in  the  following  cases  of 
spontaneous  aneurysm  (a)  when  pressure  is  considered  undesirable 
or  has  failed,  (6)  when,  owing  to  displacement  of  the  clavicle,  ligature 
of  the  subclavian  is  not  practicable ;  (c)  when  the  condition  of  the 
coverings  of  the  aneurysm  is  such  that  this  step,  even  if  carried  out, 
will  not  avert  suppuration,  sloughing,  &c.  Professor  Syme"^  quotes 
the  following  case,  in  which  this  method  was  employed. 

"  I  made  an  incision  along  the  outer  edge  of  the  sterno-mastoid  through  the 
platysma  myoides  and  fascia  of  the  neck,  so  as  to  allow  a  finger  to  be  pushed  down 
to  the  situation  where  the  subclavian  lies  upon  the  first  rib.  I  then  opened  the 
tumour,  where  a  tremendous  gush  of  blood  showed  that  the  artery  was  not  effectually 
compressed  ;  but  while  I  plugged  the  aperture  with  my  hand,  Mr.  Lister,  who 
assisted  me,  by  a  slight  movement  of  his  finger,  which  had  been  thrust  deeply  under 
the  upper  edge  of  the  tumour  and  through  the  clots  contained  in  it,  at  length  suc- 
ceeded in  getting  command  of  the  vessel.  I  then  laid  the  cavity  freely  open,  and 
with  both  hands  scooped  out  nearly  seven  pounds  of  coagulated  blood.  The  axillary 
artery  appeared  to  have  been  torn  across,and  as  the  lower  orifice  still  bled  profusely, 
I  tied  it  in  the  first  instance,  next  cut  through  the  lesser  pectoral  muscle  close  up  to  the 
clavicle,  and,  holding  the  upper  end  of  the  vessel  between  my  finger  and  thumb, 
passed  an  aneurysm-needle  so  as  to  apply  a  ligatiure  about  half  an  inch  above  the 
orifice.  The  extreme  elevation  of  the  clavicle,  which  rendered  the  artery  so  in- 
accessible from  above,  of  course  facilitated  this  procedure  from  below.  Every- 
thing went  on  favom-ably  afterwards." 

(2)  In  many  cases  of  traumatic  aneurysm  and  injury  of  the  artery. 

Lieutenant-Colonel  Sylvester  ^  collected  five  cases  of  injury  to  the  axillary 
artery  followed  by  traumatic  aneurysm,  treated  in  this  way,  all  of  which  recovered. 
The  following  is  a  good  example.  Wounded  at  Elandslaagte.  Seen  at  Wynberg 
fourteen  days  later.  Anterior-posterior  wound  (Mauser)  at  upper  end  of  humerus, 
bone  not  damaged  ;  no  severe  haemorrhage  at  time  of  woimd.  Diffuse  aneurysm, 
occupying  axillary  space,  suddenly  formed  on  twelfth  day,  and  anterior  wound 
began  to  ooze  blood.     An  incision  was  made  over  line  of  vessel,  large  quantity  of 

*■  Earabeuf  {loc.  supra  cit,  p.  44)  gives  the  following  directions  for  making  sure  of  the 
artery.  Make  an  incision  running  just  behind  the  anterior  wall  of  the  axilla.  Identify 
the  coraco-brachialis  by  opening  its  sheath.  Draw  it  outwards,  and  with  the  finger  of  the 
left  hand  sunk  in  the  wound,  depress  the  whole  bundle  of  vessels  and  nerves.  The  first 
cord  which  escapes  upwards,  when  the  finger  is  withdrawn  a  little,  is  free,  perforating  no 
muscles  :  this  is  the  median.  Isolate  it  and  have  it  drawn  outwards  with  the  coraco- 
brachiahs.     The  second  large  cord,  uncovered  by  withdrawing  the  first,  is  the  artery. 

2  Observations  in  Clin.  Surg.,  p.  148. 

^  Bept.  on  Surg.  Cases  in  the  South  African  War. 

SURGERY  I  13 


196        OPERATIONS  ON  THE  UPPER  EXTREMITY 

clot  turned  out,  and  wound  found  in  third  part  of  axillary  artery.  The  outer  coats 
of  the  vessel  had  been  grazed  for  the  space  of  an  inch,  and  the  artery  had  given 
wa^^  in  the  middle  of  tliis.  Vessel  ligatured  above  and  below,  and  divided  between. 
Uninterrupted  recovery. 

Sir  J.  Paget  and  Mr.  Callender^  made  a  — |-shaped  incision,  cutting 
parallel  with  the  lower  margin  of  the  pectoralis  major,  and  a  second, 
at  right  angles  to  the  first,  straight  up  through  the  whole  width  of  the 
pectoralis  major. 

Mention  may  also  be  made  here  of  that  most  important  accident 
which  has  happened  to  so  many  surgeons,  viz.  rupture  of  the  axillary 
artery  while  dislocations  of  the  shoulder  are  being  reduced. 

K(irte,  of  Berlin,-  is  of  opinion  that  in  many  cases  the  injury  to  the  artery  is 
caused  at  the  time  of  the  accident,  but  htemorrhage  does  not  come  on  till  after  reduc- 
tion is  brought  about,  as  the  vessel  is  compressed  by  the  head  of  the  bone.  As  to  the 
exact  cause  of  the  injury  to  the  vessel  when  it  takes  place  at  the  time  of  the  reduction, 
it  is  probable  that  some  condition  exists  to  account  for  it,  e.g.  atheroma  ;  adhesion  of 
the  artery  to  the  head  of  the  bone  ;  too  great  or  misapplied  force  in  reduction,  viz. 
use  of  the  boot  in  elevation  ;  projection  of  a  fragment  or  a  spicule  of  bone.  It  is 
usually  the  axiUary  artery,  or  one  of  its  branches,  which  gives  way  ;  much  more 
rarely  (four  out  of  forty-four  cases,  the  axillary  vein. 

The  following  case,  under  the  care  of  Dr.  N.  Raw,  of  Liverpool,^ 
teaches  a  point  which  may  be  most  valuable  in  the  treatment  of  these 
rare  but  very  grave  cases,  viz.  putting  a  temporary  ligature  round  the 
axillary  artery  until  it  is  certain  whether  both  this  and  the  vein  have 
given  way. 

The  patient  was  aged  45,  and,  five  weeks  after  a  dislocation  of  the  humerus  had 
been  reduced,  a  surgeon  had  manij^ulated  the  arm  with  his  heel  in  the  axilla.  The 
arm  began  to  swell  the  same  night.  There  was  slight  pulsation  in  both  radial  and 
ulnar  arteries.  As  the  accumulation  of  symptoms  had  been  gradual,  rupture  of  the 
axillary  vein  was  diagnosed.  The  swelling  increased,  and  burst  with  serious  loss 
of  blood.  An  incision  was  made  from  the  clavicle  to  the  anterior  fold  of  the  axilla, 
dividing  the  pectoral  muscles.  The  axillary  vessels  were  ligatured  under  the 
clavicle,  the  artery  with  a  temporary  ligature.  The  incision  was  then  prolonged 
through  to  the  axilla,  down  the  inner  side  of  the  arm  to  the  elbow,  and  several  pounds 
of  clot  turned  out.  The  axillary  vein  was  found  torn  completely  across,  and  was 
tied  at  both  ends  ;  arterial  blood  was  seen  to  be  flowing,  and  the  subscapular  artery 
was  found  cut  across  about  one  inch  from  the  main  trunk,  and  tied.  The  temporary 
ligature  was  then  removed  from  the  first  part  of  the  axillary  arteiy,  and  followed 
by  redness  and  warmth  in  the  limb,  but  no  pulsation  in  the  radial  artery.  The 
patient  made  an  excellent  recovery,  and,  six  months  later,  had  a  fairly  useful  limb. 

Treatment  should  be  on  the  lines  indicated  above,  though  in  some 
cases,  especially  in  elderly  patients,  disarticulation  at  the  shoulder 
joint  may  be  called  for. 

AMPUTATION  AT  THE  SHOULDER-JOINT 

Indications.  (1)  Compound  comminuted  fractures,  e.g.  railway  and 
machinery  accidents. 

(2)  Gunshot  injuries.  Amputation  here  is  divided  by  Dr.  Otis  ^  into 
(1)  primary,  or  before  the  third  day  ;  (2)  intermediate,  or  cases  in  which 
the  operation  was  performed  between  the  third  and  the  thirtieth  days  ; 
and  (3)  secondary,  in  which  the  operation  was  performed  later  than  the 
thirtieth  day. 

^  St.  Bartholomew's  Hasp.  Repyrtx,  vol.  ii. 

2  Arch.f.  Uin.  Chir.,  Bd.  xxvii.  Heft  .3. 

3  Liverpool  Med.  Chir.Journ.,  July  1899,  p.  328. 

4  Med.  and  Surg.  Hist,  of  the  War  of  the  Rebellion,  pt.  ii,  p.  613. 


AMPl  TATION  AT  THE  SIIOULDKR-JOINT         197 

(1)  Primary.  The  indications  for  amputation  so  soon  after  the  injury  are  chiefly : 
(a)  a  limb  torn  ofl  partially,  but  too  high  to  admit  of  any  other  amputation  ; 
{b)  Severe  comminuted  fracture  of  the  upper  end  of  the  humerus,  with  extensive 
injury  to  the  vessels  and  nerves  ;  (c)  Such  a  fracture  high  up,  with  severe  splintering 
extending  down  below  the  insertions  of  the  pectoralis  major  and  the  latissimus  dorsi.^ 

(2)  Intermediate.  The  mortality  here  was  nearly  double  that  of  the  primary.  This 
seems  to  have  been  brought  about  largely  by  the  fact  that  the  operation  was  now 
])erformed  through  soft  parts,  the  seat,  at  this  time,  of  unhealthy  inflammation, 
and  thus  prone  to  lead  to  secondary  hannorrhage,  pyaemia,  sloughing,  &c. 

(."?)  Secondary.  The  causes  for  this  deferred  operation  were  chiefly  ha-morrhage, 
gangrene,  profuse  suppuration,  hopeless  disease  of  the  humerus,  sometimes  with 
cohsecutive  implication  of  the  joint,  chronic  osteo-myelitis,  or  necrosis  of  the  entire 
humerus. 

(3)  Neiv  groivths.  If  these  involve  the  scapula  or  its  processes  the 
upper  extremity  should  be  removed  by  the  method  of  interscapulo- 
thoracic  amputation  {see  pp.  234-239).  The  question  of  the  possibility 
of  saving  the  limb  and  removing  the  growth  by  excision  of  the  head  of 
the  humerus  is  considered  at  p.  214. 

(4)  Disease  of  the  shoulder- joint  unsuited  for,  or  persisting  after 
failure  of,  excision. 

(5)  For  osteo-myelitis  and  necrosis  of  humerus  resisting  other  treatment 
or  complicated  with  early  blood-poisoning. 

(6)  For  rapidly  spreading  gangrene  or  gangrenous  cellulitis  with 
threatening  septicaemia. 

(7)  For  removal  of  the  upper  extremity  when  painful,  oedematous, 
and  heavy  owing  to  pressure  on  the  axillary  veins  and  brachhial  plexus 
by  recurrent  carcinoma.  Here  removal  of  the  upper  extremity  by 
M.  Paul  Berger's  method  {see  p.  234)  is  to  be  preferred.  For  the  advis- 
ability of  such  operations  see  "  Removal  of  the  Breast." 

(8)  Amputation  at  the  shoulder- joint  may  be  called  for  in  the  following 
cases  of  aneurysm  : 

A.  In  some  cases  of  subclavian  aneurysm  where  other  means  have  failed  or  are 
impracticable  ;  where  the  aneurysm  is  rapidly  increasing  ;  where  the  pain  is  con- 
stant and  agonising  ;  and  where  the  limb  is  threatening  to  become  gangrenous. 
While  the  principle  of  this  operation  appears  to  be  physiologically  sound,  i.e.  to 
enable  distal  ligature  to  be  performed  on  the  face  of  the  stump,  and  that,  by  removal 
of  the  limb,  the  amount  of  blood  passing  through  the  aneurysm  may  be  diminished — 
the  results  hitherto  have  not  been  very  successful. 

Thus,  in  Prof.  Spence's  case^  a  man,  aged  33,  with  a  subclavian  aneurysm, 
probably  encroaching  on  the  second,  if  not  the  first,  part  of  the  artery,  with  ex- 
cruciating pain  and  threatening  gangrene,  amputation  at  the  shoulder- joint  was 
followed  by  diminution  in  the  pulsation  and  size  of  the  sac,  but  with  little  formation 
of  coagula.  Death  took  place  four  years  afterwards,  probably  froni  extension 
of  the  aneurysm  to  the  imiominate  and  aorta.  In  this  case  the  operation,  though 
it  had  but  little  effect  in  consolidating  the  sac,  undoubtedly  prolonged  life,  as 
gangrene  was  threatening,  and  the  second  part  of  the  artery  was  almost  certainly 
affected,  thus  rendering  the  case  a  most  unfavourable  one. 

B.  With  the  same  objects  in  view,  amputation  at  the  shoulder- joint  may  be 
required  in  some  cases  of  axillary  aneurysm  complicated  with  extension  of  the  sac 
upwards,  much  elevation  of  the  shoulder,  conditions  which  may  render  compression 
or  ligature  of  the  subclavian  impossible,  removal  of  the  limb  being  additionally 
called  for  if  agonising  pain  or  threatening  gangrene  be  present. 

Prof.  Syme  3  briefly  alludes  to  two  such  successful  cases,  in  one  of  which  gangrete 
was  threatening  :  "  In  a  case  of  axillary  aneurysm  in  a  gentleman  of  about  52  yeais 
of  age,  where  ligature  was  prevented  by  intense  inflammation  of  the  arm,  rapidly 

1  In  some  of  these  the  adoption  of  the  Fumeaux  Jordan  method  (p.  191)  might  lead 
to  diminished  loss  of  blood. 

2  3Ied.  Chir.  Trans.,  vol.  lii.,  p.  306. 

3  Ibid.,  vol.  xliii,  p.  139. 

SURGERY  I  13* 


198        OPERATIONS  ON  THE  UPPER  EXTREMITY 

running  on  to  gangrene,  I  performed  amputation  at  the  shoulder- joint,  cutting 
through  the  sloughy  sides  of  the  aneurysm  and  tying  the  artery  where  it  lay  within 
the  sac." 

C.  In  some  cases  of  inflamed  axillary  aneuri/sm  threatening  suppuration.  Sir  J.  E. 
Erichsen  ^  pointed  out  that  the  question  of  this  amputation  may  arise.  As  the  old 
ojjeration  of  opening  the  sac,  turning  out  the  clots,  and  securing  the  vessel  above 
and  below  is  impossible,  owing  to  the  fact  that  the  coats  of  the  vessel,  now  softened, 
will  not  hold  a  ligature,  two  course  only  are  open  to  the  surgeon — viz.  ligature  of 
the  third  part  of  the  subclavian,  or  amputation  at  the  shoulder-joint.  While  the 
former  may  be  followed  when  the  aneurysm  is  moderate  in  size  and  when  there  is 
no  evidence  of  threatening  gangrene,  amputation  must  be  resorted  to  when  less 
favourable  conditions  are  present. 

If  haemorrhage  occur  from  an  inflamed  axillary  aneurysm  which  has  ruptured 
after  the  subclavian  has  been  already  tied,  the  same  writer,  of  the  two  courses 
open — viz.  either  to  open  the  sac  and  try  and  include  the  bleeding  spot  between 
two  ligatures,  or  to  amputate  at  the  shoulder-joint — strongly  advises  the  latter. 

D.  In  the  words  of  Sir  J.  E.  Erichsen, ^  "  there  is  another  form  of  axillary 
aneurysm  that  requires  immediate  amputation  at  the  shoulder-joint,  whether  the 
subclavian  artery  have  previously  been  ligatured  ot  not  ;  it  is  the  case  of  diffuse 
aneurysm  of  the  armpit,  with  threatened  or  actual  gangrene  of  the  limb. 

Different  methods.  Of  some  thirty-six  methods  which  have  been 
described,  most  will  be  found  to  differ  in  some  unimportant  detail. 
Five  alone  will  be  given  here  ;  they  will  be  found  amply  sufficient,  if 
modified  when  needful,  for  all  cases  ;  and  of  these  five,  Spence's,  for 
the  reasons  given  below,  is  the  best,  and  the  one  with  which  all  operators 
should  be  familiar,  The  circumstances  under  which  this  operation  is 
performed  do  not  admit  of  any  one  definite  method  being  followed. 
Thus,  after  a  railway  accident  or  gunshot  injury,  the  soft  parts  will  be 
destroyed  on  at  least  one  surface.  In  amputating  for  malignant  disease, 
skin  flaps  must  be  made  use  of,  transfixion  being  usually  inadmissible, 
as  the  muscles  should  be  cut  as  short  and  as  close  as  possible  to  their 
upper  attachments,  to  minimise  the  risk  of  extension  and  recurrence. 
Instead  of  remembering  the  length  and  size  of  differently  named  flaps, 
the  surgeon  will  have  to  be  familiar  with  the  anatomy  of  the  parts, 
the  position  of  the  vessels,  and  the  best  means  of  meeting  haemorrhage. 

The  joint  is  so  well  covered  that  sufficient  flaps^  can  nearly  always 
be  provided,  while  the  blood-supply  is  so  abundant  that  sloughing  very 
rarely  occurs,  and  even  if  it  does,  the  tissues  of  the  chest  will  come 
forward  sufficiently  to  close  the  wound.  While  the  cavity  of  the  axilla 
favours  exit  of  discharges  below,  the  abundance  of  cellular  tissue  opened 
up  favours  diffuse  inflammation  and  calls  for  adequate  drainage.^ 

The  following  methods  will  be  described  here  :  in  the  first  two,  skin 
flaps  are  made  ;  in  the  others  (save  in  the  Furneaux-Jordan  method), 
transfixion  is  made  use  of,  in  part  at  least.  In  all  cases  of  doubt, 
the  conditions  of  the  bone  and,  if  needful,  that  of  the  vessels  and 
nerves,  should  be  first  cleared  up  by  a  free  incision  as  if  for  excision 
(Figs.  109  and  110,  p.  215). 

(1)  By  lateral  skin  flaps.     The  oval  or  en  raquette  method. 

(2)  Spence's  method. 

(3)  Superior  and  inferior  flaps. 

1  Surg.,  vol.  ii,  p.  217.  ~  Loc.  supra  cit.,  p.  218. 

^  In  some  cases  of  f;;unshot  injury  it  is  necessary  to  get  the  chief  fl.ap  from  the 
axillary  region,  and  to  bring  this  up  and  unite  it  to  the  cut  margin  of  the  skin  over  the 
acromion. 

4  Finally  the  tendency  of  the  skin  to  retract  when  this  has  been  much  stretched,  as 
over  a  large  growth,  should  be  remembered. 


AMPUTATION  AT  TlIK  SIIOULDKH-.JOIXT 


191) 


(4)  Superior  or  deltoid  flaps. 

(5)  Anterior  and  posterior  flaps. 
(())  Fiiriieaux-Jordaii  ini^tliod. 

While  the  most  rapid  methods  are  those  of  superior  and  inl'eiior 
(Figs.  106  and  107),  or  anterior  and  posterior  flaps,  in  each  case  cut 
by  transfixion,  these  re(]uire  the  presence  of  an  assistant  who  can 
be  thoroughly  relied   upon    to   seize   the   artery  just  before   it    is   cut. 


Fig.  97. 


Where  there  is  time,  and  where  the  soft  parts  admit  of  it,  one  of  the 
methods  with  a  vertical  incision — e.g.  Spence's  method,  the  en  raquette, 
or  that  by  lateral  skin  flaps — is  far  preferable,  as  (1)  it  allows  of  securing 
the  artery  before  this  is  cut,  thus  dispensing  with  the  preliminary 
pressure  on  the  subclavian,  in  many  cases  a  difficult  procedure,  or  the 
seizing  of  the  artery  in  the  flap  ;  (2)  of  exploring  the  condition  of  the 
head  of  the  bone  ;  (3)  one  flap  can  be  cut  longer,  according  to  the  state 
of  the  soft  parts. 

Means  of  arresting  haemorrhage  in  amputation  at  the  shoulder- joint. 
Any  of  the  following  may  be  employed.  The  first  two  are  by  far  the 
best. 

(1)  Ligaturing  or  tivisting  the  vessels  on  the  inner  aspect  of  the  limb 
before  they  are  cut  (Figs.  99  and  102).  This  method  is  an  excellent  one 
and  suitable  to  all  cases.  The  ligature  should  be  placed  as  high  as 
possible,  so  as  to  get  above  the  circumflex  arteries.  The  surgeon  must 
be  careful  in  the  final  use  of  the  knife,  high  up  in  the  axilla,  not  to  prick 
the  artery  above  his  ligature. 


200        OPERATIONS  ON  THE  UPPER  EXTREMITY 

(2)  Compression  hij  an  assistant  of  the  inferior  or  anterior  flap,  and 
so  of  the  vessels  before  they  are  cut  (Figs.  106  and  107). 

(3)  Pressure  on  the  subclavian  as  it  crosses  the  first  rib.  Pressure  is, 
however,  always  liable  to  be  inefficient  in  short,  fat  necks  ;  in  thin 
patients,  however  well  applied  at  first  with  the   thumb   aided   by    a 


Fig.  98.  Disarticulation  at  the  slioulder-joiut,  the  humerus  being  fractured 
high  up.  The  operator  with  his  left  hand  twists  the  humerus  outwards,  while, 
with  his  right,  he  divides  the  cajisule  and  insertion  of  the  scapularis.     (Farabeuf. ) 

padded  key  or  weight,  it  is  too  often  rendered  uncertain  by  the  necessary 
changes  in  position  of  the  limb  during  the  operation,  a  violent  gush 
of  blood  at  the  last  showing  the  surgeon  that  his  confidence  in  the 
artery  being  secured  is  misplaced.  Furthermore,  an  assistant  so  employed 
is  necessarily  much  in  the  way.  For  the  above  reasons  one  of  the  first 
two  methods  is  to  be  preferred. 

(4)  Ligature  of  the  subclavian  artery.  Circumstances  may  render  this 
desirable  as  in  a  case  of  Mr.  Howard  Marsh's,  in  which  he  amputated 
at  the  shoulder- joint  for  an  enormous  "  osteo-sarcoma  "  of  the  humerus. 


AMPUTATION  AT  THE  SHOULDER-JOINT  201 

(5)  Ligature  of  the  first  fart  of  the  axillary  artery.  This  step,  originally 
recommended  by  Delpech  and  more  recently  by  Professor  Keen,  may 
be  used  in  those  cases  where  a  growth  has  extended  high  up  into  the 
axilla.  A  free  incision  between  the  pectoralis  and  the  deltoid  will  then 
trivc  free  access  to  the  apex  of  the  axilla,  and  enable  the  extent  of  the 
(Trowth  to  be  determined. 

(G)  Wi/eth\s  method  by  pins  and  elastic  tuhing.  This  method  will  be 
described"  in  the  section  dealing  with  amputation  through  the  hip-joint. 


Fig.  99.     Amputation  at  the  shoulder-joint  by  lateral  flaps.     These  are  turned 
aside,  while  the  axillary  artery  is  secured  by  torsion  before  disarticulation  is 

completed. 

It  is  not  recommended,  for,  unless  the  pins  are  inserted  very  exactly— 
not  an  easy  matter  in  operations  of  emergency— the  tubing  may  slip. 

(7)  Securing  the  vessels  lower  down,  in  the  Furneaux- Jordan  method 

{see  p.  209). 

(8)  Use  of  an  india-ruhber  band.  This  is  applied  in  the  same  way  as 
that  fully  described  in  "  Amputation  at  the  Hip-joint."  _  It  is  not  a 
reliable  method,  especially  in  those  cases  of  accident  in  which,  the  limb 
being  mutilated  high  up,  this  operation  is  largely  required.  For  in 
these  the  band,  being  applied  under  the  axilla  and  across  the  body, 


202        OPERATIONS  ON  THE  UPPER  EXTREMITY 

slips  up  as  soon  as  the  head  is  disarticulated,  allowing  of  bleeding  from 
the  vessels,  and  coming,  itself,  most  inconveniently,  and  as  a  possible 
source  of  infection,  into  the  way  of  the  operator. 

(1)  Lateral  flaps.  The  patient  having  been  propped  up  sufficiently, 
brought  to  the  edge  of  the  table,  and  rolled  over  to  the  opposite  side, 
the  surgeon,  standing  outside  the  abducted  limb  on  the  right  side, 
and  inside  it  on  the  left;  and  ha\ang  marked  out  with  his  left  forefinger 
and  thumb  a  point  just  below  and  outside  the  coracoid  process  and  a 
corresponding  point  behind  (Fig.    97),  then  reaches   over   and,   entering 


Fig.   100.     Amputation  at  the  shoulder-joint  by  the  en  ruquelte  method. 

the  knife  in  the  axilla,  close  to  the  thumb,  cuts  an  oval  flap,  about  four 
inches  long,  consisting  of  skin  and  fascia  from  the  side  farthest  from 
him.  and  ending  close  to  his  finorer.  Without  removing  the  knife  the 
surgeon  next  marks  out  a  similar  flap  on  the  other  side,  cutting  from 
above  downwards,  commencing  just  below  the  finger,  and  ending  where 
the  first  flap  began  in  the  mid-axilla.  The  assistant  in  charge  of  the 
limb  aids  the  above  by  rotating  the  arm  into  convenient  positions. 
The  flaps  are  then  dissected  up  and  held  out  of  the  way.  The  vessels 
are  next  exposed,  separated  from  the  surrounding  nerves,  and  secured, 
either  by  applying  two  pairs  of  Spencer- Wells  forceps,  di^^ding  the 
vessel  between  them  and  twisting  both  ends,  or  by  passing  an  aneurysm 
needle,  threaded  ^vith  catgut,  under  the  artery,  and  thus  securing  it 
with  two  ligatures.  The  limb  being  then  carried  across  the  chest,  the 
outer  part  of  the  capsule  is  freely  opened  by  cutting  on  the  head  of  the 


AMPUTATION  AT  TIIK  SIIOULDKR-JOINT 


208 


bone,  and  the  muscles  attached  to  the  outer  tuberosity  thoroughly 
severed.  The  limb  is  next  rotated  outwards,  and  the  subscapularis 
tendon  severed  ;  the  biceps  tendon  being  cut  and  the  capsule  freely 
divided  the  joint  is  well  opened  on  the  iinier  side.  The  head  being 
then  dislocated,'  by  an  assistant  pressing  the  elbow  forwards  and  against 
the  side,  the  knife  is  passed  from  the  outer  side  behind  the  dislocated 
head,  and,  being  kept  close  to  the  inner  side  of  the  bone,  is  brought 
out  through  the  structures  on  the  inner  aspect  of  the  arm,  care  being 
taken,  as  the  knife  cuts  its  way  out  that  it  does  so  below  the  point  where 
the  large  vessels  have  been  secured. 

In  tliis  or  any  other  amputation  here  for  tul)crcnlous  or  malignant  disease,  it 
will  he  needful  to  senitinise  earefully  the  eonditioii  of  the  i)aits  left,  to  di.ssect  out 
any  glands,  whether  enlarged  or  not,  together  with  the  synovial  membrane,  and  in 
some  cases,  to  remove  the  glenoid  cavity  with  bone  forceps,  or  preferably  a  fine  sharp 
saw. 

(2)  Method  en  raquette  with  preliminary  exploration  (Farabeuf) 
(Figs.  1()0-103).  In  this  modification  the  point  of  the  knife  having 
been  sunk  just  below  and  in 
front  of  the  tip  of  the  acromion, 
an  incision  is  made  downwards, 
sufficiently  long  and  deep  to 
admit  of  exposing  the  head  of 
the  humerus.  The  condition  of 
the  bone  is  then  explored  :  If 
amputation  is  decided  on,  the 
above  is  converted  into  one  ew 
raquette  by  making  an  oblique 
incision  which  passes  from  about 
the  centre  of  the  longitudinal  one 
(Figs.  100  and  101)  across  the 
inner  or  the  outer  aspect  of  the 
limb  (according  as  it  is  right  or 
left),  and  the  ends  behind  on  a 
level  with  the  lower  extremity 
of  the  longitudinal  one.  A 
second  exactly  symmetrical  to 
the  first  is  next  made  over  the 
opposite  aspect  of  the  limb,  be- 
ginning where  the  first  ended, 
and  terminating  in  the  longi- 
tudinal incision  opposite  to  the 
•first  (Fig.  101).  The  next  step 
is  the  exposure  of  the  artery 
by  division  of  the  muscles.  In 
the  curved  inner  incision  (Fig. 
102  are  seen  the  anterior  fibres 
of  the  deltoid  almost  blended  with  the  insertion  of  the  great  pectoral. 
This  is  raised  with  the  finger,  and  the  insertion  of  the  great  pectoral 
detached  from  the  bone.  If  now  the  inner  flap  be  folded  inw^ards,  the 
coraco-bicipital  fasciculus  comes  into  view.     The  aponeurosis  over  it  being 

^  In  any  case  where  the  leverage  of  the  humerus  is  wanting  owing  to  this  bone  having 
been  broken  higher  up,  the  use  of  lion-forceps  will  facilitate  disarticulation. 


Fig.  101.     Amputation  at  the  right  shoulder- 
joint  by  the  en  raquette  method. 


204        OPERATIONS  ON  THE  UPPER  EXTREMITY 

opened  by  a  free  longitudinal  incision,  the  muscular  fasciculus  is  drawn 
over  the  front  of  the  humerus  and  cut  across.  If  an  assistant  now 
thoroughly  retract  the  inner  flap  the  axillary  vessels  and  nerves  are  ex- 
posed. The  artery  should  be  isolated  and  tied  as  high  up  as  possible,  so  as 
to  get  above  the  posterior  circumflex.  The  knife  being  again  inserted  into 
the  outer  oblique  incision,  the  deltoid  is  boldly  cut  through  as  far 
as  the  back  of  the  axilla.  An  assistant  retracts  the  outer  and  inner 
flaps,  while  the  surgeon  opens  the  capsule  freely,  the  limb  being  rotated 
as  directed  {see  p.  203).     The  head  is  next  thrown  out  of  the  socket, 


Fig.   102.     The  anterior  fibres  of  the  deltoid,  the  insertion  of  the  pectoralis 
major,  and  tlie  coraco-brachialis  and  biceps  have  been  cut.     The  left  hand  of 
the  operator  draws  the  large  nerves  downwards,  and  thus  exposes  the  axillary 
artery  for  ligature.     (Farabeuf.) 


and  the  knife  is  carried  behind  the  head,  skirting  the  posterior- internal 
aspect  of  the  humerus  very  closely,  so  as  not  to  cut  the  secured  artery, 
and  finally  brought  out  through  the  incision  on  the  inner  side,  severing 
the  latissimus  dorsi  and  teres  major.  If  the  artery  has  not  been  tied, 
an  assistant  secures  it  between  his  thumb,  sunk  deeply  into  the  wound, 
and  his  fingers,  which  are  in  the  axilla,  or  by  using  both  hands. 

(3)  Spence's  method  (Fig.  104).  This  excellent  method  is  strongly 
recommended  on  account  of  its  simplicity,  and  the  ease  with  which 
the  vessels  may  be  secured.  It  is  further  especially  suited  to  cases 
of  failed  excision,^  or  to  cases  of  injury,  e.g.  gunshot,  where  the  surgeon 
has  to  cut  into  and  explore  the  condition  of  the  joint  before  deciding 
on  excision  or  amputation.     By  its  means  an  excision  can  readily  be 

^  At  the  present  da/,  in  cases  of  failed  excision,  the  surgeon  will  often  prefer  to  make 
use  of  the  modification  of  the  Furneaux- Jordan  method  (p.  209}. 


AMPUTATION  AT  THE  SIIOULDER-JOINT 


'JO  5 


converted  into  a  disarticulation,  if  this  step  be  found  needful.     It  has 
other  advantages,  but  less  important  ones  : 

(1)  The  posteiior  circumflex  artery  is  not  divided,  except  in  its 
small  terminal  branches  in  front,  whereas,  both  in  the  large  deltoid 
flap  and  the  double  flap  methods,  the  trunk  of  the  vessel  is  divided  in 
the  earlv  steps  of  the  operation  and,  retracting,  often  gives  rise  to 
embarrassing  haemorrhage. 

(2)  The  great  ease  with  which  disarticulation  can  be  accomplished. 


Kg.  103.     Jr'arts  composing  the  flaps  made  in  the  en  raqnette  method. 


(3)  The  better  shape  of  the  stump.  Professor  Spence  pointed  out 
that,  however  excellent  are  the  results  soon  after  other  methods,  later 
on,  the  shape  of  the  stump  is  much  altered,  not  merely  from  the  atrophy 
common  to  all  stumps,  but  from  retraction  of  the  muscular  elements 
of  the  flaps,  the  pectoralis  major  retracting  towards  the  sternum,  and 
the  latissimus  dorsi  and  teres  major  towards  the  spine  and  scapula. 
Thus  a  deep,  ugly  hollow  results  under  the  acromion. 

Fig.  105  shows  an  instance  of  this,  in  a  case  of  amputation  of  both  limbs  in  a 
young  subject.  E.  D.,  age  10,  was  admitted  under  Mr.  Jacobson's  care  in  Guy's 
Hospital  for  a  terrible  crush  of  both  upper  extremities,  from  his  having  been  run  over 
by  a  timber-waggon.  Amputation  was  performed  at  once  through  the  left  shoulder- 
joint  by  superior  and  inferior  flaps.     An  attempt  was  made  to  save  the  right  limb,  but 


206       OPERATIONS  ON  THE  UPPER  EXTREMITY 


Fig.  104.    Amputation 

at    the    shoulder-joint 

by   Spence's    method. 

(Stimson.) 


owing  to  gangrene  setting  in,  amputation  became  necessary,  and  was  performed  high 
up  through  the  humerus  by  3Ir.  G.  A.  Wright.  The  resulting  projection  of  the  left 
acromion  from  wasting  of  the  muscles  was  well  shown  when,  nine  years  later,  he 
was  again  admitted  for  a  conical  and  tender  stump  on  the  right  side,  due  here 
to  the  unbalanced  growth  of  the  upper  epiphysis.  The 
writing  below  the  figure  was  done  by  the  lad  with  his  teeth. 

(4)  Professor  Kocher  ^  points  out  that  the  longi- 
tudinal incision  in  this  method  has  the  advantage 
of  being  situated  in  the  interval  between  two 
muscular  groups  supplied  by  different  nerves  and 
that  muscular  atrophy  is  thus  avoided. 

The  operation  is  thus  described  in  Professor 
Spence's  words  :  ^  "  Supposing  the  right  arm  to  be 
the  subject  of  amputation.  The  arm  being  slightly 
abducted,  and  the  head  of  the  humerus  rotated 
outwards  if  possible,  with  a  broad  strong  knife 
I  begin  by  cutting  down  upon  the  head  of  the 
humerus,  immediately  external  to  the  coracoid  pro- 
cess, and  carry  the  incision  down,  through  the 
cla\^cular  fibres  of  the  deltoid  and  pectoralis  major, 
till  I  reach  the  humeral  attachment  of  the  latter 
muscle,  which  I  di\dde.  I  then,  with  a  gentle 
curve,  carry  the  incision  across  and  fairly  through 
the  lower  fibres  of  the  deltoid  towards  the  pos- 
terior border  of  the  axilla,  unless  the  textures  be 
much  torn.  I  next  mark  out  the  line  of  the  lower  part  of  the  inner 
section  by  carrying  an  incision  through  the  skin  and  fat  only,  from  the 
point  where  my  straight  incision  terminated,  across  the  inside  of  the 
arm.  to  meet  the  incision  at  the  outer  part.  This  ensures  accuracy 
in  the  line  of  union,  but  is  not  essential. 
If  the  fibres  of  the  deltoid  have  been 
thoroughly  divided  in  the  line  of  incision, 
the  flap  so  marked  out  can  be  easily  sepa- 
rated (by  the  point  of  the  finger,  without 
further  use  of  the  knife)  from  the  bone  and 
joint,  together  with  the  trunk  of  the  pos- 
terior circumflex,  which  enters  its  deep 
surface,  and  is  drawn  upwards  and  backwards, 
so  as  to  expose  the  head  and  tuberosities. 
The  tendinous  insertions  of  the  capsular 
muscles,  the  long  head  of  the  biceps,  and 
the  capsule  are  next  divided  by  cutting 
directly  on  the  tuberosities  and  head  of  the 
bone,  and  the  broad  scapular  tendon  es- 
pecially, being  very  fully  exposed  by  the 
incision,  can  be  much  more  easily  and 
completely  divided  than  in  the  double  flap 
method.  By  keeping  the  large  outer  flap 
out  of  the  way  by  a  broad  copper  spatula 
or  the  finger  of  an  assistant,  and  taking  care 
to  keep  the  edge  of  the  knife  close  to  the  bone,  as  in  excision, 
the  trunk  of  the  posterior  circumflex  is  protected.      Disarticulation  is 

^  Operative  Surg.,  p.  37G. 

2  Lancet,  1867,  vol.  i,  p.  143  ;  and  Lee.  on  Surg.,  vol.  ii,  p.  662. 


Fig.  105. 


AMPUTATION  AT  THE  STTOri.DKR-.TOINT 


207 


Fig.  106. 


then  accomplislied,  and  the  limb  removed  by  dividing  the  remaining 
soft  parts  on  the  axilhiiy  as])ect.  The  only  vessel  which  bleeds  is 
the    anterior    circumflex    divided    in    the    first    incision,    and  here,  if 

necessary,  a  pair  of  catch-forceps  can  be 
placed  on  it  at  once.  In  regard  to  the 
axillary  vessels,  they  can  either  be  com- 
pressed by  an  assistant  before  completing 
the  division  of  the  soft  parts  on  the  axillary 
aspect  or,  as  I  often  do  in  cases  where  it  is 
wished  to  avoid  all  risk,  by  a  few  touches  of 
the  knife,  the  vessel  can  be  exposed,  and 
then  tied  and  divided  between  the  two 
ligatures,  so  as  to  allow  it  to  retract  before 
dividing  the  other  structures."  ^ 

(4)  Amputation  by  superior  and  inJerior 
flaps.  (Figs.  lOG  and  107.)  The  patient 
having  been  brought  to  the  edge  of  the 
table,  turned  sufficiently  over,  and  his 
shoulders  supported  by  pillows  the  assist- 
ants are  arranged  as  before.  The  arm  being 
a  little  raised  so  as  to  relax  the  deltoid, 
the  surgeon  standing  inside  the  limb  on 
the  right  side  and  outside  it  on  the  left, 
lifts  the  deltoid  muscle  with  his  left  hand, 
and  sends  the  knife  (narrow,  strong,  and  no  longer  than  needful)  across 
beneath      the      muscle. 


entering  it  on  the  right 
side,  just  below  the  cora- 
coid  process,  and  bring- 
ing it  out  a  little  below 
the  most  prominent  part 
of  the  acromion  ^  or  vice 
versa,  according  to  the 
side  operated  upon.  The 
knife  should  pass  close 
to  the  anatomical  neck 
of  the  humerus,  without 
hitching  upon  it,  and 
the  flap  should  be  cut 
broadly  rounded,  and 
well  down  to  the  inser- 
tion of  the  deltoid.  It 
is  then  raised  and  re- 
tracted and,  the  capsule 
being  now  exposed,  the 
joint  is  opened  by 
cutting  strongly  upon  the  head  of  the  bone.  The  arm  being  now  rotated 
vigorously  outwards  by  an  assistant  or  by  the  surgeon,  the  subscapularis, 

^  \\Tiere  the  limb  is  very  muscular,  Prof.  Spence  recommended  to  raise  the  skin  and  fat 
from  the  deltoid  at  the  lower  part,  and  then  to  divide  the  muscular  fibres  higher  up  by  a 
second  incision,  so  as  to  avoid  excess  of  muscular  tissue. 

-  Unless  care  is  taken  to  keep  thus  below  the  acromion  process  there  will  be  some 
tendency  for  this  bone  to  protrude  in  the  wound. 


Fig.   107.     To  show  the  manner  in  which  bleeding  is 

controlled  in  the  inferior  flap  :  the  axillary  vessels  are 

compressed  by  one  thumb,  the  posterior  circumflex  by 

the  other. 


208        OPERATIONS  ON  THE  UPPER  EXTREMITY 


thus  made  tense,  and  the  biceps  are  brought  into  view  and  severed  ; 
the  limb  is  next  rotated  inwards,  being  carried  across  the  chest,  and 
the  muscles  attached  to  the  great  tuberosity  are  divided.  The  capsule 
is  then  still  more  freely  opened,  and  the  head  of  the  bone,  now  freed, 
is  pushed  up  by  the  assistant  and  pulled  outwards  from  the  glenoid 
cavity.  The  knife  is  next  slipped  behind  the  head  (Fig.  106),  and  cuts 
its  way  along  the  under  aspect  of  the  neck  and  shaft  of  the  humerus, 

so  as  to  shape  an  inferior  flap  half  the  length 
of  the  upper  one.^  As  soon  as  the  knife  is 
passed  behind  the  bone,  an  assistant  slips  his 
hands  in  behind  the  back  of  the  knife  (Fig. 
106),  following  it  so  as  to  grasp  firmly  the 
soft  parts  in  the  inferior  flap,  and  thus  con- 
trol the  axillary  vessels  (Fig.  107). 

The  large  vessels  are  next  secured,  then 
the  circumflex,  and  muscular  branches  that 
require  it ;  any  large  nerves  that  need 
trimming  are  then  cut  short,  drainage,  if 
necessary,  proxdded,  and  the  flaps  brought 
into  position. 

This  amputation  has  the  advantage  of 
being  very  quickly  done,  and  of  giving  a 
flap  which  keeps  in  position  by  its  own 
weight,  and  thus  gives  good  drainage.  If 
the  soft  parts  below  the  humerus  are 
much  damaged,  the  upper  flap  nmst  be 
cut  proportionately  long. 

(5)  Amputation  by  deltoid  or  upper  flap. 
This  is  merely  a  modification  of  the  last. 
The  deltoid  or  upper  flap  may  be  cut  by 
transfixion,  or  made  by  cutting  from  with- 
out inwards.  In  either  case  it  must  be  of 
very  full  size,  and  thus  is  useful  when  the 
axilla  is  damaged,  but  it  has  the  disad- 
vantage of  leaving  next  to  no  flap  in 
which  an  assistant  can  seize  the  axillary  vessels  ;  and,  owing  to  the 
powerful  retraction  of  the  muscles  in  the  axillary  folds,  unless  the 
upper  flap  is  cut  full  in  length  and  size,  it  will  not  cover  the  resulting 
wound.  Finally,  as  the  trunk  of  the  posterior  circumflex  is  cut, 
sloughing  of  the  large  deltoid  flap  may  take  place,  especially  if  the 
tissues  composing  it  are  at  all  damaged  previous  to  the  amputation. 
Owing  to  these  disadvantages  which  outweigh  its  rapidity,  this  method 
is  not  to  be  recommended,  a  short  under-flap  being  always  cut  if 
possible.  When  the  surgeon,  having  disarticulated,  is  cutting  straight 
down,  unable  to  make  any  flap  below,  an  assistant  should  try  to 
draw  up  the  skin  of  the  axilla,  otherwise,  owing  to  the  laxity  of  the 
skin  in  this  situation,  any  downward  traction  will  bring  the  skin  of  the 
thoracic  wall  under  the  knife. 

(6)  Amputation  by  anterior  and  posterior  flaps. 

This  is  only  indicated  when  the  soft  parts  on  the  front  and  the  inner  aspects  are 
damaged.     The  position  of  the  patient  being  as  advised  at  p.  307,  and  the  hmb  being 

^  The  surgeon  should  not  cut  this  till  he  is  told  that  the  flap  is  held  firmly ;   and,  in 
cutting  it,  he  must  be  careful  of  his  assistant's  fingers. 


Fig.   108.     Amputation  by 
deltoid  flap. 


EXCISION  OF  THE  SHOULDER- JOINT  200 

carried  somewhat  upwards,  backwards,  and  outwards,  the  surgeon,  standing,  if'ou 
the  left  side,  behind  and  outside  the  shoulder,  enters  his  knife  just  in  front  of  ,the 
posterior  fold  of  the  axilla,  thrusts  it  across  the  back  of  the  humerus  as  near  the 
head  as  possible,  so  as  to  get  in  front  of  the  tendons  of  the  teres  major  and  latissimus 
dorsi,  and  bringing  it  out  close  to  the  acromion,  cuts  with  a  sawing  movement,  a 
flap  four  to  live  inches  long.^  which  is  next  well  retracted.  The  arm  being  then 
carried  across  the  chest,  the  joint  is  freely  opened  behind,  the  muscles  attached  to 
the  tuberosities  severed,  the  knife  passed  between  the  head  and  the  glenoid  cavity 
(to  facilitate  this,  the  limb  should  now  be  carried  over  the  chest,  and  the  head  of  the 
bone  pushed  backwards),  then  between  the  bone  and  the  pectoraUs  major,  and  an 
anterior  flap.-  four  inches  long,  cut  from  within  outwards.  Hiemorrhage  from  the 
large  vessels  is  arrested  either  by  an  assistant  grasping  this  flap  as  it  is  cut,  much  as 
at  p.  207,  Fig.  107,  or  by  the  surgeon  isolating  the  axillary  vessels  (the  biceps  and 
coraco-brachialis  will  guide  him),  and  securing  them  by  torsion  or  ligature  (p.  204) 
before  he  completes  the  operation  by  cutting  the  anterior  flap.  When  operating  on 
the  right  limb,  the  patient  being  tvirned  well  over  on  to  his  left  side,  the  surgeon, 
standing  here  inside  the  arm,  which  is  held  upwards  and  backwards  so  as  to  relax  the 
deltoid,  lifts  this  muscle  up  with  his  left  hand,  and  then  passes  his  knife  from  just 
below  the  acromion,  transfixing  the  base  of  the  deltoid,  grazing  the  back  of  the 
humerus,  and  Anally  thrusts  the  point  dowaiwards  and  backwards  through  the 
skin  till  it  comes  out  at  the  posterior  margin  of  the  axilla.  This  flap,  four  or  five 
inches  long,  should  be  dissected  up,  the  joint  opened  behind,  and  the  operation 
completed  as  before. 

(7)  Furneaux-Jordan  method/^  This  may  be  made  use  of  both  as  a 
primary  and  a  secondary  amputation.     The  following  are  suitable  cases  : 

(a)  Certain  cases  of  injury.  Where,  though  the  parts  about  the  shoulder- 
joints  are  intact,  the  humerus  is  badly  split  up  into  the  joint.  The  soft  parts  are 
divided  down  to  the  bone  by  the  circular  method,  three  to  four  inches  below  the 
axilla,  the  main  vessels  secured,  and  the  humerus  then  shelled  out  by  a  longitudinal 
incision  along  the  outer  and  posterior  aspect  of  the  limb,  meeting  the  circular  one  at 
a  right  angle. 

(b)  In  cases  of  failed  excision.  Here,  after  amputation  of  the  limb  by  the  circular 
method,  the  rest  of  the  bone  is  turned  out  through  the  excision  wound  prolonged  into 
the  circular  one. 

(c)  After  amputation  in  the  middle  of  the  arm  in  some  cases.  E.g.,  when  the 
stump  is  the  seat  of  osteo-myelitis,  necrosis,  or  otherwise  does  not  do  well. 

EXCISION  OF  THE  SHOULDER-JOINT  (Figs.  109-115) 

This  operation  is  but  rarely  performed:  (1)  Owing  to  the  com- 
parative infrequency  of  disease  of  the  above  joint,  especially  of  tuber- 
culous disease,  which  requires  operative  measures  ;  (2)  from  the  fact 
that  epiphysitis  and  infective  syno\itis  usually  give,  after  free  incision 
and  drainage,  as  good  a  result  as  can  be  obtained  after  excision.  This 
is  mainly  owing  to  the  fact  that  much  of  the  stiffness  that  otherwise 
would  be  present  is  made  up  for  by  the  supplementary  mobiUty  of  the 
scapula,  especially  in  young  subjects.  Generally  speaking,  the  objects 
of  the  operation  will  be  for  the  removal  of  a  tuberculous  focus,  to  improve 
the  mobility  of  the  joint,  or  in  some  cases  for  the  relief  of  pain.  The 
above  remarks  lead  up  to  the  consideration  of  the  amount  of  movement 
which  is  gained  after  the  operation  of  excision.  The  arm  cannot  usually 
be  abducted  and  elevated  beyond  the  horizontal  line  ;  too  often  it  lies 
close  to  the  chest.  Even  if  the  deltoid  retained  its  power  of  elevation, 
it  could  not  often  exert  it,  as  in  most  operations,  owing  to  the  amount 

1  In  the  posterior  flap  wiU  be  the  posterior  part  of  the  deltoid,  the  latissimus  dorsi,  and 
teres  major. 

•  In  this  anterior  flap  will  be  the  remaining  fibres  of  the  deltoid,  the  pectoralis  major, 
and  the  large  vessels  and  nerves. 

3  For  the  details  of  this  method  see  "  Amputation  at  the  Hip-joint." 
SURGERY   I  14 


210        OPERATIONS  ON  THE  UPPER  EXTREMITY 

of  bone  removed,  the  fulcrum  of  the  head  of  the  humerus  against  the 
glenoid  cavity  has  gone. 

Sir  J.  E.  Erichsen^  spoke  of  the  four  chief  movements  of  the  shoulder- 
joint,  \\z.  '■'  (1)  abduction  and  elevation,  (2)  adduction,  (3)  and  (4)  move- 
ments in  the  anterior-posterior  direction — these  are  requisite  in  all 
ordinary  trades  for  the  guidance  of  the  hand  in  most  of  the  common 
occupations  of  Ufe.  The  movements  of  elevation  are  seldom  required 
save  by  those  who  follow  climbing  occupations,  as  sailors,  masons,  &c. 
Now,  the  mode  of  performing  the  operation,  as  well  as  the  operation 
itself,  will  materially  influence  these  different  movements.  Thus,  if 
the  deltoid  be  cut  completely  across,  the  power  of  abduction  of  the 
arm  and  of  its  elevation  will  be  permanently  lost.  If  its  fibres  be  merely 
split  by  a  longitudinal  incision,  they  may  be  regained  in  great  part.^ 

"  All  those  movements  of  rotation,  &c.,  which  are  dependent  on 
the  action  of  the  muscles  that  are  inserted  into  the  tuberosities  of  the 
humerus  will  be  permanently  lost ;  for,  in  all  cases  of  caries  of  the  head 
of  the  humerus  requiring  excision,  the  surgeon  will  find  it  necessary 
to  saw  through  the  bone  below  the  tuberosities^n  its  surgical,  and 
not  its  anatomical,  neck.^  Hence  the  connections  of  the  supra-spinatus 
and  infra-spinatus,  the  teres  minor,  and  subscapularis  will  all  be  separated, 
and  their  action  on  the  bone  afterwards  lost.  But  those  muscles  which 
adduct,  and  which  give  the  anterior-posterior  movements — \\z.  the 
coraco-brachialis,  the  biceps,  the  pectorahs  major,  latissimus  dorsi, 
and  teres  major — will  all  be  preserved  in  their  integrity  ;  and  hence 
it  is  that  the  arm,  after  this  excision,  is  capable  of  guiding  the  hand 
in  so  great  a  variety  of  useful  underhanded  movements." 

Dr.  Scudder  in  a  paper  on  excision  of  the  shoulder-joint,*  has  collected  the  late 
results  after  this  ojieration  in  nineteen  cases,  fifteen  for  injurv'  and  foiu'  for  tuberculous 
disease.  "  Following  the  excision  of  the  ujaper  end  of  the  humerus  there  will  be 
limited  power  in  the  shoulder  ;  a  distinct  diminution  in  strength  ;  muscular  atrophy; 
possibly  the  formation  of  plaques  of  new  bone  about  the  old  joint  from  detached 
periosteum.  These  pieces  of  new  bone  may  seriously  impair  the  motion.  Deformity 
and  pain  may  follow  an  excision  of  the  shoulder-joint.  .  .  .  After  injmy  the 
result  following  an  operative  reposition  or  reduction  is  better  always  than  the 
result  of  an  excision." 

Indications.  (1)  Different  forms  of  arthritis  disorganizing  the  joint, 
resisting  careful  treatment,  in  subjects  whose  age,  general  condition,  &c., 
are  satisfactory,  viz.  (a)  Tuberculous  disease,  resisting  other  treatment 
and,  as  in  aU  excisions  the  stages  of  advanced  caseation,  sinuses  and 
mixed  infection  should  be  ante-dated.  Another  reason  for  early 
excision  here  is  given  by  Watson  Cheyne  and  Burghard  :  °  "  Shoulder- 
joint  disease  is  very  frequently  associated  with  or  followed  by  disease 
of  the  lungs ;  the  exact  connection  of  the  two  is  difficult  to  understand, 

^  Surgery,  yoI.  ii,  p.  2.51. 

2  Prof.  Longmore  (Resection  of  the  Shoulder-Joint  in  Military  Surgery,  p.  12)  writes: 
"  The  loss  of  the  elevating  power  of  the  deltoid  must  be  accepted,  like  the  loss  of  the 
rotating  power  from  the  division  of  the  muscular  insertions  into  the  two  tuberosities, 
as  a  necessary  consequence  of  resection  of  the  head  of  the  humerus.  But  the  supporting 
power  of  this  muscle  exerted  upon  the  whole  upper  extremity  owing  to  its  position,  its 
extensive  origin,  and  the  manner  in  which  it  embraces  and  protects  the  mutilated  parts, 
as  well  as  its  faculty  of  assisting  in  carrying  the  arm  backwards  and  forwards,  are  all 
functions  which  may  still  remain,  and  serve  to  point  to  the  great  importance  of  preserving 
its  integrity  as  fully  as  possible." 

3  This  opinion  apjjears  to  be  too  definite  and  inelastic.  The  reader  is  referred  to  the 
remarks  below  on  the  site  of  section  of  the  bone,  and  on  subperiosteal  resection  (220). 

4  Ann.  of  Surg.,  vol.  xlix,  p.  696. 

6  Man.  of  Surg.  Treat.,  vol.  iii,  p.  237- 


EXCISION  OF  THE  SHOULDER- JOINT  211 

but  it  is  certainly  a  clinical  fact  that  a  large  number  of  patients 
suffering  from  this  affection  suffer  also  from  phthisis  and,  in  a  very- 
considerable  proportion,  the  latter  affection  only  occurs  after  the  joint 
disease  has  lasted  for  some  time."  (6)  Disorganization  of  the  joint 
after  rheumatic  fever,  gonorrhoial  arthritis,  wrenches,  &c.,  resulting  in 
crippling  ankylosis,  in  a  young  subject,  (c)  Epiphysitis,  or  infective 
arthritis  where  the  long  continued  suppuration  is  exhausting  the  patient, 
and  the  outlook  as  to  natural  cure  is  not  good. 

(2)  Gunshot  injuries,  where  the  large  vessels  and  nerves  have  escaped, 
where  fragments  of  shell  bullets,  &c.,  are  lodged  in  the  head  of  the 
bone,  especially  if  the  shaft  of  the  bone  is  not  much  damaged  {see  p.  223). 

(3)  Compound  dislocation  and  compound  fracture  with  much  damage 
to  the  capsule  and  cartilage  of  the  head  of  the  bone,  the  larger  vessels 
and  nerves  being  intact.  In  some  such  cases  primary  excision  is  indi- 
cated. Generally  replacement  should  be  effected  after  careful  cleansing  of 
the  damaged  parts.  Secondary  incision  may  be  required  for  suppuration 
or  necrosis. 

(4)  Some  cases  of  ankylosis,  e.g.  after  acute  rheumatic  or  traumatic 
arthritis  and  suppuration.  Here  the  question  of  operative  interference 
will  mainly  turn  on  how  far  the  additional  movements  of  the  scapula 
and  humerus  together  have  made  up  for  the  ankylosis,  and  the  degree 
of  atrophy  of  the  muscles. 

Dr.  E.  Souchon,  of  New  Orleans,  has  dealt  with  this  subject. "^ 

He  considers  that  operation  is  only  justifiable  in  recent  cases  in  full-grown  sub- 
jects or  in  patients  of  sufficient  age  to  ensure  that  the  removal  of  the  head  of  the 
humerus  will  not  be  followed  by  too  great  shortening.  It  is  especially  indicated  in 
ankylosis  following  arthritis  with  a  rapid  course  (dry,  acute  arthritis),  observed 
sometimes  in  subjects  affected  with  acute  rheumatism,  and  especially  bleimorrhagic 
arthritis  ;  also  in  cases  consecutive  to  suppurating  traumatic  artlnitis.  In  these 
cases  the  ankylosis  occiu's  before  the  atrophy  of  the  muscles.  The  cases  of  ankylosis 
which  should  not  be  operated  upon  are — (1 )  those  with  a  fairly  useful  limb  as  it  stands, 
unless  there  is  positive  assmance  of  improving  the  movements,  especially  those  that 
are  particularly  needed  for  the  patient's  work  ;  (2)  where  atrophy  of  the  muscles  is 
present.  The  application  of  electricity  and  massage  may  be  required  for  some  time 
before  it  is  decided  that  the  operation  will  be  useless.  Operation  is  contra-indicated, 
especially  when  the  muscles  are  irretrievably  degenerated,  as  is  the  case  in  a  great 
number  of  old  ankyloses,  and  particularly  those  following  long  articular  suppuration. 

(5)  In  some  cases  of  unreduced  dislocation  of  the  head  of  the  humerus.^ 
In  such  a  case  there  will  be  serious  loss  of  power  and  movement,  and 
not  infrequently,  especially  in  sub-coracoid  dislocations,  severe  s}Tnptoms 
of  pressure  on  the  axillary  vessels  or  the  nerves  of  the  brachial  plexus. 
In  such  a  case,  if  of  only  a  few  weeks'  duration,  an  attempt  may  be 
made  to  effect  reduction  by  manipulation  or  by  traction  under  an 
anaesthetic  ;  the  greatest  care  must  be  taken,  or  the  axillary  vessels 
may  be  injured.  If  this  does  not  succeed,  an  open  operation  should 
be  carried  out  and  every  effort  be  made  to  replace  the  bone  by  leverage 
and  by  di\dding  any  structures  which  hinder  reduction.  Should  this 
fail  excision  of  the  head  of  the  humerus  is  indicated. 

While  this  operation  is  one  of  recent  date  in  England,  credit  should  bo  given  to  those 
surgeons  who  have  practised  it,  years  ago,  elsewhere.  Cases  will  be  found  recorded  by 
Post,  of  New  York,  18G1  ;  by  Warren,  of  Baltimore,  in  1869.  In  Germany,  Langenbeck, 
Volkmann,  Cramer,  Kuster,  Kronlein,  and  others  operated  for  recurrent  dislocation  and 

^  Trans.  Amer.  Surg.  Assoc,  1896,  p.  409. 

2  Reference  may  be  made  to  a  paper  by  Dr.  A.  F.  Jonas  on  "  Old  Irreducible  Dis- 
locations of  the  Shoulder  "  ( Ann.  of  Svrg.,  1910,  vol.  li,  p.  890). 


212        OPERATIONS  ON  THE  UPPER  EXTREMITY 


old  dislocation  of  the  humerus.  M.  Leon  Tripier  published  a  successful  case  of  resection 
of  the  head  of  the  humerus,  which,  fractured  as  well  as  dislocated,  was  pressing  on  the 
brachial  artery  and  threatening  gangrene.  A  full  bibhography  is  appended  to  Dr. 
Souchon's  Article,  the  best  on  this  subject  (vide  infra,  p.  213). 

Mr.  Sheild  brought  before  the  Medico-Chirurgical  Society^  a  man, 

Coracoid  process. 


Edge  of  divided 
tendon  of  insertion 
of  pectoralis  major. 


Cephalic 
vein. 


Long  head  r 

of  biceps 


Fig.  109. 


Field  of  operation  in  habitual  dislocation  of  the  shoulder. 
(Burrdl.) 


aged  45,  on  whom  he  had  performed  excision  for  a  neglected  sub-coracoid 
dislocation  of  twelve  weeks'  standing. 

Owing  to  pressure  on  the  median  and  ulnar  nerves,  the  hand  was  almost  useless. 
Moderate  attempts  at  reduction  having  failed,  the  head  was  removed  through  the 
anatomical  neck,  this  site  being  chosen  in  order  to  disturb  the  parts  as  little  as 
need  be.  The  end  of  the  bone  was  made  as  like  the  real  head  as  possible  by  careful 
rounding.  Twelve  weeks  afterwards  the  patient  was  able  to  resume  work  as  a 
waiter.  The  movements  of  the  shoulder  were  satisfactory,  and  the  hand  gradually 
regained  strength. 

Lord  Lister  published  -  two  similar  cases  treated  by  operation,  but 
somewhat  differently. 

1  Trans.,  vol.  Ixxi,  1888,  p.  173.  ^  Brit.  Med.  Journ.,  1890,  vol.  1,  p.  1. 


EXCISION  OF  THE  SIIOULDEU-JOINT  2i;3 

Mr.  Peai'ce  Gould  and  Sir  W.  Watson  Cheyne  showed  cases  at  the 
Medical  Society.^ 

Reduction  was  in  each  case  effoctcd  after  divi.sion  of  the  muscles.  In  on^  case 
tlie  range  of  movement  was  somewhat  defective,  and  there  was  a  tendency  for  the 
head  of  the  humerus  to  sHp  forward.  Jiut  liere  four  months  had  elapsed  between  this 
dislocation  and  the  re(hu'tioi\  ;  it  was  needful  in  this  case  to  clear  out  the  glenoid 
cavity,  and  the  patient  failed  to  attend  subsequently. 

Mr.  Thorburn  ^  excised  the  head  of  the  humerus  through  the  surgical  neck,  in  a 
case  diagnosed  as  subclavicular  dislocation  and  fractiu'c  with  irregular  formation  of 
callus.  He  points  out  that  division  of  tendons  would  here  have  been  insuificient,  as 
such  a  deformed  head,  if  even  thus  reduced,  would  not  have  iittcd  into  the  glenoid 
cavity. 

Mr.  F.  C.  Wallis  published  ^  a  case  in  which  an  instructive  condition  was  found 
at  the  operation.  The  jiatient  had  had  a  dislocation  of  the  shoulder  reduced  three 
weeks  after  the  accident.  The  joint  was  ankylosed.  The  muscles  of  the  arm  were 
wasted  and  paralyt-ed,  the  movements  of  the  elbow  and  wrist-joint  very  limited  and 
the  fingers  quite  stit?.  The  limb  was  the  seat  of  neuralgic  pains.  When  the  head 
of  the  humerus  was  excised,  the  cords  of  the  brachial  plexus  were  adherent  to  the 
imier  side  of  the  bone  and  required  detachment.  Massage  was  begun  early.  The 
patient  lost  all  her  pain,  regained  good  movements  of  the  shoulder-joint,  and  could 
again  dress  and  feed  herself.     The  fingers,  remaining  stiff,  still  requu'cd  her  attention. 

The  most  complete  contribution  on  this  subject  is  a  paper  by  Dr.  E. 
Souchon,  of  New  Orleans,  "  Operative  Treatment  of  Irreducible  Dis- 
locations of  the  Shoulder-Joint,  Recent  or  Old,  Simple  or  Complicated."^ 
This  elaborate  study,  based  on  154  cases  of  operation,  abounds  with 
those  details  which  are  so  valuable  to  surgeons  who  may  have  to  deal 
with  these  occasional  but  most  difficult  cases.  The  following  are  the 
chief  conclusions  of  Dr.  Souchon  : 

"  The  anterior  incision  is  the  route.  Reduction  of  the  dislocation  is  the  more 
desirable  operation,  because  it  preserves  the  head  and  all  the  movements  depending 
thereon.  Reduction  should  be  done  only  in  cases  where  the  head  and  glenoid 
cavity  are  in  good  condition  :  when  no  extensive  dissections  have  to  be  made  ;  when 
it  is  easily  effected  without  any  great  effort  ;  when  the  head  does  not  need  to  be 
trimmed,  or  the  cup  to  be  too  deeply  scooped  or  enlarged  ;  when  the  head  readily 
remains  in  place,  but  not  too  tightly.  All  this,  regardless  of  the  time  of  standing 
of  the  dislocation.  It  should,  however,  always  be  attempted  coiLscientiously,  because 
many  have  resected,  perhaps,  when  the  dislocation  could  have  been  reduced.* 

Disregard  of  these  rules  may  lead  to  necrosis  of  the  head,  recurrence  of  the 
dislocation,  or  in  ankylosis,  with  their  inevitable  consequences.  Resection  shoul  I 
be  practised  in  all  other  cases.  When  in  doubt,  it  is  preferable  to  resect.  Ho  v 
much  to  resect — i.e.  when  to  saw  through  the  anatomical  neck  or  obliquely  and  down- 
ward outside  the  tuberosity,  or  horizontally  on  a  level  with  the  lower  margin  of  the 
head — must  be  determined  in  each  case  ;  it  is  better  to  remove  too  much  than  too 
little.  Of  course,  all  efforts  should  be  made  to  secure  aseptic  results.  A  most 
important  point  is  to  get  primary  union." 

The  folloiving  are  the  chief  obstacles  to  reduction.  (1)  The  capsule 
may  be  replaced  by  a  thick  fibrous  mass.  (2)  Adhesions  of  the  capsule 
to  the  glenoid  cavity.  (3)  Such  complete  healing  of  the  rent  in  the 
capsule  as  to  prevent  reduction.  (4)  Strong  adhesions  between  the 
new  cavity  and  the  neck  or  head  of  the  humerus.  Such  bands  may  be 
adherent  to  the  vessels  and  nerves  {see  p.  212).  (5)  Sclerosis  of  the 
muscles,  rendering  their  section  necessary.  (6)  Alteration  in  the  shape 
of  the  head  of  the  humerus.     Usually  several  of  the  above  causes  combine 

1  Lancet,  1892,  p.  474.  2  Med.  Chron.,  vol.  xiv,  p.  8. 

3  Clin.  Soc.  Trans.,  vol.  xxxi,  p.  291. 
*  Trans.  Amer.  Surg.  Assoc,  1897,  p.  311. 

^  In  young  subjects  reduction  should  always  be  preferred  to  resection,  and  if  the 
latter  is  employed  the  epiphysial  cartilage  should  not  be  injured  if  possible. 


214        OPERATIONS  OX  THE  UPPER  EXTREMITY 

to  interfere  with  reduction  or  resection.  Dr.  Souchon  shows  that 
amongst  the  difficulties  and  complications  which  may  be  expected 
during  the  operation  the  chief  are  :  A  very  thickened  capsule  or  much 
fibrous  tissue  about  the  head  of  the  humerus,  necessitating  a  tedious 
dissection,  with  persistent  oozing.  The  head  may  lie  very  deep  and 
be  adherent  to  the  adjacent  parts,  e.g.  the  ribs,  and  the  deeper  the 
position  the  greater  the  risk  of  serious  haemorrhage.  When  thus  firmly 
fixed,  the  head  may  be  prised  into  its  natural  position  by  elevators, 
scoops,  or  blunt  scissors,  and  this  failing,  division  of  the  bone  may  be 
needful,  the  head  being  then  lifted  out  by  the  above-mentioned  instru- 
ments or  loosened  with  lion-forceps.  In  other  cases  it  may  be  wiser 
to  remove  it  piecemeal.  The  glenoid  cavity  may  be  so  filled  up  as  to 
need  refashioning.^  The  vessels  and  nerves  may  lie  across  the  head  of 
the  bone.  In  the  manipulations  needful  to  get  the  head  into  place,  the 
neck  of  the  humerus  may  give  way. 

(6)  In  some  cases  where  dislocation  of  the  head  of  the  humerus  is 
associated  with  fracture  of  the  upper  extremity  of  the  bone,  especially 
through  the  anatomical  neck.  In  these  cases  reduction  of  the  dis- 
location by  such  an  incision  as  that  described  at  p.  215,  combined  with 
wiring  or  plating  of  the  fracture  will  be  preferable  to  resection  of  the 
fractured  head.  Occasionally  the  head  is  completely  separated,  or  it 
may  become  detached  during  manipulation  ;  under  these  circumstances 
it  should  be  removed.  Resection  may  also  be  called  for  as  a  secondary 
operation  if  union  fails  and  the  joint  is  stifi.  The  small  size  of  the 
upper  fragment  may  render  its  manipulation  a  matter  of  difficulty. 
To  overcome  this  the  upper  fragment  may  be  grasped  by  Peter's  bone- 
forceps  or  McBurney's  traction  hook  may  be  employed. 

(7)  A  few  cases  of  growth  {e.g.  exostosis,  chondroma,  myxochondroma, 
myeloid  growths,  and  ossifying  sarcoma)  connected  ^vith  the  upper 
extremity  of  the  humerus.  Whilst  the  priceless  value  of  the  hand 
fully  justifies  the  attempt  in  some  instances,  such  cases  must  be  extremely 
rare. 

A  well -reported  case  is  one  in  which  the  late  Sir  W.  Mitchell  Banks  2  endea- 
voured to  save  the  upper  extremity  of  a  patient  by  excising  the  upper  end  of  the 
humerus,  the  site  of  a  sarcomatous  growth  originally  regarded  as  a  chondroma. 
After  removal  in  1878,  the  growth  recurred,  and  in  three  years  had  attained  a 
very  large  size,  filling  up  the  axilla  and  extending  beneath  the  pectorals.  An  attempt 
was  made  to  excise  the  upper  half  of  the  humerus,  but  owing  to  the  involvement  of 
the  brachial  vessels  and  nerves  this  had  to  be  abandoned  and  the  limb  was  amputated 
at  the  shoulder-joint.  Though  the  shock  was  severe,  the  patient  recovered  and  was 
aUve  and  well  two  years  after  the  operation. 

Mr.  Southam  ^  has  recorded  a  successful  case  of  resection  of  the  upper 
end  of  the  right  humerus  for  an  endosteal  (mixed-ceU)  sarcoma  : 

A  large  deltoid  flap  was  made,  and  the  head  and  four  inches  of  the  shaft  of  the 
humerus  removed.  Six  months  later,  the  patient,  aged  30,  covdd  raise  her  hand  to 
her  mouth,  and  employ  her  arm  for  household  work  and  in  using  a  small  sewing 
machine.  Though,  with  the  arm  hanging  by  the  side,  there  was  an  interval  of 
about  four  inches  between  the  acromion  and  upper  end  of  the  humerus,  the  distance 
could  be  considerably  diminished  by  the  action  of  the  biceps  and  triceps,  and  coraco- 
brachialis.     A  good  illustration  accompanies  this  instructive  case 

^  If  both  the  glenoid  cavity  is  refashioned  and  the  head  of  the  humerus  resected, 
and  the  two  are  then  placed  in  contact,  ankylosis  is  likely  to  follow. 

2  Clinical  Notes  upon  Two  Years'  Work  in  the  Liverpool  Royal  Infirmary,  p.  6. 

3  Med.  Chron.,  Jan.  1887,  p.  291. 


EXCISION  OF  THE  SHOULDER  JOINT 


215 


M.  Oilier  ^  mentions  a  most  interesting  case  in  which,  by  early  inter- 
vention, resection  of  the  upper  half  of  the  humerus  for  a  sarcoma, 
central  and  subperiosteal,  saved  both  the  life  and  the  limb  of  a  child, 
6\  years  old.  The  growth  made  its  first  appearance  as  a  filbert-like 
swelling  close  to  the  insertion  of  the  deltoid.  As  the  swelling  increased 
slowly  and  resisted  treatment,  it  was  explored  by  M.  Heurtaux.  The 
sarcomatous  nature  of  the  swelling 
having  been  made  clear,  the  upper 
half  of  the  humerus  was  removed,  this 
step  being  thought  safer,  though  the 
joint  itself  was  not  involved.  No  en- 
larged glands  could  be  felt  in  the  axilla. 
Three  years  later  the  condition,  locally 
and  generally,  was  excellent.  There 
was  no  reproduction  of  the  part  re- 
moved. The  resected  end  terminated  in 
a  small  osteophytic  prolongation  joined 
to  the  scapula  by  a  fibrous  band.  The 
humerus  was  thus  unable  to  find  any 
steadying  point  so  essential  for  its 
movements.  The  limb  was  therefore 
a  flail,  but  a  very  useful  one,  thanks 
to  the  mobility  of  the  elbow  and  fingers, 
and  to  a  supporting  apparatus. 

Methods.  ( 1 )  By  an  anterior  incision 
(Figs.  110-113).  (2)  By  a  posterior  inci- 
sion, straight  or  curved.  (3)  By  a  del- 
toid flap. 

The  first  two  only  will  be  referred  to 
at  any  length  here.  The  third  interferes 
so  seriously  with  the  after-power  of 
the  deltoid  that  the  indications  for  its 
use  must  be  of  the  rarest. 

( 1 )  By  anterior  incision.  The  patient 
being    rolled    a     little    over    and  the 

humerus  abducted  from  the  trunk  to  an  angle  of  60  or  80  degrees, 
according  to  the  mobility  of  the  joint,  the  surgeon,  standing  at  the 
shoulder  facing  the  body,  with  an  assistant  opposite  to  him,  and  another 
seated  to  manipulate  the  limb,  makes  an  incision  three  and  a  half  inches 
long,  commencing  at  the  base  of  the  coracoid  process  and  on  a  level 
with  it  through  skin  and  fasci?e  ;  the  interval  between  the  deltoid  and 
great  pectoral  ^  is  then  looked  for,  and  opened  up  for  the  same  length, 

1  Loc.  supra  cit.,  t.  ii,  p.  57. 

2  The  advantage  of  an  anterior  incision  starting  from  just  outside  the  coracoid  instead 
of  from  the  acromion  is  that  the  deep  incision  is  made  either  in  the  inter-muscular  space 
or  through  the  anterior  fibres  of  the  deltoid.  In  the  latter  case  all  the  posterior  and 
outer  part  of  the  deltoid  (so  powerful  in  abduction)  is  left  intact,  together  with  the 
circumflex  vessels  and  nerve,  with  the  exception  of  the  terminal  filaments  going  to  the 
anterior  part  of  the  muscle,  which  alone  is  inteifered  with.  M.  Oilier  (loc.  supra  cit.) 
prefers  the  incision  through  the  anterior  part  of  the  deltoid,  as  owing  to  the  varying  width 
of  this  muscle  the  above  inter-space  does  not  always  correspond  to  the  coracoid  process, 
and  because  the  cephalic  vein  lies  between  the  muscles.  Where  the  soft  parts  are  much 
swollen  and  where  the  arm  cannot  be  abducted  so  as  to  bring  the  deltoid  into  rehef,  the 
operator  must  take  as  his  landmarks  the  position  of  the  coracoid  process  and  the  junction 
of  the  upper  and  middle  third  of  the  shaft  of^the^^humerus,  and  make  his  incisions  carefully. 
If  the  incision  in  the  muscular  inter-space  does  not  suflSciently  expose  the  joint,  a  flap  of 


Fig. 


110.     Anterior  oblique  incision 
for  excision  of  the  shoulder. 


21 G       OPERATIONS  ON  THE  UPPER  EXTREMITY 

retractors  inserted  and,  if  the  arm  has  been  rotated  outwards,  the 
bicipital  groove  will  usually  be  seen  lying  at  the  bottom  of  the  wound.  ^ 
The  condition  of  this  important  tendon  will  vary  much:  (I)  It  may 
be  normal;  (2)  it  may  be  surrounded  with  tuberculous  material;  (3)  it 
may  be  frayed  and  adherent  to  the  bone  ;  (4)  it  may  be  ulcerated  or 
absent. 

The  bicipital  tendon  having  been  identified,  the  capsule  is  opened 
by  a  free  incision,  the  head  examined  with  the  finger,  and  the  incision 
in  the  capsule  next  carried  downwards  along  the  bone  just  outside  the 
bicipital  groove  to  the  level  at  which  it  is  proposed  to  saw  the  bone. 
With  a  sharp-pointed,  curved,  periosteal  elevator  (Fig.  80)  the  three 
muscles  attached  to  the  greater  tuberosity  are  now  carefully  detached 


Fig.  111. 


Separation  of  the  periosteum  from  tlie  great  tuberosity,' the  arm 
being  turned  inwards.     (Farabeuf.) 


from  it.  The  assistant  in  charge  of  the  limb,  by  strenuous  rotation 
inwards,  brings  each  part  of  the  tuberosity  in  contact  with  the  elevator. 
The  operator  next  turns  his  attention  to  the  lesser  tuberosity,  the  limb 
being  now  rotated  outwards,  and  separates  the  attachment  of  the  sub- 
scapularis.  The  left  thumb,  aided  by  retractors,  protects  the  soft  parts. 
The  biceps  tendon  and  its  sheath,  if  healthy,  are  detached  bodily  with  the 
soft  parts  and  the  periosteum  on  the  inner  aspect  of  the  incision.  If 
diseased  the  sheath  must  be  opened,  and  the  tuberculous  material  removed 
with  curved  scissors  or  a  curette  while  the  tendon  is  carefully  held  aside 
with  a  blunt  hook  or  aneurysm-needle.  In  detaching  the  tendons,  and 
also,  later  on,  in  sawing  the  bone,  if  this  be  done  in  situ,  care  must  be 
taken,  by  keeping  the  arm  somewhat  separated  from  the  body,  and  the 
elbow  a  little  raised,  to  relax  all  the  parts  of  the  capsule.  Unless  this 
be  done,    the  edges  of  the  wound  in   the  capsule  are  stretched  tight, 

deltoid  may  be  turned  outwards  from  its  insertion,  if  vigorous  retraction  of  this 
muscle  does  not  suffice. 

^  Farabeuf  advises,  to  ensure  the  bicipital  groove  being  found  easily,  that  the  arm  be 
kept  midway  between  abduction  and  adduction,  a  position  secured  by  placing  the  hand 
(the  body  being  horizontal)  on  the  anterior  superior  spine. 


KXCiSIOX  OF  TlIK  SIIOrLDKH-JOINT 


217 


the  finger  is  nipped,  and  there  is  no  room  for  working  with   a   saw, 
knife,  or  elevator. 

The  bone  may  be  divided  in  two  ways:  (1)  In  situ  (Fig.  113).  A 
blunt  dissector  is  passed  under  the  bone  from  within  outwards,  so  as 
to  protect  the  soft  parts  ;  the  bone  is  completely  sawn  through  with 
a  narrow- bladed  or  a  Gigli's  saw  (Fig.  127),  seized  with  lion- 
forceps  and  twisted  out,  the  levering  movements  of  an  elevator,  or  a 
few  touches  with  the  knife,  aiding  this.  The  actual  bone  section  {see 
p.  220)  should  be  made  so  as  to  remove  the  worst  of  the  disease ;   usually 


Fig.  112.     Separation  of  the  poriosteum  from  the  le.sser  tuberosity,  the  arm 
being  turned  outwards.     (Farabeuf.) 


it  will  pass  through  the  tuberosities,  any  remaining  mischief — e.g.  in 
the  tuberosities — being  thoroughly  dealt  with  by  the  gouge.  (2)  The 
head  is  first  thrust  out  of  the  wound  by  an  assistant,  who  pushes  the 
elbow  upwards  and  backwards  and  holds  the  humerus  almost  vertical, 
and  then  sawn  off.  This  method  is  certainly  the  easier,  but  disturbs 
the  soft  parts  more.  The  former  is  perfectly  safe,  and  inflicts  less 
damage  on  the  surrounding  tissues  ;  finally,  where  ankylosis  is  present, 
it  may  be  most  difficult  to  thrust  the  head  out.  Sir  F.  Treves,  on  the 
other  hand,  considered  that  this  method  is  less  precise,  that  it  gives 
little  opportunity  of  examining  the  parts  fully,  and  that  the  tissues 
around  may  be  damaged  by  the  saw.  Whichever  plan  is  adopted, 
the  soft  parts  should  be  scrupulously  protected.  The  truncated  end 
of  the  shaft  should  be  carefully  rounded  off  with  a  saw^  or  cutting- forceps, 
especially  in  the  neighbourhood  of  the  nerves,  and  Mr.  Sheild's  plan 
of  trying  to  reproduce  the  shape  of  the  old  head  may  be  adopted. 


218       OPERATIONS  ON  THE  UPPER  EXTREMITY 


(2)  As  tuberculous  disease  of  this  joint,  which  alone  is  likely  to  need 
access  to  every  part,  is  not  common,  and  as  the  anterior  method  by  a 
free  incision  and  the  careful  use  of  retractors  allows  of  sufficient  exposure 
of  the  parts  operated  upon,  this  method  has  hitherto  been  generally 
adopted.  The  excellent  results  obtainable  by  Professor  Kocher's  posterior 
curvedincision  (Fig.  115)  more  than  justify  a  trial  of  his  method.  Professor 
Koclier  figures  a  patient  who,   after  excision  of  the  head  of  the  humerus 

by  the  above  method,  was  able 
to  raise  the  arm  vertically  by 
the  side  of  his  head.  The 
operation  was  here  performed 
for  fracture  through  the  tuber- 
osities with  rotation  of  the 
head  of  the  humerus.  The 
skin  incision  is  carried  from  the 
acromio-clavicular  joint  over 
the  top  of  the  shoulder  and 
along  the  upper  border  of  the 
acromion  to  the  outer  part  of 
the  spine  of  the  scapula,  and 
from  thence  downwards  in  a 
curved  direction  towards  the 
posterior  fold  of  the  axilla, 
ending  two  fingers'-breadth 
above  it.  The  upper  limb  of 
the  incision  passes  through 
the  superior  ligament  right  into 
the  acromio-clavicular  joint 
(the  strong  fibres  of  which 
are  divided),  and  in  the  rest 
of  its  course  divides  the  inser- 
tion of  the  trapezius  along  the 
upper  border  of  the  spine  of 
the  scapula.  The  descending 
limb  of  the  incision  divides  the  dense  fascia  at  the  posterior  border 
of  the  deltoid,  and  exposes  the  fibres  of  the  latter.  The  thrmab  is 
now  introduced  beneath  the  smooth  under-surface  of  the  deltoid,  so 
as  to  separate  it  from  the  deeper  muscles  (with  which  it  is  connected 
merely  by  loose  cellular  tissue)  up  to  its  origin  from  the  acromion 
and  its  posterior  fibres  are  divided.  The  finger  is  now  carried  along 
the  upper  border  of  the  infra- spinatus  muscle,  so  as  to  free  it 
opposite  the  outer  border  of  the  spine  and  the  root  of  the  acromion. 
In  a  similar  manner  the  supra-spinatus  is  detached  with  a  blunt  dissector 
from  the  upper  border  of  the  spine  of  the  scapula,  in  order  that  the 
finger  may  be  passed  from  above  underneath  the  root  of  the  acromion. 
The  root  of  the  acromion,  which  is  now  freed,  is  chiselled  through 
obliquely  and,  along  A^ith  the  deltoid,  is  forcibly  pushed  forwards  with 
the  thumbs  over  the  head  of  the  humerus.  In  chiselling  through  the 
bone  care  must  be  taken  not  to  injure  the  supra-scapular  nerve,  which 
passes  under  the  muscles  from  the  supra-spinous  into  the  infra-spinous 
fossa  ',  the  nerve  is  also  protected  by  the  transverse  ligament  of  the 
scapula.  It  is  desirable  before  chiselling  the  bone  to  bore  the  holes 
required  for  the  subsequent  suture.     Instead  of  dividing  the  root  of 


Fig.  113. 


Excision  of  shoulder, 
bone. 


Section  of  the 


EXCISION  OF  THE  SHOULDER-JOINT 


210 


the  acromion,  the  formation  of  the  posterior  flap  may  be  simplified 
by  merely  detaching  the  scapular  origin  of  the  deltoid  subcortically  ; 
this  allows  of  a  very  firm  union  subsequently.  After  reflecting  the 
acromio-deltoid  flap,  the  head  of  thebone  is  readily  accessible  in  its 
upper,  outer,  and  posterior  aspects,  covered  by  the  tendons  of  the 
external  rotators,  viz.  the  supra-spinatus,  infra-spinatus,  and  teres 
minor  muscles.  The  posterior  surfaces  of  these  muscles  are  also  exposed. 
An  incision  is  now  made  over  the 
head  of  the  bone  and,  in  order  to 
avoid  unnecessary  injury,  this  must 
be  done  accurately.  The  arm  being 
rotated  outwards,  a  longitudinal  in- 
cision is  carried  down  to  the  bone 
in  the  coronal  plane.  Commencing 
at  the  upper  part  of  the  lip  of  the 
bicipital  groove,  it  extends  upwards 
through  the  capsule  along  the  an- 
terior edge  of  the  insertions  of  the 
external  rotator  muscles  and  over 
the  highest  part  of  the  head  of  the 
humerus,  so  as  to  expose  the  tendon 
of  the  biceps  as  far  as  its  attach- 
ment to  the  upper  edge  of  the  glenoid 
ca\'ity.  The  insertions  of  the  ex- 
ternal rotators  are  now  separated 
from  the  greater  tuberosity  and 
drawn  backwards.  The  biceps  ten- 
don is  freed  from  its  groove  and 
drawn  forwards,  so  that  its  sheath 
mav  be  inspected.  The  whole  pro-  Fig.  114.  The  above  represents  a  fair  aver- 
cedure  is  made  easier  by  carrying  age  amount  of  movement,  such  as  may  be 
.  ,,  ,       ,  -  •'-  1        expected   after    incision    in    cmldren,    in 

the    elbow    backwards,    and    at    the    whom  the  securing  of  adequate  active  and 
same    time     rotating    the     arm    out-    passive  movement  is  always  difficult.     The 

wards.     In  this  wav  the  entire  head   ^'^^^^^  ^\^  tubercular  mischief  in   the 

.  -  .  upper  epiphvsis.     Numerous  sinuses  were 

of  the  humerus  and  the  glenoid  fossa  present  "in  front  and  in  the  axiUa. 

can  be  freely  exposed  and,  if  it   is 

not  necessary  to  do  a  complete  excision,  the  anterior  wall  of  the 
capside  and  the  insertions  of  the  anterior  muscles  can  be  preserved. 
•In  other  cases  the  insertion  of  the  subscapularis  into  the  lesser 
tuberosity  is  detached  upwards  and  inwards.  The  circumflex  vessels 
and  nerve  which  come  out  from  under  the  teres  minor  can  be  pre- 
served ;  indeed,  if  the  operation  be  properly  performed,  there  need  be 
no  fear  of  injuring  them.  When  the  head  has  been  thoroughly 
cleared,  and  especially  if  it  be  excised,  an  excellent  view  of  the  glenoid 
cavity  is  obtained,  much  better  than  is  possible  by  the  anterior  incision  ; 
and  as  it  is  most  important  to  remove  all  infected  tissues  in  tuberculous 
disease,  this  complete  exposure  of  all  parts  of  the  joint  is  the  great 
advantage  of  the  method.  Moreover,  this  free  exposure  is  obtained 
without  interfering  with  the  function  of  the  deltoid  or  other  muscles 
of  the  shoulder.  Yet  another  advantage  over  the  anterior  is,  that  when 
the  disease  in  the  head  is  limited  or  absent,  only  the  posterior  muscles 
require  to  be  separated,  while  the  anterior  part  of  the  capsule,  the 
coraco-humeral  band,  and  the  subscapularis  muscle  are  preserved  intact, 


220 


OPERATIONS  ON  THE  UPPER  EXTREMITY 


and  in  this  way  there  is  no  tendency  of  the  head  of  the  bone  to  be  dis- 
placed upwards  towards  the  coracoid,  which  so  frequently  occurs  as 
the  result  of  the  anterior  operation.  The  method  is,  therefore,  especially 
valuable  in  partial  arthrectomics. 

(3)  The  deltoid  flap  gives  more  room,  and  thus  facilitates  the  opera- 
tion considerably,  but  the  larger  scar  and,  far  greater,  in  fact  almost 
total,  impairment  of  deltoid  power,  are  such  serious  drawbacks    that 

it  is,  nowadays,  hardly  ever  used. 
If  the  head  of  the  humerus  is 
very  much  shattered,  if  the  soft 
parts  are  much  matted  and 
thickened,  if  there  is  any  special 
reason  for  completing  the  opera- 
tion rapidly,  in  the  rare  cases  of 
excision  attempted  for  large 
growths,  for  the  sake  of  more 
complete  exposure,  this  method 
may,  though  very  seldom,  be 
made  use  of. 

Site  of  section  of  the  bone 
(Fig.  113).  It  being  most  import- 
ant to  leave  the  humerus  as  long 
as  possible.not  an  atom  more  than 
is  needful  should  be  removed. 
The  section  should  be  made  just 
below  the  articular  surface  in 
every  case  where  this  will  remove 
the  whole  of  the  disease,  and 
where  all  the  head  must  go.  The 
advantages  of  sawing  here  over 
division  through  the  surgical  neck 
are  :  (1)  A  long  humerus  is  left 
to  be  brought  against  the  glenoid 
cavity  and  aid,  as  a  fulcrum,  the 
action  of  the  deltoid  in  elevating 
the  arm.  (2)  The  section  is 
made  within  the  capsule,  after,  of 
course,  freely  opening  this,  but  not  damaging  its  attachments  to  the  neck 
of  the  bone.  (3)  The  tendon  in  the  bicipital  groove  is  less  likely  to  be- 
interfered  with.  In  every  case  of  excision,  save  the  rare  one  for  new 
growths,  it  is  advisable  to  begin  by  removing  as  little  as  possible,  then 
plugging  the  wound  with  sterilised  gauze  to  test  the  freedom  in  abduc- 
tion, rotation,  &c.,  of  the  humerus  and  only  to  resort  to  further  removal 
of  bone  if  mobility  is  much  restricted. 

'The  late  Mr.  J.  N.  Davies-Colley  has  related^  a  case  of  partial 
resection  followed  by  unimpaired  movement  of  the  joint. 

As,  at  the  time  of  the  operation,  a  portion  of  the  head  of  the  humerus  seemed 
healthy,  and  the  disease  consisted  chiefly  of  a  carious  erosion  of  the  great  tuberosity 
and  the  adjacent  portion  of  the  articular  surface,  these  portions  only  were  removed, 
without  dislocating  the  head  of  the  bone.  The  part  removed  was  chiefly  the 
articular  surface  above  the  greater  tuberosity,  together  with  what  remained  of  that 
process.  The  lesser  tuberosity  appears  not  to  have  been  touched.  About  three- 
fifths  of  the  articular  surface  was  left,  being  healthy.     There  was  some  erosion  of  the 

^  Guy's  Hosp.  Rep.,  third  series,  vol.  xx,  p.  525. 


Fig.  115.     Kochcr's  posterior  incision 
for  excision  of  the  shoulder. 


EXCISION  OF  THE  SIIOULUERJOINT  221 

bone  below  the  epi])hysial  line,  but  the  greater  part  of  the  disease  was  situated  in 
the  ei)iphysis.  Tlie  section  of  the  bone  was  hard.  Seven  months  hiter  the  move- 
ment of  the  joint  ''  was  perfect  in  every  direction.  He  swings  the  arm  round  above 
his  head,  and  rotates  it  and  performs  every  action  with  as  great  freedom  and  rapidity 
as  with  the  left  shoulder-joint." 

If  the  disease  extends  lower  down,  gouging  may  be  resorted  to  or 
if  needful  one  or  two  further  sections  may  be  made  till  healthy  tissue 
is  reached,  but  as  in  the  case  of  the  elbow,  periosteal  deposits  or 
rouglionings,  which  will  subside  when  the  irritation  is  removed,  must 
not  be  mistaken  for  disease  which  calls  for  extirpation. 

The  glenoid  cavity  is  then  examined  and  gouged,  or  its  cartilage 
peeled  off  with  a  blunt  knife,  if  carious.  Cases  where  its  complete 
removal  is  called  for  must  be  most  rare.  If  really  called  for,  it  may 
be  effected  by  an  osteotome,  fine  sharp  saw,  or  cutting  bone-forceps, 
after  the  glenoid  insertion  of  the  capsule  has  been  peeled  off  to  a  suffi- 
ciently high  level ;  but  taking  away  the  glenoid  cavity  must  interfere 
with  attachments  of  the  biceps  and  triceps,  and  cause  risk  by  the  opening 
up  of  additional  cancellous  tissue. 

The  above  operation  must  be  somewhat  modified  in  cases  of  ankylosis 
and  new  growths.  In  cases  of  bony  ankylosis  the  operator  may  adopt 
one  of  the  two  following  courses  :  he  may  divide  with  a  chisel  or  gouge 
the  line  of  fusion  and  then,  the  humerus  being  movable  on  the  scapula, 
complete  the  operation  on  the  lines  already  given  ;  or,  having  sawni 
through  the  humerus  in  situ,  he  may  seize  the  bone  with  lion-forceps, 
or  drill  a  hole  and  insert  McBurney's  hook,  and  strip  it  out  of  its  periosteo- 
capsular  covering.  Much  care  must  be  taken  to  put  the  humerus  freely 
through  its  different  movements  before  it  is  decided  that  sufficient  bone 
has  been  removed,^  lest  ankylosis  recur. 

In  those  rare  cases  of  resection  of  the  upper  end  of  the  humerus  for 
new  growths  {see  p.  214),  the  operation  must  be  outside  the  periosteum, 
and  the  vessels  and  nerves  will  require  additional  attention.  More 
room  will  be  required  now  and,  to  gain  this,  the  pectoralis  major  and 
deltoid  may  each  be  detached  from  the  clavicle.  The  shoulder- joint 
itself  is  very  rarely  invaded  by  the  growth.  Owing  to  the  free  removal 
of  the  humerus,  which  is  necessary,  the  after-result  is  often  imperfect, 
though,  if  the  insertion  of  the  deltoid  can  be  preserved,  the  limb  will 
still  be  very  useful. 

Any  vessels  w^hicli  require  it,  e.g.  branches  of  the  circumflex  arteries, 
are  then  secured,  sinuses  are  laid  open,  tuberculous  tissue,  any  remnants 
of  diseased  capsule  and  synovial  membrane  removed,  and  the  sub- 
deltoid bursa,  if  involved,  dissected  out,  drainage  provided,  and  the 
upper  part  of  the  wound  closed.  The  drainage-tube  should  pass  from 
the  lowest  part  of  the  wound  in  front  (whether  this  be  within  or  below 
the  capsule),  by  means  of  a  counter- puncture,  to  the  back  of  the  upper 
arm,  so  that  the  site  of  the  operation  may  be  well  drained  while  the 
patient  is  recumbent.  In  making  the  counter-puncture,  from  within 
outwards,  the  close  contiguity  of  the  circumflex  vessels  and  nerve  must 
be  remembered. 2 

Where  excision  has  been  performed  for  tuberculous  disease,  w^th 
sinuses,  iodoform  emulsion,  and  small  tampons  of  iodoform  gauze,  which 

^  In  young  subjects  the  epiphysial  cartilage  must  be  left  undamaged,  if  jDossible. 

2  At  least  two  cases  of  fatal  injury  to  the  circumflex  artery  have  been  recorded. 
One  is  given  by  Gurlt  {Obs.,  175,  p.  750),  the  other  by  Prof.  Annandale  {Med.  Times  and 
G'az.,  May29,  1875). 


222        OPERATIONS  ON  THE  UPPER  EXTREMITY 

has  been  kept  in  a  solution  of  carbolic  acid  (1  in  20)  or  lysol  (2  per  cent.) 
will  be  employed.  At  other  times,  where  the  tissues  are  healthy,  the 
above  tampons  will  be  much  less  needed,  and  the  wound  may  be  sutured 
in  the  upper  part.  In  every  case  a  triangular  pad  of  sterilized  gauze, 
three  or  four  inches  thick  at  its  base,  should  be  placed  in  the  axilla, 
and  the  arm  carefully  secured  to  the  side,  the  elbow  being  kept  a  Httle 
forward,  and  comfortably  kept  away  from  the  thorax  by  a  suffi- 
ciently thick  layer  of  salicyhc  wool.  The  first  dressing  should  not  be 
changed  for  five  or  six  days  if  possible,  especially  in  children.  After 
the  first  dressing  the  limb  should  not  be  fastened  to  the  side,  the  fore- 
arm only  being  supported  in  a  sling.  The  tendency  to  displacement 
forwards  must  be  met  by  a  firm  pad  over  the  front  of  the  joint.  The 
axillary  pad  is  of  the  greatest  importance  and  should  be  worn  for  six 
weeks.  Otherwise,  a  limb  fixed  to  the  side  is  almost  certain.  Where 
the  parts  are  lax,  as  in  old  tuberculous  disease,  the  necessary  inter- 
ference with  the  bone,  attachments  of  tendons,  &c.,  has  been  extensive, 
less  liberty  must  be  given,  or  the  new  joint  will  be  too  loose.  While 
the  fingers  and  elbow- joint  must  be  gently  exercised  daily  from  the 
very  first,  the  date  of  commencing  movements  of  the  shoulder- joint 
will  depend  on  the  lesion  for  which  the  operation  was  performed,  and 
the  condition  of  the  parts  around.  Where  these  are  healthy,  when  but 
little  bone  has  been  removed,  where  it  is  probable  that  new  bone  will 
be  quickly  reproduced,  the  date  must  be  an  early  one.  As  a  general 
rule  it  is  of  no  use  to  begin  before  the  deep  parts  of  the  wound  are 
sufficiently  healed ;  and  this  should  be  some  time  between  the  second 
and  third  weeks.  The  chief  points  to  pay  attention  to  are  :  (1)  Care 
in  carrying  out  abduction,  lest  the  new  head  of  the  bone  be  lodged  close 
to  the  coracoid  process  instead  of  in  the  glenoid  cavity  ;  (2)  massage 
and  electricity  to  the  muscles,  especially  the  deltoid  and  the  muscles 
attached  to  the  tuberosities ;  (3)  exercise  of  the  rotator  muscles ; 
(4)  making  the  patient  carry  out  the  movements  of  his  humerus  inde- 
pendently of  those  of  the  scapula — an  end  very  difficult  to  ensure  in 
the  case  of  a  child  or  in  cases  where  the  ankylosis  has  long  existed. 
The  above  must  be  daily  and  assiduously  carried  out,  with  the  occasional 
aid  of  an  anaesthetic  if  needful.  The  practice  of  such  movements  as 
bringing  a  gun  up  to  the  shoulder,  sweeping  with  a  short  brush,  lifting 
and  carrying  light  weights  with  the  limb  abducted,  are  valuable  aids. 

Question  of  subperiosteal  resection.  As  one  of  the  chief  draw- 
backs of  the  operation  is  the  poor  amount  of  abduction  and  elevation 
which  remains  owing,  in  large  measure,  to  the  humerus  being  too 
short  to  be  brought  into  the  glenoid  cavity  when  the  deltoid  acts, 
it  may  be  strongly  urged  that  in  this  joint  a  trial  of  the  sub- 
periosteal method  should  be  carefully  made,  to  ensure  as  much  repro- 
duction of  bone  as  possible.  Von  Langenbeck^  gives  more  than  one 
case  in  which  the  arm  could  be  raised  vertically,  and  the  movements 
were  excellent.  While  it  is  true  that  these  were  cases  of  resection  for 
gunshot  injury,  and  therefore  the  patients  probably  healthy  adults,  on 
the  other  hand  preservation  of  the  periosteum  is  not  likely  to  be  so 
easily  eft'ected  here  as  in  those  cases  where  it  is  softened  by  disease. 
Even  if  the  periosteum  cannot  be  completely  preserved,  an  additional 
half  inch  or  inch  in  length  gained,  and  an  irregular  knob  or  nodule-like 
mass  which  may  be  moulded  into  a  rudimentary  head  within  the  new 
1  Arch.  J.  Min.  Chir.,  1874,  vol.  xvi. 


GUNSHOT  INJURIES  OF  THE  SHOULDER- JOINT    22.3 

capsule,  may  make  much  difference  in  the  future  mobiUty  and  useful- 
ness of  the  limb.  M.  Oilier  ^  ligures  and  describes  a  specimen  of  a  resected 
humerus  nine  years  after  the  operation. 

The  patient,  a>t.  20,  had  had  miscliief  in  tlic  joint  for  tlu'cc  years,  with,  latterly, 
suppuration  and  live  listuhe.  Five  centimetres  of  the  hum(;ruH,  measured  from  the 
summit  of  the  head,  were  removed.  After  the  operation  he  was  able  to  follow  his 
work  as  a  hawker,  and  to  use  both  arms  equally  well  in  lifting  weights.  The  upper 
end  of  the  humerus  was  irregularly  expanded,  showing  numerous  bosses  and  de2:)res- 
sions  into  which  the  insertion  of  the  capsule  and  different  muscles  could  be  followed. 

Treatment  of  gunshot  injuries  oJ  the  shoulder- joint.  Lieutenant- 
Colonel  Hickson,  R.A.M.l^,-  writes  : 

"  From  the  small  number  of  reported  cases,  wounds  of  this  joint  seem  to  be 
relatively  rare.  Only  twenty-seven  cases  have  been  noted,  of  which  nine  were 
perforations  and  eighteen  comminutions  or  fissures  of  various  degrees  of  severity. 
Of  the  nine  perforations  all  were  aseptic,  and  of  the  eighteen  comminutions  sixteen 
were  septic,  one  was  aseptic,  and  the  remaining  one,  in  which  a  primary  amputation 
proved  fatal,  has  been  classed  as  doubtful. 

(1)  Perforations.  As  in  other  joints,  the  issue  of  pure  perforations  was  most 
favourable.  Eight  of  these  cases  recovered  without  any  operative  measures  being 
necessary,  the  treatment  consisting  of  antiseptic  dressings,  with  rest ;  they  re- 
mained aseptic  throughout.  Incision  for  the  extraction  of  a  retained  bullet  in  the 
dorsal  region  was  required  in  one  case  of  perforation  ;  in  this  case  also  sepsis  did 
not  occur. 

(2)  Comminuted  Fractures.  These  resulted  either  from  serious  fractures  of  the 
upper  end  of  the  diaphysis  of  the  humerus  with  fissures  extending  into  the  joint, 
or  from  the  impact  of  the  larger-bore  bullets,  such  as  the  Martini -Henry,  from 
expanding  bullets,  or  from  fragments  of  shell.  The  very  destructive  natiu-e  of  some 
of  the  injuries  of  this  type  will  be  seen  from  the  fact  that  in  sixteen  of  the  eighteen 
cases  of  this  description  of  wounds,  operative  interference  was  called  for.  Thus,  in 
three  cases  recovery  followed  the  removal  of  fragments  ;  in  eight,  excision  of  the 
shattered  head  of  the  humerus  was  successfully  carried  out;  in  four,  amputation  at 
the  shoulder- joint  was  required,  one  of  wliich  died,  and  in  one  Berger's  interseapulo- 
thoracic  amputation  was  successfully  performed.  The  two  remaining  cases  which 
recovered  without  any  operative  measures  were  the  two  examples  of  aseptic  com- 
minutions. It  will  be  seen  from  the  above  analysis  that  either  partial  or  complete 
excision  of,  or  amputation  at,  the  shoulder-joint  was  carried  out  in  sixteen  septic 
comminutions  out  of  a  total  of  eighteen  such  wounds,  or  in  nearly  one-half  of  the 
total  number  of  reported  cases  of  every  variety."  ^ 

The  following  advice  of  Professor  Oilier  as  to  the  treatment  of  gun- 
shot and  other  injuries  of  the  shoulder- joint  will  be  found  most  useful. 

If  the  head  only  be  fractured,  and  not  in  more  than  two  or  three  fragments, 
and  if  these  are  held  together  and  not  widely  separated  he  would  trust  to  anti- 
sepsis. If  suppuration  occurred,  he  would  advise  resection  ;  and  he  points  out  that 
a  deferred  excision  has  one  advantage,  i.e.  that  time  may  have  elapsed  for  inflamma- 
tion of  the  periosteum  to  have  occurred,  and  thus  its  osteogenetic  properties  may 
be  aroused.  If  the  head  of  the  humerus  be  badly  shattered,  and  the  fragments 
much  separated  from  each  other  and  from  their  periosteum,  he  would  perform  a 
primary  excision,  endeavouring  to  reshape  the  extremity  into  a  new  head.  If 
the  splintering  and  damage  to  the  bone  does  not  affect  more  than  three  or  four 

^  Loc.  supra  cit.,  t.  i,  p.  35,  t.  ii,  p.  85. 

2  Rept.  of  Surg.  Cases  noted  in  the  South  African  War. 

^  Mr.  G.  H.  Makms  (Surg.  Experiences  in  South  Africa,  1899  1900,  p.  236)  gives  the 
following  experience  of  the  results  of  small  bullets  of  high  velocity  :  '•  Wounds  of  this 
articulation  were  by  no  means  common.  This  depended,  I  think,  on  two  points  in  the 
architecture  of  the  joint :  first,  a  bullet  to  enter  the  front  of  the  cavity  and  transverse 
the  joint  needed  to  come  with  a  great  exactitude  from  the  immediate  front ;  secondly, 
wounds  received  from  a  purely  lateral  direction  calculated  to  pierce  the  head  of  the 
humerus  and  the  glenoid  cavity  were  naturally  of  very  rare  occurrence.  Wounds  of  the 
prominent  tip  of  the  shoulder  received  while  the  men  were  in  the  prone  position  were  not 
uncommon,  but  it  was  remarkable  how  rarely  the  shoulder- joint  was  impUcated  in  these. 


224        OPERATIONS  ON  THE  UPPER  EXTREMITY 

centimetres  of  it,  all  the  damaged  bone  may  be  resected  ;  but  if  the  mischief  extends 
lower  down,  some  risk  must  be  run  and  the  injured  bone  left. 

And  his  course  would  be  the  same  in  the  case  of  a  comjiound  fracture  of  the  neck  of 
the  humerus  with  dislocation.  If  jjart  of  the  head  had  escaped  splintering,  he  would 
leave  this  attached  to  the  shaft.  Removal  of  splinters  Prof.  Oilier  directs  to  be 
done  with  the  greatest  care  of  the  periosteum,  every  atom  of  this  being  left  in  the 
wound.  Wliile  bullet-wounds  may  be  used  for  drainage,  it  is  rarely  well  to  enlarge 
them  or  to  throw  one  into  another  so  as  to  employ  them  as  the  operation  wound  ; 
this  should  be  made  in  the  usual  place.  With  regard  to  the  comparative  value  of 
primary  and  later  excision,  Prof.  Oilier  allows  that  bone  production  is  less  likely  in 
the  former  owing  to  the  periosteum  being  uninflamed  and  more  difficult  to  save. 
On  the  other  hand,  he  points  out  that,  as  yet,  we  scarcely  know  what  antiseptic 
precautions  and  the  use  of  proper  periosteal  elevators  will  effect.  Moreover,  in 
primary  resection  for  gunshot  injuries  the  patients  are  usually  young  adults,  and 
their  muscles  in  excellent  order. 

In  the  case  of  gunshot  and  other  injuries  in  which  the  damage  is  not  limited  to 
the  head  and  surgical  neck  of  the  humerus,  but  splinters  the  upper  half  or  three- 
quarters  of  the  humerus,  resection  is  still  urged  by  Prof.  Oilier  (vide  supra)  as  long  as 
the  soft  parts  are  sufficiently  sound  to  survive.  Though  the  function  of  a  limb  thus 
preserved  will  be  very  imperfect,  the  result  will  be  far  superior  to  that  of  amputation 
at  the  shoulder-joint.  In  any  such  resection  the  antiseptic  precautions  should 
be  as  comijlete  as  possible,  and  any  long  splinters,  which,  however  much  the  bone  be 
shattered,  preserve  their  relation  to  the  periosteum  should  be  left,  as,  with  the  aid 
of  the  bone  production  of  the  periosteum  around  them,  they  will  maintain  the 
continuity  of  the  bony  column. 

Recurrent  dislocation  of  the  shoulder.  Dr.  Burrell  and  Dr.  Lovett, 
of  Boston,  have  contributed  a  paper  on  this  subject,  with  six  cases, 
two  of  which  were  operated  upon,  with  an  excellent  result  in  each  case.^ 
Amongst  the  pathological  conditions,  which  vary  widely,  these  writers 
consider  the  following  to  be  established  : 

(1)  Laxity  of  the  capsule  ;  (2)  Tearing  away  of  the  capsule  from  the  glenoid 
cavity  ;  (3)  and  4)  Partial  fracture  of  the  head  of  the  humerus  or  the  glenoid 
cavity  ;  (5)  Tearing  away  of  muscular  insertions,  or  rupture  of  the  biceps  tendon  ; 
(6)  Altered  shape  of  the  head  of  the  humerus,  probably  the  result  of  chronic 
inflammation. 

The  following  are  the  chief  steps  of  the  operation  performed  by  Dr.  Burrell  in 
the  two  cases  referred  to  above.  Where  a  trial  of  primary  fixation  for  a  few  weeks, 
combined  with  massage  of  the  muscles,  followed  by  careful  movements  of  the  joint, 
fails  after  ten  weeks,  partial  resection  and  suture  of  the  capsule  -  is  recommended, 
unless  any  abnormalities  be  found  which  require  removal  of  the  head  of  the  humerus. 
A  free  incision  having  been  made  in  the  pectoro-deltoid  interval,  the  cephalic  vein 
drawn  aside,  the  coraco-brachialis  and  biceps  are  recognised  in  the  upper  and  the 
pectoralis  major  in  the  lower  part  of  the  wound.  Division  of  the  ujjper  three- 
quarters  of  the  insertion  of  the  latter  muscle  is  recommended  so  as  to  expose 
thoroughly  the  head  and  neck  of  the  bone.  The  long  tendon  of  the  biceps  will  be 
seen  and  felt  through  its  sheath.  The  incision  should  be  carried  in  its  whole  depth 
up  to  the  coracoid  jjrocess,  and  the  tendons  of  the  biceps  and  coraco-brachialis  cleared 
up  to  this  point.  By  rotating  the  head  outwards  and  drojiping  it  backwards,  the 
insertion  of  the  subcupularis  is  stretched  over  the  bone.  A  portion  of  this  insertion 
should  be  divided.  The  arm  is  next  abducted,  raised  to  a  horizontal  position,  and 
the  head  of  the  bone  pressed  backwards  so  as  to  prevent  its  coming  up  under  the 
coracoid  process,  which  it  tends  to  do  in  these  cases,*  and  also  to  relax  the  front  of 
the  caspule.  If  the  joint  ajipear  normal  the  loose  part  of  this  ligament  is  then 
grasped  with  vulsellum  forceps,  and  a  fold  three-quarters  of  an  inch  in  length  and 
three-eights  of  an  inch  wide  excised.  The  gap  is  then  sutured,  rendering  the  capsule 
distinctly  tighter  and  shorter. 

Mr.  Southam  *  published  a  case  in  which  he  had  excised  the  shoulder-joint  for  a 
frequently  recurring  dislocation  in  a  woman,  aged  45. 

1  Trans.  Amer.  Surg.  Assoc,  1897,  p.  293. 

2  The  credit  of  first  taking  this  step  is  due  to  Dr.  Gerster,  of  New  York. 

*  Two  details  in  the  operative  and  after-treatment  intended  to  meet  this  displacement 
are  given  at  pp.  219,  222. 

*  Brit.  Med.Jovrn.,  1892,  vol.  ii,  p.  1193. 


FRACTURES  OF  THE  HUMERUS  225 

Nothing  abnormal,  beyond  slight  grating,  could  bo  detected  on  examination, 
but  under  anaesthesia,  a  sub-oaracoid  dislocation  could  bo  readily  produced,  and  as 
readily  reduced. 

At  the  operation  a  small  part  of  the  anterior  rim  of  the  glenoid  cavity  was 
absent.  Tlie  head  of  the  humerus  was  sawn  through  the  anatomical  neck  ;  gentle 
passive  movements  were  begun  three  weeks  after  the  o])eration,  and,  twelve  months 
later,  tliere  had  been  no  recurrence  of  the  dislocation.  The  arm  was  then  very 
useful,  with  good  movements,  the  patient  being  able  to  perform  her  ordinary  house- 
hold duties. 

Operative  treatment  of  simple  fractures  of  the  upper  extremity  of  the 
humerus,  lu  these  injuries,  especially  fractures  of  the  surgical  neck 
and  through  or  of  the  tuberosities,  it  may,  owing  to  the  small  size  of 
the  upper  fragment,  be  impossible  to  secure  good  position  by  mani- 
pulation. Owing  to  the  proximity  of  the  articular  surface,  which  may 
itself  be  involved,  any  excess  of  callus  is  likely  seriously  to  impair  the 
mobiUty  of  the  joint.  Under  these  circumstances,  if  the  age  and  general 
condition  of  the  patient  are  satisfactory,  the  joint  should  be  opened 
by  an  anterior  incision  similar  to  that  above  described,  the  fragments 
manipulated  into  position  and  secured  by  a  plate  or  sutured  by  silver 
wire.  The  arm  must  be  bandaged  to  the  chest  to  immobilise  the  joint. 
Massage  and  passive  movements  are  commenced  on  the  tenth  day 
when  the  stitches  are  removed.  Needless  to  say,  a  careful  considera- 
tion of  radiograms  should  be  made  before  operative  measures  are  decided 
upon.  Reference  should  be  made  to  the  remarks  on  p.  213  on  the 
advantages  of  reposition  over  excision. 

In  fractures  of  the  great  tuberosity  the  small  fragment  will  be  dis- 
placed backwards  and  rotated  outwards  while  the  shaft  of  the  humerus 
is  rotated  inwards.  Satisfactory  union  is  very  unlikely  to  occur  with 
splints  or  by  fixing  the  arm  in  a  position  of  external  rotation.  An 
incision  should  be  made  over  the  tuberosity  which  is  then  fixed  in 
position  by  a  screw  or  peg. 

Operative  treatment  of  separation  of  the  upper  epiphysis  of  the 
humerus.  This  is  often  a  difhcult  lesion  to  treat.  Under  certain  cir- 
cumstances operative  treatment,  with  the  safety  that  modern  pre- 
cautions, duly  carried  out,  give  nowadays,  should  be  resorted  to.  We 
may  divide  the  cases  that  call  for  it  into  the  following  groups  :  A.  Cases 
of  simple  injury.     B.  Cases  of  compound  injury. 

A.  Simple.  These  may  be  further  divided  into  :  (a)  Those  of 
recent  date.     (6)  Those  of  longer  standing. 

(a)  Simple  cases  of  separation  of  recent  date.  Here  interference  is 
justified  when  there  is  very  great  difficulty  in  effecting  reduction  owing 
to  complete  separation  of  the  two  parts,  aided  by  the  rotation  of  the 
epiphysis  and  the  very  small  size  of  the  upper  fragment.  Mr.  Poland, 
in  his  "  Traumatic  Separation  of  Epiphyses  "  (p.  226),  states  that  one 
of  the  chief  difficulties  in  reduction  occurs  from  the  insertion  between 
the  fragments  of  bands  of  periosteum,  fascia,  or  muscle,  or  from  the 
penetration  of  the  periosteal  sheath  by  the  diaphyseal  end."  Other 
cases  are  those  where,  if  the  displacement  is  corrected,  there  is  much 
difiiculty  in  maintaining  the  reduction,  when  a  sharp  portion  of  the 
lower  fragment,  having  penetrated  the  deltoid,  is  projecting  under 
the  skin,  and  where  there  is  evidence  of  pressure  on  the  vessels  and 
nerves. 

The  operation  should  be  performed  on  some  such  fines  as  these. 
An  incision  is  made  freely  in  the  interval  between  the  pectoral  and 

SURGERY  I  i-  5 


226        OPERATIONS  ON  THE  UPPER  EXTREMITY 

deltoid  ;  the  cephalic  vein  is  drawn  aside  or  tied  between  double  liga- 
tures. The  soft  parts  having  been  widely  retracted,  the  ends  of  the 
two  fragments  are  next  identified  and  examined,  any  rent  in  the  peri- 
osteum being  carefully  enlarged  if  needful.  It  will  now  be  found  possible, 
in  some  cases,  to  replace  the  fragments  in  position,  and  then,  owing 
to  the  conical  shape  of  the  epiphysis,  fixation  by  plate  or  wire  will  not 
be  necessary.  The  edges  of  the  rent  in  the  periosteum  and  capsule 
should  be  carefully  sutured,  and  it  may  be  well  at  the  same  time  to 
close  any  opened-up  periarticular  planes  of  connective  tissue.  It  may 
be  needful,  when  the  fragments  cannot  otherwise  be  brought  into 
position,  to  remove  any  projection  from  the  lower  fragment.  If  there 
is  any  difficulty  in  retaining  the  fragments  in  position  it  will  be  best  to 
wire  them  together. 

In  those  cases  where  the  epiphysis  is  not  only  separated,  but  dis- 
located owing  to  the  severity  of  the  injury  having  lacerated  the  capsule 
freely,  Poland  ^  advises  as  follows :  '  Seeing  that  it  is  almost  impossible 
to  reduce  the  head  of  the  bone  in  these  extremely  rare  cases,  an  incision 
should  be  made  through  the  skin  and  deltoid  down  to  the  seat  of  separa- 
tion, and  the  epiphysis  replaced  in  position.  It  will  be  found  necessary 
to  open  the  capsule  of  the  shoulder- joint  before  the  epiphysis  can 
be  reduced.  This  should  be  accomplished  by  direct  manipulation  of 
the  head  into  its  place  by  pressure  of  the  thumb  and  fingers,  or  by 
means  of  a  traction  hook  inserted  into  a  hole  drilled  in  it  after 
the  method  advocated  by  McBurney.  The  fragments  should  then 
be  fastened  together  in  their  normal  position  by  means  of  pegs  or 
sutures." 

(2)  Cases  of  older  date.  Here,  where  some  weeks  or  months  have 
elapsed,  interference  may  be  called  for,  owing  to  the  limitation  of  move- 
ment, especially  as  regards  abduction,  elevation,  and  rotation,  brought 
about  by  the  overlapping  of  the  fragments,  their  union  in  a  faulty 
position,  and  the  projecting  callus.  Here,  after  exposure  of  the  seat 
of  union,  and  free  retraction  of  the  soft  parts,  the  surgeon  will  have 
to  follow  the  advice  of  M.  C.  Walther,^  and  then  decide  between 
the  necessity  of  completely  resecting  the  callus  in  order  to  place 
the  fragments  absolutely  in  position,  or  to  freely  remove  any  pro- 
jecting ends  of  the  diaphysial  fragment,  and  plane  away  any  excessive 
callus. 

B.  Compound  cases.  Here  resection  of  the  projecting  end  of  the 
diaphysis  will  usually  be  required  before  reduction  can  be  effected, 
a  step  that  will  facilitate  the  thorough  cleansing  of  the  parts  which  is 
so  much  required.  Wiring  with  sufficiently  stout  wire,  and  suture  of 
the  rent  in  the  periosteum,  will  be  required,  as  already  indicated  above. 
About  a  fortnight  after  any  of  these  operations,  passive  movements 
should  be  begun,  and  perseveringly  continued,  together  with  friction 
and  massage. 

Arthrotomy  of  the  shoulder.  This  operation  will  be  indicated  in 
cases  of  acute  suppurative  arthritis,  usually  pyeemic  in  origin. 

In  order  to  avoid  the  tendon  of  the  biceps  an  incision  should  be  made  for  two 
inches  just  below  the  acromion,  dividing  the  skua  and  the  fibres  of  the  deltoid.  The 
capsule  is  then  easily  exposed  and  may  be  opened  by  a  vertical  cut.     For  effective 

^  Loc.  supra  cit.,  p.  243. 

*  Rev.  d'Orthop.,  Jan.  1897,  p.'43,  quoted  by  Poland,  loc.  supra  cit,  p.  240. 


ARTHROTOMY  OF  THE  SHOULDER      227 

drainage  a  counter  iiuMsion  is  required  in  flie  lowest  part  of  the  caj)sule.  Burghard 
advises  tliat  this  sliould  be  made  as  follows:  "The  best  plan  is  to  raise  the  arm 
above  the  head  so  as  to  render  the  liead  of  the  hunierus  as  prominent  in  the  axilla 
as  possible,  and  then  to  cut  down  upon  this  by  an  incision  about  two  inches  long 
just  below  the  axillary  vessels.  The.^e  are  identified  and  ])ulled  upwards  so  as  to 
expose  the  capsule  below  and  behind.  The  head  of  the  bone  can  be  made  out  by  the 
finger  in  the  axilla.  The  capsule  may  be  o])ened  by  cutting  down  directly  upon  the 
head  of  the  bone  ;  this  may  be  facilitated  by  bringing  the  arm  dowii.  and  pa.ssing  a 
long  pair  of  dressing  forceps  across  the  joint  from  the  ujjper  incision  and  making 
their  points  project  beneath  the  capsule  so  that  they  can  be  cut  down  upon  and  made 
to  seize  the  drainage  tube  and  pull  it  into  position." 


CHAPTER  X 

EXCISION  OF  THE  SCAPULA 

Indications.      (1)   New    growths,    especially    sarcoma.      (2)  Caries    and 
necrosis.     (3)  Accidents,  e.rj.  railway  and  machinery  accidents. 

( 1 )  As  the  first  of  the  above  is  practically  the  only  condition  which 
calls  for  the  removal  of  the  bone,  and  as  these  cases  present  the  greatest 
difficulties,  it  is  to  removal  of  the  scapula  for  new  growths  that  most 
of  the  follo^^^ng  remarks  will  apply. 

A.  Partial  removal  o£  the  scapula.  In  a  very  few  cases  {e.g.  where 
the  surgeon,  operating  on  an  exostosis,  is  uncertain  as  to  the  nature 
of  its  base  and  does  not  feel  satisfied  with  gouging  this,  or  where  he  is 
certain  that  he  is  dealing  with  a  chondroma  and  not  with  a  chrondrifying 
sarcoma,  partial  removal  of  the  bone  may  be  sufficient.  Caries  or 
necrosis,  too,  will  only  in  very  rare  cases  call  for  more  than  a  partial 
excision.  The  chief  points  here  are  :  (1)  To  expose  freely  the  growth 
by  appropriate  flaps,  so  that  the  limits  may  be  clearly  defined ;  (2)  to 
be  provided  with  reliable  instruments  of  keen  temper,  owing  to  the 
exceeding  hardness  which  may  be  met  with  here. 

While  some  continental  writers  have  given  elaborate  directions 
for  partial  removal  of  the  scapula,  it  is  only  in  the  above  few  cases  that 
this  operation  is  likely  to  be  used  by  English  surgeons.  Mr.  Pollock, 
in  a  paper  on  two  cases  of  removal  of  the  scapula, ^  thus  advises  on  this 
matter:  "If  a  portion  of  the  scapula  be  removed,  it  should  only  be  the 
lower  portion.  But  even  if  this  be  attempted,  the  loss  of  blood  would 
probably  be  much  greater  than  if  the  whole  bone  were  removed  ;  for 
the  wound  is  more  confined,  and  the  wounded  arteries  are  more  apt 
to  retract  behind  the  bone  above,  and  offer  great  obstacles  to  their 
being  secured.  However,  should  the  lower  angle  be  alone  the  seat  of 
disease,  the  attempt  to  remove  the  lower  portion  only  is  justifiable." 
It  must,  however,  be  borne  in  mind  that,  when  a  bone  is  once  the  seat 
of  disease  which  requires  removal,  the  disease  is  very  apt  to  recur  in 
the  portion  left,  and  is  less  liable  to  re-appear  if  the  whole  bone  be 
removed. 

When  in  doubt  as  to  partial  or  complete  removal  of  the  scapula  for 
a  cartilaginous  tumour,  the  surgeon  will  be  chiefly  guided  by  the  duration 
and  the  rate  of  progress  of  the  growi:h,  its  density,  how  far  it  is  strictly 
localised,  and  whether  there  is  any  evidence  of  adjacent  nodules  of 
cartilage,  pointing  to  an  infection  of  the  medulla. 

B.  Removal  o£  the  entire  scapula  by  itself  {e.g.  cases  where  the  growth 
is  primary  in  the  scapula,  and  where  there  is  no  extension  to  the  humerus 
or  into  the  axilla).-     Preparations  against  shock  should  be  taken,  the 

1  St.  George's  Hospital  Reporf.%  vol.  iv,  p.  236. 

"  In  cases  where  the  question  lies  between  removal  of  the  scapula  and  interscapulo- 

228 


EXCISION  OF  THE  SCAPULA  229 

extremities  being  bandaged  in  cotton  wool,  the  head  kept  low,  and 
the  materials  for  infusion  in  readiness.  The  patient  is  placed  at  the 
edge  of  the  table  and  rolled  over  to  the  opposite  side.  If  the  growth 
is  verv  vascular,  or  the  patient  weakly,  pressure  on  the  subclavian, 
if  effectual,  may  help  ;  or  if,  from  the  extension  of  the  growth,  this  is 
rendered  difficult,  it  may  be  effected  by  making  an  incision  down  to  and 
through  the  deep  fascia  over  the  artery  itself,  in  order  to  enable  an 
assistant  to  put  his  thumb  or  finger  directly  upon  it.  This  may  be 
done  by  a  separate  incision,  or  by  an  extension  of  that  by  which  the 
clavicle  is  divided.  But  as  movements  of  the  limbs  may  easily  dislodge 
the  assistant's  finger,  the  operator  will  do  better  to  trust  to  plenty  of 
Spencer-Wells  forceps  and  tying  the  vessels  as  they  are  divided.  Sir 
W.  Watson  Cheyne  recommends  preliminary  ligature  of  the  subscapular 
artery.  This  surgeon  has  made  use  of  a  preliminary  anterior  incision 
in  the  removal  of  the  scapula  for  a  large  chondroma  which  filled  up  the 
axilla,  '■  projecting  the  pectoralis  forwards  to  a  marked  degree,"  an 
incision  which  he  recommends  in  all  cases. ^  "In  the  first  instance  an 
incision  was  made,  beginning  below  at  the  junction  of  the  axillary  and 
brachial  vessels,  and  running  up  in  the  line  of  the  former,  so  that  the 
axilla  was  freely  opened  in  its  whole  extent.  The  anterior  fold  of  the 
axilla  was  raised  so  as  to  expose  the  coracoid  process  ;  the  three  muscles 
attached  to  this  were  next  divided  w^ith  blunt-pointed  scissors  kept  close 
to  the  bone.  This  fully  exposes  the  axillary  artery  and  its  subscapular 
branch  is  at  once  ligatured.  The  patient  was  then  turned  over,  and 
the  operation  completed  in  the  ordinary  way.  ...  The  ligature  of  the 
subscapular  artery  answered  admirably.  In  this  case  the  patient  lost 
extremely  little  blood,  probably  not  more  than  an  ounce  altogether. 
The  detachment  of  the  muscles  attached  to  the  coracoid  process  also 
enabled  the  operation  to  be  completed  very  rapidly,  for  after  the  posterior 
scapular  muscles  had  been  divided,  and  the  trapezius  and  the  deltoid 
had  been  raised,  the  acromio- clavicular  joint  and  the  muscles  going 
to  the  head  of  the  humerus  were  practically  the  only  things  which  had 
to  be  divided." 

The  patient  being  turned  over,  flaps  are  quickly  and  freely  turned 
back,  usually  by  a  T-shaped  incision,  one  limb  running  from  the  acromio- 
clavicular joint  inwards  to  the  superior  angle  of  the  scapula,  while  the 
other  and  longer  is  made  at  right  angles  to  the  first  down  to  the  ai  gle 
of  the  scapula.  In  another  case  the  surgeon  may  prefer  to  make  an 
incision  along  the  vertebral  border  of  the  scapula,  and  the  other  at  right 
angles  to  it  across  the  centre  of  the  growth. ^  (Fig.  116).  In  either  case 
care  must  be  taken  not  to  open  the  capsule  of  the  tumour. 

thoracic  amputation,  J.  J.  Buchanan,  who  has  considered  fully  the  three  operations  of 
partial  and  complete  removal  of  the  scapula  and  interscapulo-thoracic  amputation 
(Philadelphia  Med.  Journ.,  1900),  advises  that  the  proposal  of  Jennel  (Le  Mid.  Med. 
1895,  vol.  i,  p.  251)  be  followed.  "  In  every  case  in  which  it  is  suspected  that  the  axillary 
vessels  and  nerves  may  be  involved  in  a  growth  of  the  scapula,  the  operation  should  be  so 
conducted  that  it  may,  if  desirable,  be  converted  into  a  formal  interscapulo-thoracic 
amputation.  He  makes  the  posterior  and  clavicular  incision  of  Berger,  divides  the  attach- 
ments of  the  deltoid,  and  through  this  incision  makes  a  digital  examination  of  the  relation 
of  the  growth  to  the  vessels  and  nerves.  If  satisfactory  information  cannot  be  thus 
gained  he  resects  the  outer  third  of  the  cla^dcle,  separates  the  muscular  attachments  to 
the  coracoid,  and  thus  gains  better  access  to  the  vessels  and  nerves."  Probably  it  would 
be  safer  to  follow  Berger,  and  in  all  doubtful  cases  to  begin  with  resection  of  the  clavicle. 

1  Kiyig's  College  Hospit'd  Report^\  vol.  ii,  p.  83;  Clin.  Soc.  Trans.,  1895,  vol.  xxviii, 
p.  284. 

^  If  the  skin  is  involved  the  flaps  must  be  shaped  so  as  to  isolate  this. 


230        OPERATIONS  OX  THE  UPPER  EXTREMITY 

When  the  whole  mass  is  thoroughly  exposed,  the  trapezius  and 
deltoid  are  first  severed,  the  arm  being  pulled  away  from  the  trunk. 
The  levator  anguli  scapulae  and  the  rhomboids  are  next  cut  through,^ 
the  posterior  scapular  artery  secured,  and  the  serratus  magnus  divided, 
being  first  made  tense  by  lifting  the  scapula  off  the  ribs  upwards  and 
outwards.  The  muscles  on  the  upper  border  are  now  dealt  with,  viz. 
any  remains  of  the  deltoid,  the  omo-hyoid,  and  the  supra-spinatus — 
and  the  supra-scapular  artery  secured.  The  acromio-clavicular  joint  is 
next  opened,  or  else  the  acromion  or  clavicle,  according  to  the  extension 
of  the  growth  in  this  direction,  severed  by  bone  forceps  or  a   narrow 

saw.  If  the  acromion  can  be  safely 
left,  the  resulting  deformity  —  viz. 
dropping  of  the  shoulder  and  entire 
loss  of  the  action  of  the  trapezius — 
will  be  lessened. 

The  lower  angle  being  freed  and 
the  latissimus  dorsi  (if  involved) 
resected,  the  scapula  can  now  be 
dragged  away  from  the  chest  by  slip- 
ping two  or  three  fingers  over  the 
upper  or  vertebral  border.  Thus, 
by  tilting  the  scapula  outwards,  the 
axillary  border  can  be  inspected,  the 
teres  and  infra-spinatus  muscles 
severed,  the  position  of  the  sub- 
scapular artery  defined  by  a  finger 
passed  beneath  it.  and  care  taken 
that  this  vessel,  already  tied  through 
the  preliminary  incision,  remains 
safely  secured.  The  scapula  being 
still  further  pulled  away  from  the 
chest,  the  muscles  attached  to  the 
coracoid  process  will  be  seen  severed, 
Fio.  llG.  Incision  for  excision  and  the  scapula  is  removed  by  cut- 
of  the  scapula.  ting    into    the  shoulder    joint    and 

severing  the  capsule  and  the  tendons 
of  the  biceps  and  triceps.  The  coracoid  process  may  become  detached 
at  this  stage  if  partially  eroded  by  extension  of  the  growth,  or  if  the 
patient  be  young.  If  this  happens  it  must  be  carefully  dissected  out 
afterwards.  2 

The  different  arteries,  besides  the  subscapular,  must  be  secured  if 

'  It  is  a  bad  sign  if  any  of  the  muscles  severed  are  infiltrated  with  growth.  That 
this  is  not  incompatible  with  a  good  recoverj'  is,  however,  shown  by  the  case  quoted  on 
p.  232. 

-  If  the  growth  has  involved  the  axillary  vessels  and  nerves,  this  outlj-ing  portion 
may  be  dealt  with  later  on,  after  the  main  mass  has  been  separated  and  removed.  If  it 
is  desired  to  remove  this  extension  of  the  disease  now  while  in  continuity  with  the  scapular 
growth  itself,  the  surgeon  will  liave  both  his  hands  free  for  what  is  a  troublesome  dis- 
section, by  asking  an  assistant  to  drag  the  main  mass  strongly  backwards.  But  it  wiU 
be  well,  in  cases  where  there  is  evidence  of  the  scapular  growth  having  encroached  upon 
the  large  vessels  and  nerves,  to  obtain  leave  for  the  performance  of  an  inter-scapulo 
thoracic  amputation.  The  first  step  in  the  operation  should  now  be  division  and  sufficient 
removal  of  the  clavicle,  so  as  to  clear  up  the  state  of  the  above  important  structures. 
If  they  are  involved  by  the  growth  the  more  extensive  operation  should  at  once  be  resorted 
to       " 


EXCISION  OF  THE  SCAPULA  231 

possible  before  they  are  cut.  Too  many  Spencer- Wells  forceps  must 
not  be  left  in  at  one  time,  or  they  will  be  found  to  interfere  with  the 
needful  manipulation  of  the  bone.  Every  vessel  must  be  carefully 
secured  by  lij^'ature  ;  otherwise  oozing  is  liable  to  occur  a  few  hours 
later.         '         • 

Haemorrhage  may  be  best  avoided  by  attention  to  the  following 
points  :  (1)  Making  use  of  Sir  W.  Watson  Cheyne's  method  and  securing 
the  subscapular  artery  early.  (2)  Where  this  method  is  not  available 
a  trial  of  adequate  pressure  on  the  subclavian,  this  being  effected  by 
a  special  incision,  if  needful,  to  command  the  vessel.  Reasons  for  not 
trusting  to  this  have  been  given  at  p.  229.  (3)  Dealing  with  the  axillary 
border  and  scapular  artery  last.  (4)  In  any  case  rapid  use  of  knife 
or  scissors  by  the  operator,  aided  by  intelligent  help  from  assistants  in 
securing  bleeding-points,  and  from  an  anaesthetist  who  will  not  be 
unduly  anxious,  is  essential.  (5)  Taking  care  not  to  cut  into  the 
growth  itself.  (G)  By  some  it  is  recommended  to  make  the  incisions 
gradually,  not  larger  than  are  required  at  the  time,  as  a  means  of 
minimising  the  haemorrhage.  It  must  be  remembered,  with  regard  to 
this  point,  that  small  and  cramped  incisions  interfere  with  a  free  and 
rapid  hand  and  sufficient  exposure  of  the  parts,  conditions  which  con- 
duce to  thorough  dealing  with  bleeding-points,  and  thus  facing  one  of 
the  chief  difficulties  of  this  important  operation. 

Adequate  drainage  is  now  provided  on  account  of  the  liability  to 
subsequent  oozing,  the  attachments  of  the  trapezius  and  deltoid  sutured 
together  with  fine  sterilized  silk,  the  flaps  united,  and  the  arm  secured 
to  the  side  for  a  few  days,  after  which  it  may  be  supported  in  a  sling 
if  the  head  of  the  humerus  does  not  tend  toprotrude. 

The  malignancy  of  these  sarcomata  is  well  known, ^  together  with 
their  tendency  to  involve  surrounding  parts  and  to  creep  into  regions 
inaccessible  to  the  surgeon.     Early  operation  is  imperatively  required. 

In  the  case  of  operation,  the  prognosis  will  be  best,  however  large 
the  growth,  when  the  rate  of  progress  has  been  slow,  when  the  growth 
is  uniformly  hard,  or  if  only  a  certain  amount  of  elasticity  is  combined 
with  the  hardness,  when  the  outline  is  distinct  and  well  defined,  and  the 
mass  movable  upon  the  ribs.- 

1  The  malignancy  of  these  cases  and  the  indifferent  results  of  excision  of  the  .scapula 
are  shown  in  a  paper  by  Dr.  Charles  B.  Nancrede,  on  the  End  Results  of  Excision  of 
the  Scapula  for  Sarcoma  (.4n/i.  of  Surg.,  1909,  vol.  1,  p.  1).  Dr.  Nancrede  collected  65 
cases.  Of  these  26  died  in  less  than  one  year,  3  inside  eighteen  months,  2  in  two  years; 
2  survived  for  three  years  and  1  for  five  years.  Only  one  case  was  certainly  cured  and 
6  probably  cured. 

2  That  this  mobility  is  a  matter  of  great  importance  is  shown  by  the  following  case, 
quoted  by  M.  Scdillot  at  p.  5.50  of  his  Traite  de  Medicine  operatoire  :  "  Nous  refusames  un 
jour  d'operer  un  jeune  homme  atteint  d'un  cancer  enorme  du  scapulum,  dont  les  limites 
n'etaient  pas  ncttement  fixees,  et  nous  dumes  nous  applaudir  de  notre  abstention  en 
decouvrant  plus  tard,  a  la  nccropsie,  que  la  tumeur  avait  penetre  dans  la  poitrine  et 
cnvahi  un  lobe  pulmonaire."  The  following  case,  under  the  care  of  the  late  Mr.  Marma- 
duke  Shield,  shows  how  easily  a  sarcoma  of  the  subscapular  fossa  may  implicate  the  thorax, 
without  any  exact  diagnosis  of  the  position  and  extent  of  the  growth  being  possible. 
A  boy,  fct.  10,  was  admitted  under  his  care  with  a  swelling,  the  size  of  an  orange,  on 
the  axillary  border  of  one  scapula.  This  swelling  was  somewhat  fixed,  moving  but 
slightly  when  the  arm  and  scapula  were  raised  at  the  operation.  The  intercostals  and 
pleura  were  found  to  be  blended  with  the  growth.  In  the  attempts  to  separate  them  the 
pleural  sac  was  opened.  Pneumothorax  ensued,  and  death  took  place  the  next  day. 
The  specimen  which  illustrates  this  instructive  case  will  be  found  in  the  Hunterian  collec- 
tion, R.C.S.,  No.  586B. 


282       OPERATIONS  ON  THE  UPPER  EXTREMITY 

On  the  other  hand,  the  prognosis  is  less  favourable  when  the  outline 
is  uniform  rather  than  nodulated  or  bossed,  the  feel  semi-elastic  instead 
of  hard,  the  progress  rapid  and  painful,  the  different  parts  of  the  scapula 
much  obscured  and  its  mobility  much  impaired,  the  outline  of  the 
growth  ill  defined  and  lost  indistinctly  in  the  axilla.  Pulsation,  bruit, 
enlarged  glands,  infiltration  of  the  skin,  and  any  local  rise  in  tempera- 
ture are  also  of  evil  omen.  In  these  cases,  when  the  prognosis  is  un- 
favourable, the  surgeon  will  do  well  to  resort  to  interscapulo-thoracic 
amputation. 

Condition  of  the  limb  after  removal  of  the  scapula.  A  limb  thus 
preserved  will  be  strong  and  useful.  If  the  clavicle  has  not  been  much 
interfered  with,  the  clavicular  fibres  of  the  deltoid  will  remain,  and 
these,  especially  if  sutured  to  the  trapezius,  together  with  the  latissimus 
dorsi  and  pectoralis  major,  will  probably  confer  a  fair  amount  of  move- 
ment on  the  limb.  In  one  of  Professor  Syme's  cases,  after  removal  of  the 
scapula  and  the  outer  third  of  the  clavicle  and,  by  a  previous  operation, 
the  head  of  the  humerus,  the  patient  was  able  to  lift  heavy  weights, 
and  to  fill  the  appointment  of  provincial  letter-carrier. 

In  a  very  successful  case  of  Mr.  Symonds,^  in  which  the  scapula 
was  removed  for  osteosarcoma,  the  man  was  in  good  health  two  years 
and  a  half  after  the  operation. 

He  was  able  to  do  all  the  light  work  of  a  carpenter,  including  the  use  of  a  plane. 
Overhead  work  he  could  not  do.  In  this  case  the  articular  surface  of  the  humerus 
had  also  been  removed  about  a  month  later,  as  it  was  thought  to  be  the  cause  of 
prolonged  suppuration. 

The  following  case  is  of  interest  from  the  extension  of  the  sarcoma 
into  one  of  the  scapular  muscles,  the  ill- defined  outline  and  soft  feel 
of  the  growth,  its  long  duration,  and  yet  the  long  period  of  relief  which 
has  followed  : 

In  March  1892  one  of  the  nurses  at  the  Canterbury  Hospital  was  sent  to  Mr. 
Jacobson  by  Dr.  Alexander  of  Faversham.  The  outline  of  the  left  scapula  was 
replaced  by  a  large  mass,  of  uniform  outline,  fairly  defined  over  the  lower  two- 
thirds  of  the  bone,  but  above  very  indistinct,  semi-elastic  to  the  feel,  without  any 
nodules  or  bosses  of  harder  growth.  The  scapula  was  movable  upon  the  ribs.  The 
history  was  one  of  pain  for  eight  months.  For  the  last  three  months  the  increase 
in  the  size  of  the  swelling  and  in  the  pain  had,  alike,  been  rapid.  The  scapula 
was  removed  in  Guy's  Hospital.  The  most  interesting  point  about  the  case  was 
that  the  sarcoma,  which  appeared  to  have  begun  in  the  infraspinous  fossa,  had 
perforated  the  bone,  and  in  many  places  greyish  masses  of  growth  could  be  seen 
blending  with  and  replacing  the  delicate  fasciculi  of  the  subscapularis.  The  chief 
difficulty  met  with  in  the  after-treatment  was  keeping  the  patient  quiet.  The  wound 
did  not  run  an  aseptic  course.  Ten  days  later,  incisions  were  required  for  drainage 
of  the  suppuration  which  followed.  Later  on,  the  articular  surface  and  epiphyses 
of  the  head  and  tuberosities  of  the  humerus  became  detached.  Two  years  after  the 
operation  the  antero-posterior  movements  of  the  shoulder- joint  were  good. 
The  patient  could  nurse  a  delicate  mother,  use  her  needle,  &c.,  but  abduction  and 
elevation  were  almost  completely  abolished.  In  spite  of  infiltration  of  one  at 
least  of  the  muscles,  there  was  no  evidence  whatever  of  any  recurrence. 

Age  of  the  'patient.  The  scapula  has  been  successfully  removed  for 
growth  at  ages  varying  between  "about  seventy"  and  "about  eight." 
The  former  was  a  patient  of  Professor  Syme,  who  died  about  two  months 
after  the  operation,   apparently  of  internal  deposits.     The  latter  case 

1  Clin.  Soc.  Trans.,  vol.  xx,  p.  24. 


EXCISION  OF  THE  SCAPULA  233 

occurred  in  India,  the  upper  extremity  being  removed  at  the  same  time. 
Mr.  Stephen  Paget  has  recorded^  a  successful  case  of  excision  of  the 
scapula  for  sarcoma  in  a  boy  a't.  9. 

Dangers  of  the  operation  and  causes  of  death.  Tliesc  will  be  the 
same  as  those  given  at  the  end  of  the  next  cliapter. 

(2)  Removal  oj  the  scapula  for  caries.  This,  which  will  be  very  rarely 
called  for,  needs  no  especial  mention.  The  parts  being  sufficiently 
exposed,  the  operation  will  be  conducted,  as  far  as  possible,  sub- 
periosteally,  by  means  of  appropriate  blunt  dissectors  or  periosteal 
elevators. 

^  Clin.  Soc.  Trann.  vol.  xxxvi,  p,  244. 


CHAPTER  XI 

REMOVAL  OF   THE  UPPER  EXTREMITY,  ARM,   SCAPULA, 
AND  GREATER  PART  OF  THE  CLAVICLE 

INTERSCAPULO-THORACIC  AMPUTATION  ^ 

This  operation,  performed  chiefly  for  growths  of  the  humerus  which 
cannot  be  completely  removed  by  amputation  at  the  shoulder  joint, ^ 
occasionally  for  growths  of  the  scapula,  and  for  those  of  the  axilla, 
as  in  Mr.  Stanley  Boyd's  case  {see  p.  237).  More  rarely  it  may  be  called 
for  in  cases  of  injury,  for  persistent  carcinoma  of  the  breast  {see  p.  756), 
for  tuberculous  disease,  or  for  spreading  gangrene.  It  has  been  advo- 
cated and  described  by  M.  Paul  Berger,  by  wdiose  name  it  is  commonly 
distinguished  ^  amongst  continental  surgeons,  and  by  Sir  F.  Treves  arid 
others  in  this  country  and  America.  The  method  described  below  is 
that  of  M.  Berger  ;  a  very  clear  account  is  also  given  by  M.  Farabeuf, 
by  Sir  F.  Treves,*  and  by  Professor  Kocher.  These  have  been  largely 
consulted. 

First  step.  Division  of  the  clavicle  and  securing  the  vessels.  The 
patient  being  brought  to  the  edge  of  the  table,  with  his  shoulders  raised, 
the  surgeon,  standing  outside  the  limb,  makes  an  incision  with  a  stout 
scalpel  along  the  whole  length  of  the  clavicle,  from  just  outside  the 
ster no- mastoid  to  a  point  immediately  beyond  the  acromio-clavicular 
joint.  The  incision  divides  the  periosteum  down  to  the  bone  over  the 
middle  of  the  clavicle.  At  this  stage  venous  oozing  from  the  large 
superficial  veins  here  met  with  may  be  very  free.  With  a  curved  elevator 
the  periosteum  is  separated  from  the  middle  portion  of  the  clavicle.^ 
A  large  blunt  hook  or  a  blunt  dissector  being  passed  under  the  inner 
end  of  the  bared  part  of  the  clavicle,  this  is  divided  with  a  narrow  saw. 
The  outer  part  of  the  clavicle  being  now  raised  and  steadied  with  lion- 
forceps,  and  the  periosteum  completely  separated  from  its  under  surface, 

1  Dr.  Norman  B.  Carson  has  published  (Ann.  of  Surg.,  1913,  vol.  Ixvii,  p.  796)  an 
interesting  paper  on  this  subject  giving  details  of  a  number  of  cases. 

^  As  in  Mr.  Barling's  case  (Brit.  Med.  Journ.,  1898,  vol.  i,  p.  883).  any  surgeon  in 
doubt  as  to  the  necessity  of  submitting  his  patient  to  so  severe  an  operation,  should  begin 
by  an  incision  between  the  deltoid  and  the  pectoralis  major,  and  then,  when  the 
muscles  are  thoroughly  retracted,  examine  the  condition  of  the  axilla,  the  glands,  and 
determine  the  extent  of  the  growth  and  whether  the  large  vessels  and  nerves  are 
involved.  In  other  cases  division  and  partial  removal  of  the  clavicle  may  be  required  to 
clear  up  the  doubtful  point.  In  every  case  this  preliminary  incision  should  be  made  at 
the  time  when  the  operation  is  to  be  completed,  not  as  a  preliminary  step.  On  this 
point  see  a  paper  by  Dr.  Cobb,  of  Boston  {Ann.  of  Surg.,  February  1905,  p.  267). 

3  U Amputation  du  membre.  superieur  dan.s la  contujuite  du  trpnc,  Paris,  1887. 

*  Oper.  Surg. 

s  Preliminary  detachment  of  periosteum  was  recommended  by  M.  Oilier  as  a  safeguard 
against  wounding  the  vessels.  It,  however,  obscures  the  subclavius  and  has  to  be  divided 
immediately.     In  addition  in  malignant  disease  it  may  favour  recurrence  of  the  growth. 

234 


INTERSCAPULO-TIIORACIC  AMPUTATION  235 

the  l)()iie  is  again  divided  at  the  outer  end  of  its  middle  third.  If  re- 
section of  part  of  the  clavicle  is  performed,  the  removal  of  bone  must  be 
free  enough  to  facilitate  the  finding  of  the  subclavian  vessels.  Limited 
removal  of  bone  will  much  increase  the  difficulties  of  the  above  step. 
The  tendency  of  the  upper  extremity  to  fall  outwards  after  division 
of  the  clavicle  will  increase  the  space  between  the  two  parts  of  this  bone. 
The  exposed  subclavius  with  its  sheath  is  now  isolated  and  cut  through 
close  to  the  site  of  the  iinier  section  of  the  clavicle,  dissected  up  so  as 
to  expose  the  large  vessels,  and  turned  outwards.^  Fasciae  of  varying 
thickness  will  have  to  be  divided  before  the  vessels  are  reached.  During 
this  step  the  great  pectoral  should  be  freely  divided,  especially  in  muscular 
subjects,  and  the  upper  border  of  the  pectoralis  minor  should,  if  possible, 
be  defined  ;  the  surgeon  must  be  prepared  for  troublesome  bleeding 
from  the  cephalic  vein  and  branches  of  the  acromio-thoracic  vessels, 
and  he  may  find  a  guide  recommended  by  Berger — viz.  the  external 
anterior  thoracic  nerve — easy  to  see  or  feel.  This  nerve,  if  followed 
upwards,  leads  to  the  interval  between  the  artery  and  vein.^  These 
large  vessels  are  then  secured  and  divided  between  double  ligatures, 
pushed  well  apart  in  each  case  and  tied  securely  before  the  vessel  is 
cut.  The  ligatures  should  be  placed  upon  the  subclavian  vessels  them- 
selves, at  a  point  to  which  the  tubercle  on  the  first  rib  will  be  a  guide. 
The  artery  should  be  secured  first,  and  the  arm  well  raised  while  the 
ligatures  are  placed  around  the  vein,  so  that  as  little  blood  as  possible 
be  left  in  the  extremity.  Tying  the  artery  first  will  lessen  the  size  of 
the  vein  and  render  the  securing  of  it  less  difficult ;  furthermore,  as 
pointed  out  by  Professor  Keen,  if  the  vein  be  injured,  as  happened  in 
his  case,  while  it  is  being  tied,  the  wound  will  not  be  flooded  with  blood. 
If,  however,  the  vein  be  so  much  distended  as  to  obscure  the  artery, 
the  former  vessel  must  be  taken  first.  In  either  case  the  greatest  care 
must  be  taken  not  to  injure  this  vessel  for  fear  of  air  entering  the  cir- 
culation. If  any  such  accident  occurs,  the  spot  must  be  instantly  closed 
and  the  wound  flooded  with  sterile  saline  solution.  While  exposing  the 
subclavian  vessels,  the  supra- scapular  artery  and  vein  will  probably 
be  seen  crossing  the  upper  part  of  the  wound  and  should  be  secured. 
The  nerve-cords  should  be  cut  square  and  as  high  up  as  possible.  Before 
they  are  severed  each  should  be  injected  with  novocain  or  eucaine  to 
guard  against  shock.  Mr.  Stanley  Boyd  in  his  case  {vide  infra)  finding 
that  removal  of  the  inner  third  of  the  clavicle  was  insufficient  to  permit  of 
easy  ligature  of  the  vein,  which  lay  beneath  the  inner  third,  removed 
another  inch  from  the  bone.  He  also  found  that  division  of  most  of 
the  brachial  plexus  facilitated  ligature  of  the  artery,  the  plexus  at 
once  starting  into  relief  on  division  of  the  clavicle. 

Dr.  Le  Conte,  of  Philadelphia,^  recommends  disarticulation  of  the  sternal  end 
of  the  clavicle  as  preferable  to  resection.  In  the  latter  the  large  vessels  are  ex- 
posed in  a  narrow  field  and  at  a  considerable  depth.  Disarticulation  he  believes  to 
be  simpler,  quicker,  and  safer,  by  giving  a  much  fuller  exposure  of  the  vessels.  The 
incision  is  begun  over  the  sternal  end  of  the  clavicle,  carried  to  its  middle,  and  then 
curved  downwards  to  the  anterior  axillary  fold.  The  skin  and  superficial  fascia  are 
dissected  up,  exposing  well  the  inner  two-thirds  of  the  clavicle.  The  bone  is  then 
disarticulated  by  severing  its  attachments  to  the  sternum  and  rhomboid  ligament, 
the  clavicular  part  of  the  stemo-mastoid  and  pectoralis  major.     The  clavicle  is 

1  The  subclavius  must  be  thoroughly  divided  in  order  to  obtain  room  for  securing 
the  vein. 

2  Feeling  for  the  pulsation  of  the  artery  will  be  another  guide. 
'  Ann.  oj  Surg.,  September  1809. 


236       OPERATIONS  ON  THE  UPPER  EXTREMITY 

now  pulled  upwards  and  outwards,  and  the  subclavius  stripped  off  or  divided,  and 
the  vessels  thus  well  exposed. ' 

Second  stage.  Formation  of  the  flaps.  These  are  pectoro-axillary 
and  cervico-scapular,  and  in  forming  them  the  surgeon  must  be  guided 
by  the  extent  of  the  disease.  The  patient  being  so  placed  and  steadied 
that  the  whole  of  the  scapular  region  is  free  of  the  table,  and  the 
surgeon  standing  to  the  inner  side,  i.e.  between  the  limb  and  the  trunk, 
the   pectoro-axillary  flap  is  cut  as  indicated  in  Fig.   117.      As    there 


Fig.  117.     Interscapulo-thoracic  amputation.     Outline  of  the  flaps  (leftside). 
The  posterior  or  cervico-scapular  flap  is  shown  dotted.     (Farabeuf.) 

shown,  it  commences  at  the  middle  of  the  incision  over  the  clavicle, 
runs  downwards  and  outwards  just  above  the  coracoid  process,  and 
then  parallel  with,  but  a  little  external  to,  the  depression  between  the 
deltoid  and  the  pectoralis  major.  On  reaching  the  point  where  the 
anterior  fold  of  the  axilla  and  the  arm  j"oin,  the  knife  is  carried  over 
the  lower  edge  of  the  pectoralis  major  across  the  axillary  aspect  of  the 
arm  (Fig.  117),  and  then  backwards  and  downwards  (the  limb  being 
well  raised  by  an  assistant)  so  as  to  pass  over  the  lower  edges  of  the 
latissimus  dorsi  and  teres  major  and  end  over  the  apex  of  the  scapula 
(Fig.  117).  The  above  incision  only  divides  skin  and  fasciae.  The 
pectoralis  major  is  next  cut,  and  the  pectoralis  minor  found  and  severed 
near  the  coracoid  process.  The  top  of  the  axilla  being  now  well  opened 
up,  the  cords  of  the  plexus,  if  not  already  severed,  are  divided  at  the 
same  level  as  the  great  vessels,  great  care  being  taken  of  the  central 
ligatures  on  these,  the  patient  being  rolled  over  on  to  his  sound  side, 

1  Dr.  Le  Conte  also  points  out  that  complete  removal  of  the  bone  is  safer  in  cases  of 
growth  than  leaving  the  sternal  end.  This  step  would  also  be  indicated  where  there 
are  great  dilEculties  in  finding  the  subclavian  artery  where  the  clavicle  itself  is  involved. 
In  the  latter  case,  however,  it  may  be  questioned  whether  any  operation  is  advisable. 


TNTKRSCAPULO-THORACTC  AMPUTATION  237 

and  the  limh  drawn  across  the  chest.  The  cervico- dorsal  flap  is  now 
nia(h»  by  drawiiifj;  the  knife  from  the  outer  extremity  of  the  clavicular 
incision,  straight  back  over  the  spine  of  the  scapula  to  the  lower  angle 
of  this  bone,  where  it  meets  the  first  incision.  The  skin  and  fascia 
divided  by  this  incision  are  reflected  to  the  vertebral  border  of  the 
scapula. 

Nothing  now  remains  but  the  third  mid  last  stage,  viz.  the  removal 
of  the  limb.  This  is  elVected  by  the  division  of  the  trapezius,  omohyoid, 
latissimus  dorsi,  levator  anguli,  rhomboids,  and  serratus  magnus.  While 
these  muscles  are  severed  the  flaps  are  well  held  back,  and  the  limb 
suitably  manipulated,  partly  by  an  assistant  and  partly  by  the  left 
hand  of  the  operator. 

During  this  stage  the  posterior  scapular  and  the  supra-scapular 
nmy  or  may  not  require  ligatures,  according  as  they  spring  from  the 
first  or  the  third  part  of  the  subclavian,  in  the  latter  case  being  on  the 
distal  side  of  the  ligature  (Spencer).  But,  of  course,  the  mere  mention 
of  normal  arteries  gives  no  idea  of  the  number  of  both  veins  and  arteries 
that  will  be  met  with,  enlarged,  in  cases  of  new  growths.  This  makes 
it  all  the  more  important  to  secure  first  the  subclavian  artery  and  vein. 

The  flaps  and  all  the  recesses  of  the  large  wound  are  most  carefully 
scrutinized  for  any  evidence  of  infiltration  or  extension  of  new  growth. 
The  muscles,  especially  the  pectorals,  should  be  cut  short  to  avoid  any 
possibility  of  infiltration.  Where  it  is  thought  advisable  to  shorten 
the  nerve-cords,  each  of  these  should  again  be  injected  with  eucaine 
{see  p.  235).  The  condition  of  the  glands  in  the  posterior  triangle 
should  also  be  investigated.  Drainage  should  always  be  employed  on 
account  of  the  subsequent  oozing. 

Mr.  Stanley  Boyd  ^  has  reported  the  following  instructive  case  : 

Five  weeks  previously  a  man,  set.  25,  had  come  under  his  care  at  the  Charing 
Cross  Hospital  for  sarcoma  of  the  axilla,  which  had  attained  the  size  of  two  fists  in 
three  months.  It  was  not  fixed  to  bone,  but  was  closely  attached  to  some  soft 
parts.  There  was  no  evidence  of  pressure  on  the  great  vessels  or  nerves,  of  involve- 
ment of  the  supra-clavicular  glands,  or  of  secondary  growths  in  the  viscera,  &c. 
Operation  proved  that  the  great  vessels  and  nerves  were  so  surrounded  by  growth 
that  only  an  interscapulo-thoracic  amputation  would  remove  the  disease.  As  con- 
sent had  not  been  obtained,  nothing  further  was  done  then.  Four  weeks  later  the 
mass  round  the  vessels  had  increased  considerably,  and  amputation  was  performed 
on  Berger's  lines,  with  certain  improvements  in  two  or  three  details,  which  have 
been  mentioned  above.  The  patient,  at  the  time  of  the  report,  was  making  an 
excellent  recovery. 

Dangers  of  the  operation  and  causes  of  death.     These  are  : 
(1)  Hcemorrhage.^    This  may  be  met  with  from  the  main  trunk,  the 
scapular  branches  of  the  subclavian,  the  branches  of  the  axillary,  and 
the  enlarged  anastomizing  veins  in  cases  of  growth.     The  first  two  of 

1  Brit.  Med.  Journ.,  vol.  1, 1898,  p.  883. 

-  Control  of  this  is  the  key  to  the  situation.  The  following  cases  show  what  dififi- 
culties  may  be  met  with  in  meeting  it.  Mr.  Macnamara  {Lancet,  vol.  i,  1878,  p.  669), 
after  resecting  part  of  the  clavicle,  was  unable  to  find  the  artery  owing  to  the  large  veins 
exposed.  The  haemorrhage  was  very  great,  and  the  patient  died  on  the  following  day. 
A  portion  of  growth  was  found  to  have  passed  upwards  behind  the  scaleni  muscles. 
Prof.  Keen  (Amer.  Journ.  Med.  Sci.,  June  1894)  met  with  great  trouble  in  securing  the 
subclavian  vein.  "  A  large  vein  under  the  inner  sawn  end  of  the  clavicle  tore,  and  gave 
me  much  tro>ible.  but  finally,  partly  by  a  hgature  round  the  tissues  in  which  lay  the  vein, 
and  partly  by  a  ligature  which  was  applied  temporarily  round  the  tissues  and  round  the 
sawn  end  of  the  clavicle  in  a  groove  sawed  in  the  bone,  so  as  to  prevent  the  slipping  of  the 
Hgature,  I  was  able  to  control  it." 

Another  most  instructive  case  is  given  by  Prof.  Keen  (Ann.  of  Surg.,  June  1895). 


238        OPERATIONS  ON  THE  UPPER  EXTREMITY 

these  dangers  and  the  third,  to  a  large  extent,  will  be  met  by  tying  the 
subclavian  vessels  after  Berger's  method.  This  also  prevents  entrance 
of  air  into  the  large  veins,  allows  of  section  of  vascular  muscles  like 
the  great  pectoral  with  scarcely  any  bleeding,  while  division  of  the 
posterior  muscles,  where  the  arterial  supply  has  not  been  cut  off,  is 
reserved  for  the  last  step  of  the  operation. 

If,  after  resection  of  the  clavicle,  it  is  found  impossible  to  secure 
the  third  part  of  the  subclavian  vessels  owing  to  the  profuse  venous 
oozing,  or  to  the  displacement  of  the  parts  from  invasion  of  the  growth. 
Sir  F.  T.  Chavasse  advises  proceeding  at  once  to  make  the  upper  part 
of  the  anterior  flap,  dividing  the  two  pectoral  muscles  and,  after  fully 
exposing  the  first  part  of  the  axillary  vessels,  tracing  these  up  to  the 
scalenus  anticus  and  tying  the  subclavian  artery  and  vein.  Other 
courses  open  are  to  tie  the  subclavian  vessels  in  their  part  in  the  usual 
way.  If  all  the  precautions  described  above  be  taken,  the  amount  of 
blood  lost  will  be  very  small.     Professor  Kocher  ^  says  : 

"We  performed  this  oiieration  in  1902  on  a  boy  for  a  diffuse  sarcoma  of  the 
scapula,  which  involved  the  shoulder- joint  and  the  upper  portion  of  the  humerus. 
Only  two  teaspoonfuls  of  blood  were  lost,  and  in  jfive  days  the  wound  was  simply 
covered  with  a  strip  of  collodion,  a  single  glass  drainage  tube  having  been  inserted 
through  a  special  opening  in  the  posterior  fold  of  the  axilla." 

(2)  Shock.  This  will  be  met  by  taking  every  step  to  prevent  shock 
and  hasmorrhage,  bandaging  the  limbs  and  abdomen,  keeping  the  body 
warm  on  a  hot-water  table,  administering  ether,  emptying[the  limb 
of  venous  blood  before  the  vein  is  tied,  and  completing  the  'operation 
as  speedily  as  possible.  Afterwards,  infusion  of  saline  fluid  'should  be 
resorted  to,  while  subcutaneous  injection  of  strychnine,  ether,  or  brandy, 
enemata  of  port  wine  and  beef- tea,  and  bandaging  of  the  other  limbs 
may  also  be  employed. 

This  will  be  a  fitting  place  to  refer  to  an  important  point  raised  by 
Harvey  Gushing-  in  the  avoidance  of  shock  in  major  amputations  by 
cocainization  of  large  nerve-trunks  preliminary  to  their  division  as  first 
advised  by  Crile.^  "  The  term  '  shock  '  represents  a  peculiar  state  of 
depression  of  the  central  nervous  system.  Such  a  condition  is  usually 
brought  about  by  injury  of  one  sort  or  another  to  peripheral  afterent 
nerves,  the  impulses  from  the  injury  having  acted  reflexly  upon  the 
vaso- motor  mechanism  in  the  medulla,  so  as  to  cause  a  marked  fall 
in  the  blood-pressure.  While  shock  may  be  diminished  by  perfect 
hsemostasis  and  preventing  chills,  in  cases  where  shock  is  already  present 
before  operation,  the  possibility  of  prolonged  anaesthesia  and  some 
further  loss  of  blood  render  it  certain  that  a  further  especial  risk  is 
attendant  upon  the  division  of  important  sensory  nerve-trunks.  As 
cocaine  injected  into  a  nerve-trunk  effectually  blocks  the  transmission 
of  all  centripetal  or  sensory  impulses,  cocainization  of  main  nerve- 
trunks  central  to  the  proposed  site  of  their  division  in  a  major  amputa- 
tion prevents  the  conduction  of  those  impulses  resulting  from  this 
further  injury,  which  otherwise,  by  acting  reflexly  through  the  medullary 
centre,  might  become  further  factors  in  the  production  of  shock." 

In  illustration  of  the  above  principle,  Cushing  relates  two  cases  of  interscapulo- 
thoracic  amputation,  one  of  which  was  done  without,  the  other  with  cocainisation  of 
the    chief  nerve-trunks.      In  both  hsemostasis  was  complete,  and,  except  for  the 

1  Oper.  Surg.,  p.  382.  2  jinn.  of  Surg.,  September  1902. 

^  Problems  Relating  to  Surgical  Operations,  Philadelphia,  1891. 


INTEUSCAPULO-TIIOUACIC  AMPUTATION  2.30 

above  difTorencc  in  operative  technique,  the  cases  were  in  every  respect  similar. 
Two  eliarts  recording  the  {)ulse-rat(i  are  given,  showing  distinctly  that  in  the  case  in 
whicli  t  he  nerve-t  runlcs  were  divided  without  cooainization  (hen;  was  marked  evidence 
of  shock,  which  was  absent  in  the  case  wliere  cocaine  was  emjiloyed. 

Jjund  ^  relates  a  case  of  the  above  operation  for  sarcoma  of  the  brachial  plexus, 
probably  dating  to  an  injury  and  originating  in  the  median  nerve,  in  which  each  cord 
of  the  brachial  ])lexus  was  injected  with  ten  minims  of  a  0'25  per  cent,  solution  of 
cocaine  before  division.     The  pulse  was  iniafTected. 

(3)  SeftiocBtnia.  This  is  a  very  probable  danger,  if  the  flaps  (perhaps 
left  needlessly  full)  slough,  or  if  retention  and  bagging  of  discharges 
are  allowed  to  occur  in  the  large  cavity  which  will  be  present  in  the 
stump,  unless  this  is  obliterated  by  pressure,  or  sufficient  drainage 
employed. 

(•i)  Entrance  of  air  into  veins.  This  very  nearly  proved  fatal  in  a 
case  in  which  Mr.  Jessop,  some  years  ago,  removed  the  scapula,  outer 
half  of  the  clavicle,  and  the  upper  extremity.''^ 

In  this  case  the  scapula  seems  to  have  been  removed  owing  "  to  considerable 
deficiency  of  cover  "  after  removal  of  an  upper  limb  much  damaged  by  a  machinery 
accident.  "  Whilst  cutting  through  the  last  attachments  of  the  scapula,  two  dis- 
tinct loud  whiffs  were  heard,  caused  by  the  rush  of  air  into  the  subclavian  vein." 
The  operation  was  completed  while  artificial  respiration  ^  was  being  performed,  and 
the  lad  recovered. 

(5)  Recurrence.  While  the  results  of  this  severe  operation  are,  as 
far  as  immediate  recovery  goes,  good,  recurrence,  in  the  case  of  periosteal 
sarcomata,  takes  place,  as  a  rule,  within  six  or  twelve  months.  Sir  F. 
Treves  *  writes  on  this  point :  "  Although  interscapulo-thoracic  am- 
putation is  probably  the  best  measure  in  all  cases  of  sarcoma  (ossifying 
or  not)  of  the  upper  part  of  the  humerus,  the  prognosis  is  very  gloomy. 
In  at  least  75  per  cent,  fatal  recurrence  has  followed  within  a  year." 
The  statistics  collected  for  M.  Berger  show  that  the  prognosis  is 
better  in  cases  of  sarcoma  of  the  humerus  than  in  those  where  the 
growth  affects  the  scapula  or  the  soft  parts,  and  that  it  is  best  of  all  in 
chondromata. 

(6)  If  the  patient  survive,  an  artificial  limb  should  be  fitted  at  an 
early  date.  It  may  not  admit  of  active  usefulness,  but  it  will  be  of 
service  in  preventing  the  feeling  of  most  irksome  lopsidedness  which 
in  the  convalescence  and  early  getting  about  causes  these  patients  so 
much  discomfort  in  balancing  themselves. 

(7)  With  regard  to  the  mortality  of  the  operation,  some  recent 
statistics  are  those  collected  by  MM.  Jeanbrau  and  Riche  for  M.  Berger 
and  brought  by  him  before  the  Society  of  Surgery  of  Paris.^  It  will  be 
seen  that  it  varies  widely  according  to  the  origin  of  the  growth.  In 
cases  of  growth  of  the  humerus  the  mortality  is  stated  to  have  been 
2-75  per  cent.  ;  in  growth  of  the  scapula  23-80  per  cent.  ;  and  in  growths 
of  less  certain  origin,  e.g.  soft  parts,  glands,   &c.,  11-76  per  cent. 

^  Boston  Med.  and  Surq.  Journ.,  April  16,  1903. 
2  Brit.  Med.  Journ.,  1874,  vol.  i,  p.  12. 

^  Unless  the  wound  is  kept  flooded,  this  step  is  not  without  risk  of  drawing  in  more 
air.  *  Oper.  Swrgf.,  2nded.,  vol.  i,  p.  381. 

5  Bull,  et  Mem.,  May  16,  1905,  p.  435. 


CHAPTER  XII 
OPERATIONS  ON  THE  CLAVICLE 

REMOVAL  OF  THE  CLAVICLE 

Removal  may  be  occasionally  required  for  new  growths  or  necrosis. 
In  either  case  it  is  but  rarely  called  for.  That  for  necrosis  differs  in  no 
way,  save  for  the  importance  of  surrounding  parts,  from  the  same 
operation  elsewhere. 

Removal  of  the  entire  clavicle  Jor  new  growths.  The  following  are 
the  chief  points  to  bear  in  mind,  viz.  that  (I)  the  degree  of  malignancy 
of  sarcomata  of  bone  varies  here,  as  elsewhere,  within  very  wide 
limits.  (2)  That  slowness  of  growth,  a  well-defined  outline,  regularity 
of  expansion,  together  with  absence  of  swelUng  of  the  hand,  will  be 
favourable.  (3)  A  free  incision  is  needed  along  the  curves  of  the 
bone,  with  any  additional  one  that  is  required.  (4)  Plenty  of  Spencer- 
Wells  forceps  must  be  at  hand.  (5)  The  acromial  end  should  be  set 
free  first,  either  by  opening  the  joint  or  by  sawing  the  bone,  if  healthy. 
(6)  The  freeing  of  the  coraco-  and  costo-clavicular  ligaments  is  often 
a  matter  of  much  difficulty  owing  to  their  depth  and  the  way  in  which 
the  bone  may  be  tied  down  by  the  growth.  (7)  With  periosteal  sarco- 
mata of  any  duration,  outlying  processes  may  be  present.  (8)  If  this 
be  the  case  towards  the  inner  end  of  the  growth,  it  will  require  the 
greatest  caution  to  avoid  opening  up  connective  tissue  which  is  con- 
tinuous with  that  of  the  mediastina.  (9)  Division  of  the  clavicle— 
a  step  sometimes  taken  to  facilitate  its  removal— should  be  avoided, 
if  possible,  as  the  wound  may  thus  become  infected  with  growth.  (10)  As 
in  all  removal  of  bones  infiltrated  with  growth,  the  clavicle  may  fracture 
during  operation  ;  the  outer  end  should  then  be  seized  with  lion-forceps 
and  dissected  out  so  as  to  give  more  room  for  dealing  with  the  sternal 
extremity. 

Operation.  A  horizontal  incision  is  made  along  the  whole  length 
of  the  clavicle,  with  a  vertical  incision  if  necessary  over  the  most  prominent 
part  of  the  growth.  The  skin  and  fasciae  are  reflected  so  as  to  thoroughly 
expose  the  superficial  aspect  of  the  tumour.  The  clavicular  head  of  the 
sterno-mastoid,  the  clavicular  attachments  of  the  pectoralis  major, 
the  deltoid,  and  the  trapezius  are  then  divided  beyond  the  limits  of  the 
growth.  The  acromio- clavicular  joint  is  then  opened  and  the  outer 
extremity  of  the  bone  drawn  strongly  forwards  and  upwards  by  means 
of  a  blunt  hook.  The  subclavius  muscle  and  the  coraco- clavicular 
and  rhomboid  ligaments  are  then  severed  by  a  knife  or  scissors,  the 
greatest  care  being  taken  to  avoid  injury  to  the  subclavian  vein.  These 
points  are  illustrated  in  the  following  case  by  Mr.  Bowerman  Jessett  ^ 
of  removal  of  the  entire  clavicle  for  a  large  periosteal  sarcoma. 
1  Lancet,  1889,  vol.  i,  p.  1077. 
240 


EXCISION  OF  THE  CLAVICLE  241 

The  patient  was  a  girl,  a't.  1(1  ;  the  growth  was  of  more  than  a  years  duration, 
and  extended  over  the  iinier  two-thirds  of  the  clavicle.  The  following  were  the 
chief  i)oints  which  led  the  surgeon  to  reeonunend  operation.  The  age  of  tlie  patient. 
The  fact  that  the  growth  extended  nuieh  further  on  to  the  chest  wall  than  it  did 
into  the  neck.  It  had  originated  on  the  front  of  the  clavicle  and  had  only  lately 
caused  any  pressure  on  the  vessels.  The  skin  was  not  implicated.  A  '■— )-shaped 
incision  was  made,  the  long  limb  along  the  clavii-le  and  the  shorter  one  over  the 
sti'rno-tlavicular  joint  and  growth.  Fla])s  being  reflected,  the  muscles  were  detached 
from  the  bone  as  far  as  possible,  and  the  outer  fibres  of  the  sterno-mastoid 
divided.  The  bone  was  next  divided  at  the  junction  of  the  outer  and  middle 
thirils  by  a  narrow  saw  and  bone  forceps.  The  inner  fragment  was  then  pulled  for- 
wards with  lion-forceps,  while  the  subcla^dus  was  carefully  detached  with  scissors 
curved  on  the  Hat.  Home  difficulty  was  met  with  in  o])ening  the  sternoclavicular 
joint,  as  this  was  operlapped  by  the  growth.^  A  further  extension  of  this  over  the 
top  of  the  first  rib  made  it  difficult  to  divide  the  costo-clavicular  ligament,  which  was 
effected  with  scissors  after  suitable  dragging  up  and  rotation  of  the  fragment  and 
the  growth.  Care  was  taken  to  leave  untouched  the  sternal  head  of  the  sterno- 
mastoid.  The  outer  part  of  the  clavicle  was  then  seized  with  lion-forceps  and 
removed  after  division  of  the  muscular  and  ligamentous  attachments.  There  was 
very  little  loss  of  blood.  The  patient  made  a  good  recovery,  and  three  months 
later  "  the  movements  were  equally  good  with  those  of  the  opposite  side."  In 
1893,  speaking  at  a  meeting  of  the  Medical  Society,  Mr.  Jessett  said  that  several  small 
recurrent  growths  had  been  removed. 

In  Prof.  Mott's  case  2  the  subclavius  could  not  be  seen,  being  incorporated  with 
the  diseased  mass.  This  greatly  increased  the  difficulty  of  keeping  above  the  sub- 
clavian vein  which,  though  firmly  adherent,  was  finally  detached  by  cautious  use  of 
the  handle  and  blade  of  the  knife  alternately.  The  patient  lost  from  sixteen  to 
twenty  ounces  of  blood,  but  made  a  good  recovery.  The  growth  was  an  osteo- 
sarcoma, the  size  of  two  adult  fists.  The  necropsy,  fifty-four  years  later  (the 
patient's  death  not  being  due  to  the  growth),  showed  that  three-quarters  of  an  inch  of 
the  acromial  end  had  been  left,  the  rest  of  the  site  of  the  bone  being  occupied  by  a 
ligamentous  band.  And  the  latter,  no  doubt,  is  the  condition  present  in  other  cases 
where  the  after  use  of  the  limb  has  been  so  good.  The  use  of  the  arm  is  said  to 
have  been  perfect. 

Dr.  Vaughan  ^  performed  complete  excision  for  a  mixed-celled  sarcoma.  Twelve 
months  later  the  man  was  in  good  health,  and  had  been  carrying  on  his  work  as  a 
fireman  on  a  steamboat.  Here  it  was  thought  that  suture  of  the  detached  sterno- 
mastoid  and  trapezius  to  corresponding  points  in  the  pectoralis  and  deltoid  had  con- 
tributed to  the  excellent  functional  lesuit. 

In  February  1899  Mr.  Symonds  removed  the  clavicle  for  a  mixed-cell  sarcoma. 
The  outline  of  the  bone  was  here  masked  by  the  growth,  and  the  boundaries  of  the 
latter  not  well  defined.  The  operation  was  rendered  difficult  throughout  by  the  very 
free  bleeding  at  all  jDoints,  the  extent  to  which  the  bone  was  tied  down,  and  the 
consequent  difficulty  of  getting  at  the  coraco-clavicular  and  costo-clavicular 
ligaments.     The  patient  made  a  rapid  recovery,  and  remained  well  a  year  later. 

A  case  of  angeio-sarcoma  of  the  clavicle  is  recorded  by  Dr.  Beatson, 
of  Glasgow."*  The  drawing  accompanying  the  paper  shows  the  usual 
globular  swelling,  and  gives  as  good  an  idea  of  the  fixity  which  may  be 
met  with  as  it  is  possible  for  an  illustration  to  do.  The  second  rib, 
where  eroded  by  the  growth  ,required  gouging,  and  some  enlarged 
glands,  the  nature  of  which  is  not  given,  were  removed  from  the  posterior 
triangle,  and  six  months  later  a  further  removal  of  glands  was  performed 
which  the  microscope  left  undecided  whether  they  were  sarcomatous 
or  inflammatory.  Yet  the  patient  was  alive  and  well  two  years  after 
the  first  operation. 

^  In  a  case  of  Mr.  Caddy's,  of  Calcutta,  (3Ied.  Bee,  November  19,  1892),  in  which  the 
inner  two-thirds  of  the  right  clavicle  were  removed  for  a  periosteal  sarcoma,  the  pleura 
and  innominate  vessels  were  exposed  in  dissecting  away  a  tongue  of  growth  which  i^assed 
down  behind  the  manubrium.     The  patient  recovered  with  perfect  movement  of  the  arm. 

2  Amer.  Journ.  Med.  Sci.,  vol.  iii,  O.S.  p.  100. 

3  Med.  News,  January  8,  1898. 

*  Brit.  Med.  Journ.,  1902,  vol.  i,  p.  128. 
SURGERY   I  16 


242        OPERATIONS  ON  THE  UPPER  EXTREMITY 

A  good  instance  of  partial  removal  of  the  clavicle  is  recorded  by  Sir 
J.  Bland  Sutton  :  ^ 

Here  the  acromial  half  was  removed  for  a  myeloid  growth  in  a  woman,  aged  26. 
The  chief  difificulties  met  with  were,  first,  the  tightness  with  which  the  bony  capsule 
was  tied  down  over  the  coracoid  process  by  the  coraco-clavicular  ligaments,  these 
structures  requiring  careful  division  with  scissors.  Secondly,  the  supra-scapular 
nerve  ran  in  a  shallow  groove  in  the  eapusle  of  the  tumour,  and  was  reflected  without 
injury.  Nearly  four  years  later  there  was  no  evidence  of  recurrence.  A  fibrous 
band  united  the  remains  of  the  clavicle  and  the  acromion,  and  the  patient  could 
l^erform  all  movements  of  the  extremity  perfectly. 

Mr.  S.  B.  Radley  and  Mr.  W.  Duggan  give  an.  account  ^  of  an  interesting  case 
of  a  thyroid  tumour  of  the  clavicle  treated  by  excision.  The  patient,  a  muscular 
man  aged  46,  had  been  operated  upon  for  an  adenoma  of  the  thyroid  in  September 
1910.  In  October  1912  he  was  admitted  to  the  Manchester  Royal  Infirmary  for  a 
painful  swelling  of  the  right  shoulder  ;  the  thyroid  was  then  normal  in  size  and 
moved  freely.  The  operation  of  total  excision  of  the  clavicle  was  performed  by 
Mr.  Thorburn.  Histologically  the  tumour  closely  resembled  a  secondary  thyroid 
carcinoma,  though  colloid  material  was  absent. 

OCCASIONAL    CONDITIONS    OF    THE    CLAVICLE,    ACROMION,    OR 
THEIR  JOINTS  WHICH  MAY  CALL  FOR  OPERATION 

A.  Fractures  of  the  clavicle.  (Operative  interference  may,  very 
rarely,  be  called  for  in  some  of  the  following  cases  :  (1)  In  recent  cases 
with  very  marked  displacement  difficult  to  reduce  or  keep  in  position, 
as  in  fracture  of  the  acromial  end,  outside  the  coraco-clavicular  liga- 
ments. (2)  In  compound  and  comminuted  cases,  after  the  wound 
has  been  enlarged  so  as  to  promote  asepsis,  wiring  of  the  fragments  will 
be  quite  justifiable,  especially  if  they  are  comminuted.  (3)  In  cases 
where  there  is  injury  to,  or  pressure  upon,  the  vessels  or  nerves,  either 
at  the  time  of  the  accident,  or  later  owing  to  excessive  callus.  (4)  In 
rare  cases  of  pseudarthrosis,  the  non-union  being  probably  due  to  the 
interposition  of  a  portion  of  the  subclavious.  (5)  Where  an  ugly  union 
or  pointed  process  of  bone  presses  on  the  skin  or  causes  disfigurement. 

An  excellent  instance  of  pseudarthrosis  ^  in  which  pressure  on  the 
nerves  supervened  later,  most  successfully  treated,  has  been  recorded 
by  Mr.  Barker.* 

A  boy,  aged  12,  was  noticed  soon  after  birth  to  have  a  fracture  of  the  right 
clavicle  the  cause  of  this  being  uncertain.  Ujd  to  nine  years  of  age  the  child  had 
no  inconvenience.  He  was  then  gradually  more  and  more  troubled  with  pressure 
on  the  brachial  plexus,  pain  down  the  arm,  and  a  tendency  of  the  fingers  to  become 
stiff  and  fixed  in  a  flexed  position  in  writing,  this  condition  soon  amounting  to  one  of 
painful  spasm,  rendering  the  writing  quite  illegible. 

Mr.  Barker  made  an  incision  about  two  inches  long,  with  its  ends  on  the  clavicle 
and  its  convexity  downwards.  The  flap  of  skin  thus  formed  was  turned  upwards 
to  expose  the  false  joint.  The  outer  end  of  the  inner  fragment  was  then  divided 
obliquely  in  a  plane  mnning  from  within  outwards  and  from  before  backwards. 
The  inner  end  of  the  outer  fragment  was  divided  in  a  plane  corresponding  to  that  of 
the  section  of  the  inner  fragment.  The  inner  end  of  the  outer  fragment  was  then 
separated  from  the  brachial  plexus  and  its  cut  surface  placed  upon  that  of  the  inner 
portion  of  the  bone.  The  two  were  then  united  by  silver  wire.  The  wound  was 
closed,  and  after  the  dressing  was  applied  the  arm  was  fixed  to  the  side  by  a  plaster  of 
Paris  bandage.  This  was  removed  at  the  end  of  fourteen  days,  when  the  healing 
was  complete  and  a  mass  of  callus  could  be  felt  at  the  seat  of  the  operation.     A  week 

^  Clin.  Soc.  Trans.,  vol.  xxiv,  p.  12. 

*  Bril.  Journ.  Swg.,  vol.  i. 

^  As  a  rule,  non-union  or  psoudai-throsis  of  the  clavicle  does  not  cause  the  patient 
much  trouble,  if  it  has  occurred  in  early  life.  Though  the  ends  of  the  bone  may  be 
atrophied,  the  muscles  will  be  found  hypcrtrophied. 

*  Clm.  Soc.  Trans.,  vol.  xJx,  p.  J.04. 


EXCISION  OF  THE  CLAVK  LE  2iH 

later  the  power  of  writing  was  found  to  be  inurh  iininovcd,  and  tlic  arm  eventually 
beeame  perfect  in  all  its  functions. 

Mr.  Bilton  Pollard  ^  records  a  case  of  ununited  fracture  of  about  four  months' 
duration,  in  an  infant  aged  eighteen  months,  in  which  he  resected  aiid  wired  the 
fragments  with  an  excellent  result.  Sound  union  followed,  and  the  arm,  previously 
hardly  used  at  all,  was  moved  as  wx'll  as  the  other. 

In  those  cases  where  much  deformity  has  followed  union  of  a  fractured 
clavicle,  especially  where  a  pointed  process  of  bone  projects  under  the 
skin,  it  will  be  quite  justifiable,  with  strict  aseptic  precautions,  to  explore 
and  to  remove  the  projecting  bone  with  an  osteotome  or  saw. 

B.  Dislocations.  It  is  well  known  that  occasionally  dislocations  of 
the  clavicle,  especially  those  of  the  sternal  end,  are  most  difficult  to 
maintain  in  place  after  reduction.  In  these  cases,  especially  where  the 
sternal  end  has  been  displaced  backwards  or  upwards,  in  which  situation 
it  is  liable  to  press  upon  the  trachea,  cesophagus.  or  large  veins,  operation 
is  indicated.  The  displaced  bone  is  exposed  by  a  suitable  incision,  and 
then,  after  resection  of  a  portion  of  the  extremity,  the  dislocation  can 
be  reduced  and  the  bone  wired  in  position. 

In  1890  Mr.  Jacolson  removed  the  sternal  end  of  the  clavicle  for  an  old  disloca- 
tion upwards  and  backwards  in  a  patient  at  Guys  Hospital.  Only  the  cartilage 
required  to  be  removed  from  the  sternal  facet.  The  wire  was  removed  in  three 
weeks.  When  the  patient  left  the  hospital,  five  weeks  after  the  operation,  the 
deformity  was  entirely  removed  and  the  parts  were  somidly  consolidated.  Four 
weeks  later  he  had  resumed  his  work.  He  could  raise  his  arm  to  a  right-angle, 
and  the  movements  were  increasing. 

Resection  of  the  acromion-clavicular  joint  was  performed  as  long  ago  as  1861 
by  an  American  surgeon.  Cooper  of  San  Francisco.-  He  resected  the  joint  in  three 
eases  of  acromio-clavicular  dislocation.  In  each  case  the  lesion  was  of  several  years' 
standing,  and  the  usefulness  of  the  limb  much  impaired.  In  all  three  the  result 
was  excellent.  ]\lr.  Jacobson  has  operated  bj-  resection  and  wiring  in  three  cases  of 
acromio-cla^^cular  dislocation,  two  of  these  being  primary  and  one  a  secondary 
operation.  In  two  the  result  was  perfect.  In  the  third,  one  of  the  primary  cases, 
infection  followed,  and  the  wire  had  to  be  removed.  The  deformity  was,  however, 
removed,  and  the  union  was  secure. 

C.  Disease  o£  the  ioints.  It  is  well  known  how  obstinately  tuber- 
culous disease  sometimes  attacks  the  sterno-clavicular  joint.  The 
simplicity  and  the  superficial  position  of  this  joint  render  erasion, 
followed,  if  need  be.  by  removal  with  a  chisel  or  osteotome  of  one  or 
both  bone  ends,  a  most  successful  operation. 

1  Brit.  Mcd.Journ.,  1887.  vol.  i.  p.  676. 
*  Atiier.  Journ.  of  Med.  Set'..  April  1861. 


PART    II 
THE   HEAD   AND   NECK 

CHAPTER  XIII 
OPERATIONS  ON  THE  SCALP 

But  few — viz.  those  for  large  fibro-cellular  growths  and  the  vascular 
tumours  known  as  aneurysms  by  anastomosis  or  cirsoid  aneurysms,  &c. — 
will  require  mention  in  a  work  like  this. 

FIBRO-CELLULAR  GROWTHS,  MOLLUSCUM  FIBROSUM,  OR 
PACHYDERMATOCELE  OF  THE  SCALP 

These  rare  growths,  occasionally  require  removal,  on  account  of  their 
hideous  deformity.^  The  chief  points  of  importance  in  such  operations 
are  :  (I)  The  haemorrhage.  This  may  be  terrific-  copious,  and  weeping 
from  every  part,  owing  to  the  huge  size  of  the  growth  and  the  vascularity 
of  the  parts.  It  is  best  met  by  an  ingenious  precaution  of  Mr. 
Hutchinson's,^  who  prevented  all  arterial  haemorrhage  during  an 
extensive  operation  of  this  kind  by  applying  round  the  head,  just  above 
the  ears,  a  Petit's  tourniquet  with  a  narrow  strap,  cotton-wool  being 
placed  over  the  eyes.  Nowadays  india-rubber  tubing  which  can  be 
sterilised,  or  Makka's  clamps  {see  Fig.  118,  p.  255)  would  be  preferable. 
(2)  The  need  of  maintaining  strict  asepsis.  As  nearly  the  whole  thick- 
ness of  the  scalp  affected  must  usually  be  sacrificed,  the  pericranium 
may  be  damaged  and  the  bone  necessarily  exposed.  The  risk  of 
septic  osteitis  and  then  phlebitis  of  the  veins  of  the  diploe  is  well 
known,  with  the  inevitable  result  of  pyaemia.  In  very  large  growths 
two  or  more  operations  may  be  required.  Thiersch's  method  of  grafting 
{see  p.  43)  will  be  very  useful,  either  at  the  close  of  the  operation  or 
later  on. 

Recurrence  is  not  unlikely  even  after  extensive  operations,  and 
von  Recklinghausen  has  shown  that  the  proliferation  of  the  connective 
tissue  takes  place  along  the  nerves  ;  it  is  therefore  obviously  possible 
that  such  tissue  left  along  any  of  the  nerves  may  serve  as  a  fresh  starting- 
point. 

^  A  gooi  illustration  of  these  growths  is  given  by  Mr.  Hutchinson  [Lond.  Hosp.  Rep., 
vol.  ii,  frontispiece),  and  another  by  Sir  J.  E.  Eriehsen  {Surg.,  vol.  ii,  p.  533).  The 
drawing  in  this  case  is  said  to  be  taken  from  a  patient  of  Sir  W.  Stokes. 

2  It  is  so  described  by  Sir  W.  Stokes  {loc.  supra  cit.).  The  patient,  a  man  aged  33, 
in  good  condition,  almost  died  on  the  table. 

3  Loc.  suprn  cit.,  p.  118.  The  piece  of  scalp  removed  here  was  twice  as  large  as  the 
palm  of  the  hand.     Owing  to  the  precautions  taken,  there  was  no  arterial  hcemorrhage. 

In  Sir  W.  Stokes'  case  the  base  of  the  growth  was  very  wide,  reaching  from  above  and 
in  front  of  the  right  ear  to  the  left  of  the  occipital  protuberance,  upwards  as  high  as  the 
vertex,  and  hanging  down  as  low  as  the  shoulder. 

244 


OrKKATIONS  ON  TllK  SCALP  24.5 

ANEURYSM  BY  ANASTOMOSIS  (CIRSOID  ANEURYSM) 

The  treatiueiit  ot  these  .sometimes  most  dillicult  cases  is  given  under 
the  head  of  "  Ligature  of  the  External  Carotid." 


QUESTION  OF  OPERATIVE  INTERFERENCE  IN  GROWTH  OF  THE 
CRANIAL  BONES  AND  DURA  MATER 

CucUh'  this  heading  reference  will  be  niadi;  to  ( 1 )  Exostoses  ;  (2)  those 
malignant  growths,  usually  sarcomata,  which,  springing  from  the  scalp 
(often  the  pericranium),  the  diploe,^  the  meninges,  and,  more  rarely, 
the  brain,  are  capable  of  perforating  the  skull  from  within  outwards 
or  in  the  reverse  direction.  (3)  Epitheliomata.  These  growths  are 
the  ones  in  which  the  advisability  of  operation  is  most  likely  to  arise. 

(1)  Exostoses.  It  is  only  the  ivory  variety  that  needs  reference 
here.  These  exceedingly  hard  slowly  growing  tumours  usually  grow 
from  the  fiat  bones  of  the  skull,  especially  in  the  walls  of  the  frontal 
sinus  or  in  the  external  auditory  meatus.  The  best  incision  to  expose 
it,  in  the  former  situation,  is  one  transversely  outwards  from  the  root 
of  the  nose,  through  the  eyebrow,  and  another  upwards  along  the  middle 
line  of  the  forehead.  The  anterior  wall  of  the  frontal  sinus  must  be 
freely  removed  with  trephine  or  chisel,  for  it  is  essential  to  get  at  the 
root  or  base  of  the  exostosis  and  to  divide  this,  and  not  merely  to  break 
ofi  pieces  of  the  exostosis.  For  division  of  the  extremely  dense  bone 
a  burr  worked  by  electricity  is  preferable  to  chisels  and  saws.  Where 
the  latter  are  relied  upon  several  must  be  at  hand.  When  the  pedicle 
is  detached  there  is  often  much  difficulty  in  prising  out  the  exostosis. 
The  surgeon  must  be  prepared  for  opening  the  posterior  wall  of  the 
sinus  and  exposing  the  meninges,  and  perforating  the  roof  of  the  orbit, 
and  the  delicate  tissue  of  the  ethmoid.  In  some  cases  it  will  be  well 
to  obtain  leave  to  remove  the  eyeball.  Careful  drainage  must  be  pro- 
vided for  the  first  few"  clays  in  case  of  infection  from  the  nose,  and  for 
the  same  reason  the  wound  should  not  be  too  closely  sutured  at  first. 

(2)  Sarcomata.  Periosteal,  endosteal,  and  those  originating  in  the 
dura  mater.  The  following  remarks  by  von  Bergmann,^  by  von  Bruns, 
and  von  Mikulicz  may  be  useful.  Sarcomata  of  the  skull  may  be 
periosteal  or  central.  The  temporal  bone  is  most  frequently  attacked, 
after  this  the  frontal,  parietal,  and  occipital.  Even  at  an  early  stage 
the  surgeon  has  to  face  the  c[uestion  whether  he  is  dealing  with  a  sarcoma 
of  the  skull  or  one  perforating  from  within.  In  the  majority,  whether 
periosteal,  central,  or  from  the  dura  mater,  spindle-cells  predominate 
Those  arising  in  the  dura  mater  are  characterized  by  calcification. 
In  large  periosteal  sarcomata  the  abundant  blood-supply  may  lead  to 
distinct  pulsation.  At  a  very  early  stage  this  form  shows  a  tendency 
to  increase  by  secondary  nodules,  seated  at  first  near  the  base  of  the 
original  growths.  This  tendency  to  local  dissemination,  which  can  only 
be  determined  by  the  microscope,  explains  the  frequency  of  recurrences. 
Metastases  in  the  viscera,  especially  the  lungs  and  in  the  bones,  are  very 
common.     The  lymphatic  glands,  as  a  rule,  are  not  involved. 

^  While  the  vault  is  affected  more  often  than  the  base,  sarcomata  of  the  skull  may  be 
present  in  both  situations,  simultaneously. 

^  Syst.  of  Pract.  Surg.,  by  von  Bergmann,  von  Bruns,  and  von  Mikulicz  (Amer.  Trmis., 
by  Drs.  Bull  and  Martin,  vol.  i,  p.  124). 


246       opp:rations  on  the  head  and  neck 

Only  ill  the  early  stages,  and  under  conditions  rarely  present,  is  it 
possible  to  determine  whether  a  sarcoma  of  the  skull  is  central,  periosteal, 
or  arises  from  the  dura  mater.  If  the  surface  be  hard  and  bone-like 
it  can  only  be  a  central  sarcoma  or  possibly  a  local  periosteal  hyper- 
ostosis. In  central  sarcoma  the  surface  soon  becomes  altered  by  softer 
areas  which  bulge  outwards  ;  often  the  summit  of  the  swelling  is  soft 
while  the  periphery  remains  hard.  In  this  way  the  appearance  is  very 
similar  to  that  of  a  perforating  sarcoma  of  the  dura  mater.  The  latter, 
however,  never  lifts  up  the  bony  wall  of  the  skull,  but  destroys  it  by 
infiltration  ;  the  growth  is  therefore  surrounded  by  a  bony  ring.  The 
latter  is,  however,  on  a  level  with  that  of  the  general  surface  of  the 
skull,  and  does  not,  as  in  the  case  of  the  central  sarcoma,  extend  from 
the  base  of  the  growth  towards  its  summit.  In  the  case  of  the  central 
sarcoma  the  outer  and  inner  tables  feel  as  if  they  had  been  forced  apart, 
while  in  that  of  the  periosteal  sarcoma  the  tables  show  a  jagged  edge. 
If  every  periosteal  sarcoma  were  composed  only  of  soft  tissues  it  would 
be  easy  to  distinguish  it  from  a  central  sarcoma,  as  long  as  the  latter 
possessed  a  bony  shell  at  its  base,  if  not  at  its  summit.  However,  osteo- 
sarcoma of  periosteal  origin,  a  frequent  growth,  has  a  bony  feeling  also, 
both  at  the  periphery  and  summit.  The  latter  possess  no  bony  shell, 
but  numerous  spicules  of  bone  extend  into  the  growth  from  the  site  of 
its  attachment.  On  palpation  these  growths  give  the  impression  of 
a  bony  capsule,  and  this  leads  to  mistaking  an  osteo-sarcoma  for  a 
central  sarcoma.  The  most  certain  indication  of  the  origin  of  a  new 
growth  in  the  diploe  is  the  presence  of  the  bony  wall  rising  above  the 
level  of  the  surface  of  the  skull  and  extending  towards  the  summit  of 
the  growth.  Sarcoma  of  the  dura  mater  is  recognized  in  exceptional 
cases  only  by  the  above-mentioned  peculiarities  of  the  gap  in  the  skull, 
its  situation  within  the  plane  of  the  surface  of  the  bone,  and  its  sharp 
outline.  It  may  be  diagnosed  earlier  by  other  symptoms.  "  If 
previously  existing  symptoms,  especially  those  of  intracranial  pressure, 
disappear  as  soon,  or  soon  after,  a  tumour  appears  at  the  surface  of 
the  skull,  the  surgeon  is  safe  in  assuming  that  the  growth  originated 
in  the  dura.  Such  a  tumour  begins  to  develop  within  the  cranial  cavity, 
and  brings  about  symptoms  due  to  encroachment  on  the  intracranial 
cavity.  As  soon  as  the  tumour  makes  its  exit  from  the  interior  of 
the  skull  the  diminution  of  space  and  the  combination  of  symptoms 
resulting  therefrom  cease.  In  the  second  place,  perforating  dural 
sarcoma  usually  palsates  as  a  result  of  the  pulsation  of  the  brain  being 
transmitted  to  it.  In  the  third  place,  such  a  tumour  may  be  forced 
by  pressure  into  the  cranial  cavity,  causing  temporary  headache,  slowing 
of  the  pulse,  and  loss  of  consciousness.  If  these  three  symptoms  be 
present  the  surgeon  can  with  certainty  diagnose  sarcoma  of  dural 
origin  which  has  perforated  the  skull  and  continued  to  proliferate  out- 
side. Conversely,  he  cannot,  however,  exclude  the  dural  origin  of  a 
growth  in  which  the  characteristic  symptoms  are  absent.  A  tumour 
may  be  so  closely  adherent  to  the  edge  of  the  defect  in  the  skull  that 
no  pulsation  of  the  brain  can  be  transmitted  to  it,  or  that  pressure 
cannot  force  the  growth  into  the  cranial  cavity.  The  presence  of  cerebral 
symptoms  accompanying  a  tumour  on  the  surface  of  the  skull  has  no 
bearing  on  the  differential  diagnosis  under  discussion,  for  periosteal, 
as  well  as  myelogenous,  growths  may  proliferate  inwardly  as  well  as 
outwardly.     The  diagnostic  importance  of  cerebral  symptoms  depends 


OPERATIONS  ON  THE  SCAT.P  247 

upon  the  fact  that  tliey  occur  before  the  tumour  becomes  noticeable, 
and  disappear  after  it  has  ur.uU^  its  ap])earance  on  the  surface.  As 
soon  as  the  tumour  reaches  the  surface  of  the  skull  it  spreads  out  to 
an  extraordinary  dej^ree,  the  defect  in  the  skull  completely  covered, 
and  there  is  no  longer  anything  to  distinguish  it  from  periosteal  and 
myelogenous  sarcomata,  which  similarly  proliferate  and  attain  an 
enormous  size." 

TrcdliHcnf.  It  remains  to  be  seen  what  operative  attacks,  aided  by 
modern  surgery,  may  avail  in  these  cases,  but  for  the  present,  unless  an 
opportunity  arise  for  attacking  such  growths  quite  early — e.g.  while 
they  are  oidy  of  small  size — it  will  be  wiser  not  to  inferfere.^  And  this 
warning  is  especially  true  of  those  cases  in  which  sarcomata  of  a  specially 
malignant  kind  appear,  often  after  an  injury,  on  the  crania  on  children,'^ 
where  the  swellings  of  the  scalp  are  nudtiple,  or  where  they  are  travelling 
out  of  the  skull  by  any  of  the  apertures,  ('.(/.  the  orbit.  Large  size,  any 
evidence  of  fixity,  duration  of  any  length  will  cause  any  operation  to 
be  set  aside,  owing  to  the  dangers  of  the  operation,  the  possibility  of  its 
being  incomplete,  especially  where  the  brain  is  involved,  and  the  risk 
of  its  being  impossible  to  close  the  gap.  In  addition  to  the  question 
of  metastases  in  such  cases,  the  frequent  presence  of  minute  local 
secondary  nodules  {.see  p.  245)  must  be  remembered. 

The  necessary  difficulty  and  tediousness  in  isolating  the  affected 
bone,  if  of  any  size,  by  sufficient  trephine-crowns,  and  joining  these 
with  a  Gigli's  saw  {see  p.  314),  or  the  forceps  of  De  Vilbiss  {.see  p.  312), 
or  a  chisel.^  It  must  be  remembered  that  the  overlying  soft  parts  were 
extremely  vascular  and  perhaps  (from  the  enlarged  gland)  already 
involved  in  the  growth.  The  position  of  these  growths  will  not  always 
admit  of  the  use  of  an  india-rubber  band  round  the  head.  In  isolating 
and  going  wide  of  the  affected  bone,  it  was  uncertain  whether  one  or 
more  sutures  would  not  be  crossed,  and  sinuses,  such  as  the  superior 
longitudinal,  met  with  and  need  securing  (this,  whether  by  underrunning 
or  otherwise,  not  being  always  an  easy  matter),  thus  leading  to  profuse 
hgemorrhage.  In  addition  to  this  source  of  hsemorrhage  there  is  that 
certain  to  be  met  with  in  dealing  with  the  soft  parts  and  with  the 
diploe  around  the  affected  bone,  unless  this  be  extensively  sclerosed, 
when  another  difficulty  presents  itself. 

Tlien.  supposing  the  bone  sufficiently  removed,  wide  of  the  growth, 
in  many  pieces,  either  because  of  its  involvement  in  the  disease,  or  to 
allow  of  further  investigation  in  the  case  of  a  growth  of  doubtful  origin, 
if  this  be  found  to  arise  from  the  dura  mater,  this  membrane  must 
certainly  be  dealt  with,  and  the  same  would  very  likely  be  the  case  if, 
originating  in  the  diploe,  the  growth  had  crept  inwards.  In  further 
isolating  the  disease,  if  it  had  merely  pressed  upon  the  brain  and  not 
involved  it  most  delicate  w^ork  would  be  required  ;    enlarged  branches 

1  An  interesting  case  is  published  by  Sir.  H.  Morris  {Path.  Soc.  Tra?^.,  vol.  xxxi, 
p.  259).  The  disease  hei'e  certainly  took  six  years  in  running  its  course  ;  other  deposits 
were  present.  The  patient  died  away  from  London.  The  growth  is  stated  to  have  begun 
in  the  diploe,  and  to  have  compressed,  not  involved,  the  brain.  Dr.  Drummond  of  New- 
castle, published  three  interesting  cases  {Brit.  Med.  Journ.,  1883,  vol.  ii,  p.  762).  In 
none  of  them  was  operation  possible.  Other  instances  of  sarcomata  of  the  cranial  bones  or 
the  dura  mater  are  figured  by  Tilmanns  {Text-book  of  Surg.,  vol.  ii). 

2  A  good  instance  of  such  traumatic  sarcomata  is  recorded,  with  illustrations  by  Mr. 
Hewetson,  of  York  {Lancet,  189,3,  vol.  i,  p.  1441). 

'  The]  best  means  of  removing  bone  from  the  skull  on  a  large  scale  are  given  at 
pp.  311-313. 


248  OPERATIONS  ON  THE  HEAD  AND  NECK 

of  the  middle  meningeal  and,  ven'  likely,  dilated  sinuses  would  require  to 
be  dealt  with.  If  the  disease  had  involved,  instead  of  merely  displacing, 
the  brain,  new  and  special  risks  would  have  to  be  encountered  just  when 
the  patient's  condition,  after  an  already  prolonged  operation,  was  least 
fitted  to  bear  them.  Thus  the  operator  may  find  that  he  is  dealing 
^^ith  a  non-encapsuled  growth  of  the  brain  itself,  and  all  that  he  can 
do  is  to  try  and  shell  it  out  with  the  finger  or  sharp  spoon.  Lastly, 
the  arrest  of  all  hsemorrhage  and  the  possibility  of  closing  the  wound 
and  gap  in  the  skull,  usually  by  a  second  operation,  if  the  patient  survive, 
have  to  be  remembered. 

Such  are  among  the  chief  diflSculties  and  dangers  which  are  very 
likely,  if  not  certain,  to  be  met  with. 

Moreover,  in  these  and  in  other  prolonged  operations  which  deal 
with  the  brain  and  its  membranes,  the  fact  must  never  be  lost  sight 
of  that,  with  all  the  necessary  interference  with  vital  organs,  and  what 
with  the  ansesthetic,  the  margin  left  to  the  patient  between  hfe  and 
death  may  be  a  ver\'  narrow  one.  Even  if  the  growth  is  small  and 
circumscribed,  and  there  is  good  reason  to  beheve  that  it  is  single,  it 
will  probably  be  wiser  to  dixade  the  operation  into  two  stages  if  the 
dura  mater  be  involved. 

The  results  given  by  von  Bergmann.^  especially  when  due  weight 
is  given  to  his  unusual  experience  and  operative  skill,  do  not  seem 
encouraging.  The  last  sentence  referring  to  "  cases  apparently  per- 
manently cured*'  is  too  vague  to  be  of  any  real  value.  '  The  author 
has  done  extensive  resections  in  four  cases  of  cranial  sarcoma  ;  in  one 
of  these  the  patient  died.  The  tumour  had  prohferated  a  considerable 
depth  into  the  occipital  lobe,  and  the  profuse  bleeding  which  resulted 
caused  collapse.  The  three  other  patients  recovered.  Two  died  at 
the  end  of  one  and  a  half  and  two  years,  respectively,  as  a  result  of 
recurrence  of  the  growth.  Regarding  the  fate  of  the  third,  he  was  not 
able  to  obtain  any  information.  Grunberg  investigated  the  histories 
of  all  operations  published  during  the  last  two  decades.  Twent^'-two 
operations  were  performed  on  seventeen  patients.  In  three  cases  two 
or  more  attempts  at  interference  were  made  necessary  by  recurrence  of 
the  growths.  The  operation  was  completed  in  seventeen  cases.  Three 
of  the  patients  died  as  a  result  of  the  operation,  death  being  caused 
by  entrance  of  air  into  sinuses,  thrombosis  of  sinuses,  and  cerebral 
abscess.  In  seven  cases  recurrence  took  place  soon  after  the  operation. 
In  two  no  information  was  obtainable.  Of  seventeen  cases  five  were 
apparently  permanently  cured,  which  is  a  good  result,  considering  the 
fatal  termination  otherwise." 

(3)  Another  similar,  but  distinct,  class  of  these  growths  is  formed 
by  those  epitheliomata  of  the  scalp  which  have  extended  through  the 
cranium  to  the  dura  mater  or  even  the  brain.  Tillmanns  '  gives  good 
illiLstrations  of  two  such  epitheliomata  invohnng  the  frontal  region  : 
one.  in  a  girl  of  14.  which  perforated  the  skull,  was  successfully  removed 
by  Braun  ;  the  other,  in  a  man  of  56,  was  operated  on  by  Tillmanns. 
Here  recurrence  rapidly  took  place.  A  xevy  instructive  case  of  carcinoma 
of  the  frontal  region,  invohdng  the  skull,  was  successfully  operated  on 
by  Mr.  Battle  and  is  fully  described  in  the  Clin.  Soc.  Trans.,  1899.  vol. 
xxxii;  p.  127.  Mr.  Shattock  pronounced  the  growth  to  be  a  spheroidal- 
celled  carcinoma,  probably  originating  in  the  glandular  structures  of 
1  Loc.  supra  cit..  p.  148.  *  Surg.,  vol.  ii. 


OPERATIONS  ON  THE  SCALP  249 

tli('  skill.     Mr.  Battle's  remarks  on  the  mode  chosen  for  removal  of  the 

cranial  hone  arc  \'crv  noteworthy  : 

"  Of  the  priiic;ij)al  methods  of  removing  large  portions  of  the  skull,  the  one 
whieh  was  brought  to  my  notice  by  Messrs.  Down — that  of  a  circular  saw  worked 
by  a  motor — appeared  the  most  likely  to  fulfil  the  object  in  a  satisfactory  manner. 
There  was,  however,  much  difHcuitj'  in  guitling  the  saw  along  the  line  which  I  had 
selected,  and  it  travelled  slowly  through  the  dense  bone,  whilst  the  cable  attached 
to  it  was  cumbrous  and  difficult  to  hold.  Were  I  again  called  upon  to  perform  a 
similar  operation,  or  one  requiring  the  excision  of  much  bone,  1  should  use  the 
method,  since  suggested,  of  the  wire  saw,  worked  across  from  one  trcpine  opening 
to  another,  and  applied  from  witliiii  outwards." 


CHAPTER  XIV 
TREPHINING 

OPERATIVE  INTERFERENCE  IMMEDIATE  OR  LATERE  IN 
FRACTURES  OF  THE  SKULL 

Indications.     The  chief  are  : 

(1)  Compound  depressed  fractures.  Whether  symptoms  of  com- 
pression are  present  or  no  these  fractures  should,  as  a  rule,  be  explored 
by  reflecting  adequate  flaps,  then  elevating  any  depressed  fragments 
and  remo\ang  any  which  are  quite  loose.  At  the  same  time  the  surface 
of  the  dura  mater,  where  exposed,  should  be  carefully  scrutinized  and, 
together  with  the  rest  of  the  wound,  thoroughly  cleansed. 

Operative  interference  is  indicated  in  tliese  cases  for  two  reasons  : 
(a)  Even  if  no  symptoms  of  compression  are  present  at  first,  secondary 
inflammation  is  very  likely  to  follow  in  a  few  days,  it  not  ha\ang  been 
possible  by  expectant  treatment  completely  to  cleanse  the  wound. 
If,  now,  some  minute  fragment  of  the  brittle  inner  table  has  pricked 
the  dura  mater,  fatal  infective  meningitis  is  almost  certain.  Should, 
therefore,  the  surgeon,  in  these  cases,  wait  for  evidence  of  compression 
as  a  justification  of  operative  interference,  he  will  too  often  wait  till 
it  is  too  late.  E\'idence  of  the  presence  of  dirt,  especially  of  dirt  ground 
down  to,  or  into,  the  bone,  is  a  reason  for  exploring  the  wound,  even 
if  no  symptoms  of  compression  are  present,  (b)  If  the  patient  recover 
from  the  immediate  effects  of  the  fracture,  injury  to  the  inner  table, 
insufficient  to  cause  symptoms  at  the  time,  and  not  detectable  save  by 
an  operation,  may  be  present  all  the  time  and  cause  serious  future 
trouble.  In  the  words  of  Professor  Xancrede  :  -  "  Undoubtedly  many 
patients  recover  in  whom  the  bone  is  not  elevated,  but  in  too  many 
epilepsy,  insanity,  chronic  cerebral  irritation,  &c.,  render  life  a  burden, 
and  operations  are  then  required,  which  often  prove  useless.^  Operations 
for  traumatic  epilepsy  show  at  times  that  in  the  effort  to  unite  the 
irregular  fragments,  and  from  constant  irritation  due  to  the  cerebral 

^  By  these  terms  it  is  intended  to  make  a  distinction  between  those  cases  in  which 
operative  interference  is  made  use  of  within  a  few  days  after  a  fracture,  and  those  in 
which  it  is  only  employed  a  long  time  after  the  injury.  {See  "  Trephining  for  Traumatic 
Epilepsy.") 

2  Intern.  Encycl.  of  Surg.,  toI.  v,  p.  24. 

3  Dr.  Gunn  {Trans.  Amer.  Surg.  Assoc,  vol.  i,  p.  89),  speaking  of  later  trephining 
for  the  relief  of  old  depressed  fractures,  says  "Although  results  of  these  secondary-  opera- 
tions do  not  show  a  flattering  percentage  of  success,  I  think  that  the  reason  may  be  looked 
for  in  the  late  period  at  which  the  operation  is  performed.  It  is  rare  that  the  patient 
submits  to  the  operation  till  years  have  been  wasted  in  the  vain  endeavour  to  effect  a 
cure  by  medication.  In  the  meantime,  the  constant  irritation  has  begotten  a  permanent 
impression  upon  the  brain  and  nervous  system  which  remains  after  the  offending  point 
of  irritation  has  been  removed." 

2.50 


THKPIIINIXG  251 

pulsation  (liiviii<i;  the  dura  mater  against  the  bony  fragments,  Nature 
throws  out  osteopliytic  masses,  which  eventually — poihaps  after  years 
— set  up  serious  trouble.'  The  surgical  treatment  of  traumatic  epilepsy 
is  now,  when  a  large  number  of  cases  operated  upon  have  been  carefully 
watched,,  found  to  be  very  disappointing  [see  p.  272).  It  is  by  a  more 
freipient  immediate  exploration  of  all  doubtful  injuries  to  the  head 
that  we  may  best  hope  to  bring  about  a  diminishing  frequency  of  trau- 
matic epilepsy,  {c)  Locality  is,  of  itself,  an  indication  for  interference. 
Thus  aphasia  may  follow  on  a  fracture  over  the  region  of  the  anterior 
inferior  angle  of  the  left  parietal,  and  paresis  on  one,  apparently  trivial, 
over  the  motor  area.  Moreover  it  is  injuries  to  the  frontal  and  parietal 
regions  which,  if  left  unexplored  or  insufficiently  treated,  are  so  liable 
to  be  followed  by  epilepsy. 

A  word  of  warning  is  needed  here.  While  the  more  localized  is  the 
depression  of  a  fracture  over  the  motor  area,  the  more  will  the  surgeon 
be  justified  in  interfering;  he  must  not  be  certain  that  he  will  thereby 
prevent  epilepsy  in  the  future.  Von  Bergmann's  words  on  this  matter 
are  weighty  ones.^  "  As  a  matter  of  fact,  epilepsy  occurs  as  frequently 
in  connection  with  head  injuries  in  which  no  fracture  exists.  Depression 
is  no  more  a  factor  in  the  etiology  of  this  disease  than  any  other  scar 
of  the  brain  or  external  soft  parts  that  has  become  adherent  to  the 
skull.  At  present  it  is  known  that  where  an  act  of  \HoIence  not  exceeding 
the  limits  of  elasticity  of  the  skull  flattens  or  bends  in  the  latter  without 
producing  fracture,  the  portion  of  brain  underlying  the  point  of  impact 
may  be  contused.  The  depressed  fragment  of  skull,  being  elastic, 
springs  back  into  its  former  position,  but  the  portion  of  brain  injured 
at  the  moment  of  depression  undergoes  a  sclerotic  degeneration  from 
which  may  originate  an  attack  of  Jacksonian  epilepsy  ;  the  same  may 
take  place  as  the  result  of  damage  to  the  cerebral  cortex  following 
depressed  fracture." 

(2)  Simple  depressed  fractures.  Where  symptoms  of  depression  are 
present,  operative  interference  is  the  only  course  open.  But  where 
no  such  symptoms  are  present,  the  expectant  treatment  is  by  most 
surgeons  held  to  be  sufficient.  We  may  perhaps  come  best  to  a 
decision  as  to  using  operative  interference  in  simple  depressed  frac- 
tures, without  symptoms,  by  dividing  them  into  the  three  following 
groups  : 

(1)  Where  the  depression  extends  over  a  considerable  area,  where 
it  is  slight  in  degree  (e.g.  not  more  than  a  sixth  of  an  inch),  especially 
if  the  patient  be  young  and  the  bones  yielding,  expectant  treatment  is 
no  doubt  the  best. 

(2 )  But,  on  the  other  hand,  where  the  depression  is  limited  and  defined, 
where  the  depressed  fragment  not  only  affects  a  small  area,  but  is  turned 
down  angularly  or  edgeways,  operative  interference  should  be  resorted 
to  at  once,  even  though  no  symptoms  are  present,  and  whether  there 
is  a  wound  or  no,  to  prevent  the  onset  of  dangers,  immediate  and  remote, 
fully  alluded  to  later  on. 

(3)  There  is  a  large  class  of  cases  intermediate  between  the  above, 
where  the  fracture  is  a  simple  one,  where  symptoms  are  absent,  and 
w^here  the  depression  is  sufficient  to  cause  anxiety,  though  not  so  sharply 
defined  as  to  call  imperatively  for  operation.  Here,  when  in  doubt  as 
to  the  severity  of  the  case,  the  surgeon,  if  able  to  rely  on  his  operative 

^  Syst.  ofPract.  Surg.,  Amer.  Trans.,  by  Dr.  Bull  and  Dr.  Martin,  vol.  i,  p.  98. 


252  OPERATIONS  ON  THE  HEAD  AND  NECK 

skill  and  on  the  wound  running  an  aseptic  course,  will  do  best  to  explore 
the  fracture.  This  is  especially  the  case  in  fractures  of  the  frontal  and 
parietal  regions,  owing  to  the  frequency  with  which  these  are  followed, 
at  a  later  date,  by  epilepsy. 

Finally,  in  any  fracture  in  which  the  question  of  operative  inter- 
ference arises,  the  kind  of  violence  must  be  remembered.  Was  this 
concentrated  over  a  small  area,  and  thus  likely  to  bring  about  serious 
depression  and  comminution  of  the  internal  table,  or  was  it  indirect 
and  diffuse,  and  thus  likely  to  have  produced  a  long  fissure-fracture 
with  little  depression,  but  perhaps  tearing  open  meningeal  vessels  or 
sinuses,  opening  up  the  middle  ear,  nose,  or  pharynx,  and  spreading 
far  into  the  base  ? 

Influence  of  site.  It  is  often  said  that  a  depressed  fracture,  even 
if  distinctly  marked,  over  the  frontal  sinuses,  does  not  require  operative 
interference,  and  that  any  such  steps  should  be  avoided  for  fear  of 
leaving  a  fistulous  opening  leading  to  passage  of  air  and  troublesome 
emphysema.  But  it  must  be  remembered  that  these  sinuses  do  not 
appear  before  the  age  of  fifteen  or  sixteen,  and  that,  even  in  adult  skulls, 
the  extent  of  their  development  is  most  uncertain,  the  sinuses  being 
sometimes  represented  by  a  small  unilateral  cell  instead  of  fair-sized 
bilateral  cavities.  Other  sites,  which  it  is  well  to  avoid  in  trephining, 
if  possible,  are  the  position  of  large  venous  sinuses,^  that  of  the  trunk 
and  chief  branches  of  the  middle  meningeal  artery-  and  also  the  lines 
of  the  sutures,  apart  from  any  subjacent  sinuses,  as  here  the  dura  mater 
is  firmly  attached  unless  it  chance  to  be  loosened  by  a  violent  blow. 
Age,  too,  must  have  proper  weight  attached  to  it,  it  being  well  known 
that  in  the  first  few  years  of  life  a  very  considerable  depression  may  take 
place  after  an  injury,  and  yet  be  followed  by  absence  of  head  symptoms 
and  by  spontaneous  recovery. 

(3)  Punctured  fractures.  Here,  however  slight  be  the  injury  to  the 
outer  table,  that  inflicted  upon  the  inner  is  certain  to  be  much  more 
serious.  And  the  more  the  diploe  is  present,  the  more  extensive  will 
be  the  damage  which  its  fragments,  when  driven  down,  will  inflict  upon 
the  brittle  inner  table.  It  must  be  remembered  that  punctured  fractures, 
with  all  their  serious  results,  may  be  caused  by  blunt,  though  pointed, 
bodies  as  well  as  by  sharp  ones.  Instances  of  these  are,  blows  with  a 
pickaxe,  fragments  of  coal  or  stone,  the  trigger  of  a  clubbed  gun,  or 
falls  on  a  fender  ornament.  Immediate  operative  interference — and 
here  owing  to  the  limited  injury  to  the  outer  table  the  trephine  will  be 
called  for — is  imperatively  demanded  in  all  punctured  fractures,  how- 
ever insignificant  be  the  damage  to  the  scalp  and  outer  table.     The 

^  It  is  worth  while  to  boar  in  mind  that  if  a  large  venous  sinus  is  ojjened,  the  haemor- 
rhage can  be,  usually,  at  once  arrested  by  very  moderate  pressure  applied  at  the  right 
spot.  The  pressure  should  at  first  be  made  by  the  finger,  and  kept  up  if  needful 
by  a  strip  of  sterilised  gauze  left  in  .■^ilii  for  two  or  three  days.  Sir  H.  Cameron  {Lancet, 
1884,  vol,  i,  p.  931)  was  able  to  complete  a  trephining  while  very  slight  pressure  with 
lint  controlled  the  bleeding  from  a  wound  in  the  superior  longitudinal  sinus.  He  points 
out  that  the  imaginary  fear  of  fatal  hajmorrhage  may  at  times  deter  from  a  necessary 
operation  with  the  trephine  and  it  is  well  that  it  should  be  dissipated.  Dr.  Hopkins 
{Ann.  of  Surg.,  vol.  ii,  p.  67)  in  a  case  of  extensive  compound  fracture  of  the  skull,  found 
that  a  small  lint  plug,  lightly  applied  to  a  wound  in  the  superior  longitudinal  sinus  exposed 
by  elevation  of  fragments,  readily  arrested  the  hemorrhage,  which  persevering  efforts  had 
failed  to  control  by  a  ligature.  The  strictest  precautions  should  be  taken  when  dealing 
with  wounds  of  these  sinuses  owing  to  the  risk  of  septic  phlebitis  and  pyaemia. 

2  The  treatment  of  haemorrhage  from  the  middle  meningeal  artery  is  given  at 
p.  262. 


THKIMIINING  253 

dangers  of  iiijuiy  to  the  dura,  inater  and  septic  infection  must  also  be 
borne  in  mind.     The  foHowing  is  an  instructive  case  : 

A  child  aged  tw'euty  mouths  was  left  alone  by  its  inotlier  sitting  in  a  chair. 
There  were  a  number  of  articles  left  littered  about  on  t\w  floor  among  which  was  a 
metal  boot-toe  protector  provided  with  three  sharp  jjoiuts  for  it,  attachment  to 
the  sole  of  tlu'  boot.  The  child  fell  to  the  floor,  striking  tiie  boot  protector,  which 
was  flrmly  driven  into  its  forehead.  On  admission  to  the  hospital  the  plate  was 
levered  away  and  investigation  with  a  probe  showed  that  the  outer  of  two  punctures 
had  reached  the  bone.  The  wound  was  accordingly  explored  and  it  was  then  found 
that  the  bone  was  perforated.  The  nail-like  points  were  so  short  that  it  was  thought 
that  the  diua  mater  could  not  possibly  be  damaged.  The  wound  was  therefore 
cleaned  and  drained  without  tre})hining.  Three  days  later  the  child  had  severe 
convulsions,  when  the  wound  was  again  oj)ened  up  and  a  disc  of  bone  removed. 
The  dura  mater,  which  was  inflamed  and  jjerforated,  was  freely  incised,  when  some 
pus  escaped.  Unfortunately  this  was  not  localised,  and  the  child  died  next  day  with 
diffuse  suppurative  meningitis. 

(4)  l7i  some  cases  of  fracture  about  the  inner  angle  of  the  orbit.  These 
grave  injuries  which  may  be  caused  by  direct  violence  from  thrust 
wounds  at  the  inner  angle  of  the  orbit,  or  root  of  the  nose,  e.g.  with 
scissors,  slate  pencils,  ferrules  of  walking-sticks,  &c.,  should  always 
be  explored  at  once. 

An  incision  should  be  made  from  without  inwards  along  the  supra- 
orbital arch,  just  below  the  eyebrow,  to  a  point  within  the  puncture  ; 
a  flap  should  be  turned  down,  the  eyeball  gently  depressed,  and  the 
inner  wall  of  the  orbit  and  adjacent  parts  carefully  chipped  away  with 
a  small  chisel  or  gouge.  The  haemorrhage  from  the  angular  vessels 
may  be  troublesome.  Any  foreign  body  or  infective  material  is 
thoroughly  removed  ;  the  dura  mater  is  also  inspected.  If  this  be 
lacerated  it  should  be  thoroughly  exposed,  the  damaged  part  excised, 
and  the  subjacent  brain  carefully  cleansed  with  sterilised  saline  solu- 
tion. The  cavity  is  then  drained  with  sterilised  gauze,  a  drainage 
tube  being  used  as  well  if  needful.  The  dressings  are  changed  daily, 
and  if  there  is  much  discharge,  hot  boracic  fomentations  may  be 
employed. 

The  apparent  slightness  of  these  injuries,  the  trifling  wound — owing 
to  the  mobility  of  the  skin  and  the  slightness  or  absence  of  any 
sub-conjunctival  haemorrhage,  the  wound  may  appear  not  to  have 
perforated  the  orbit — the  period  of  latency  of  symptoms,  and  the 
onset  of  fatal  brain  mischief — inevitable,  though  delayed,  if  let  alone 
—should  always  be  remembered  when  dealing  with  these  injuries. 
Especially  misleading  are  those  cases  in  which  an  instrument  has 
slipped  under  the  lid,  reaching  the  roof  of  the  orbit  and  the  base 
of  the  skull,  leaving,  it  may  be,  merely  a  patch  of  ecchymosis  on  the 
conjunctiva. 

(5)  For  the  removal  of  foreign  bodies  fissuring  or  fracturing  the  skull. 
These  are  rare,  e.g.  penknife-blades,  pieces  of  stone,  bullets,  &c.  To 
ensure  certainty  of  complete  removal  the  trephine  will  usually  be 
required.  The  following  case  of  Professor  Nancrede's  shows  how  the 
gravest  results  may  ultimately  follow  on  the  overlooking  of  a  small 
piece  of  knife-blade.  The  apparent  slightness  of  the  injury,  the 
long  absence  of  symptoms,  then  their  sudden  onset,  the  difficulties 
met  with  during  trephining,  the  results  of  promptly  meeting  them, 
and  finally  death,  due  to  a  hernia  cerebri,  are  all  deserving  of  careful 
attention. 


254  OPERATIONS  ON  THE  HEAD  AND  NECK 

J.  Y.,  set.  19,  walked  into  the  Episcopal  Hospital,  complaining  of  a  sore  on  the 
top  of  his  head,  the  result  of  a  blow  received  two  months  previously.     On  examining 
the  wound,  in  the  centre  of  an  ulcer,  corresponding  in  position  to  the  centre  of  the 
left  parietal  lobe,  was  found  the  broken  end  of  a  knife-blade.     On  being  told  of  this 
he  seemed  thoroughly  surprised.     But  little  could  be  made  out  as  regards  the  inci- 
dents of  the  attack,  except  that  a  man  had  struck  him  on  the  top  of  the  head  so 
forcibly  that  he  had  fallen  on  his  hands  and  knees,  but  that  he  had  recovered  himself 
almcst  immediately.     He  said  that  he  did  not,  at  that  time  or  afterwards,  lose 
consciousness,  nor  had  he  suffered  from  headache.     He  did  not  complain  of  any 
pain  or  uncomfortable  sensation   when  the  knife-blade  was  removed,   but  in  the 
afternoon  of  the  same  day  he  had  slight  pains  in  the  head.     The  following  day  the 
temperature  was  101°,  and  slight  retinal  hyperiemia  was  noticed.     Epileptiform 
seizures  set  in  next  day,  beginning  with  twitching  of  the  right  arm.  but  soon  becoming 
general.     The  bone  was  trephined  over  the  seat  of  injury,  and  the  poition  removed 
showed  a  slight  depression  of  the  inner  table.     The  position  which  the  blade  had 
occupied  could  be  seen  in  the  dura  mater,  there  being  an  opening  surrounded  with 
dense  cicatricial  tissue.     The  dura  mater  did  not  seem  to  be  congested,  and  there 
was  evidently  no  pus  or  fluid  beneath  it.     Diu-ing  the  next  three  weeks  the  fits 
ceased,   but  symptoms  indicating  cerebral  abscess — viz.,  temperature  subnonnal, 
slow  pulse,    marked   mental  dulness — set  in.     The  patient   then   developed   right 
hemiplegia   and   became   unconscious.     The   flap   covering   the  trephine   hole  was 
reflected  and  was  found  to  be  occujjied  by  the  tense  dm-a  mater,  pulsating  strongly. 
It  was  incised  and  an  aspirating  needle  introduced  in  several  places  but  without 
success.     Feehng  convinced  that   pus  was  present.   Prof.   Xancrede   trephined  in 
front  of  and  below  the  first  opening,  which  was  slightly  behind  the  fissure  of  Rolando. 
Before  the  skull  was  divided  both  pulse  and  respiration  ceased.     The  operation 
being  rapidly  completed,  the  dura  mater  was  here  incised  without  result.     At  this 
moment  pus  was  observed  to  be  oozing  from  one  of  the  aspirator  punctures.     A  knife 
being  plunged  into  the  brain  substance,  from  one  to  two  ounces  of  pus  were  evacuated. 
The  patient  revived  after  vigorous  and  prolonged  artificial  respiration.     The  next 
day  a  hernia  cerebri  as  large  as  a  walnut  was  protruding  from  the  wound  in  the  dura 
mater.     This  increased  in  size,  and  broke  down,  the  patient  dying  four  days  later. 
At  the  autopsy  the  left  parietal  lobe   contained  an  enormous  abscess  cavity  which 
had  destroyed  the  greater  portion  of  the  upper  part  of  the  left  hemisphere. 

TREPHINING!  IN  FRACTURED  SKULL  (Figs.  119,  120) 

The  scalj)  having  been  shaved  and  thoroughly  cleansed,  the  patient 
anaesthetised  vnth.  C.E.  or  chloroform,-  unless  a  condition  of  un- 
consciousness renders  this  unnecessary ;  the  head  is  supported  on  sand 
bags  at  a  convenient  height.  The  fracture  is  next  exposed,  the  old- 
fashioned  crucial,  T-  or  Y-shaped  incisions  being  now,  when  possible 
replaced  by  the  semilunar  flap  of  Sir  V.  Horsley.  The  flap  should  be 
so  arranged  as  to  fully  expose  the  field  of  operation  on  the  skull.  Its 
base  is  usually  below  to  ensure  a  good  blood-supply.  The  incision  goes 
down  to  the  bone,  and  the  pericranium  is  divided,  with  the  flap  raised 
cleanly  and  uniformly  with  an  elevator.  If  it  be  needful  to  operate 
through  the  temporal  muscle,  its  fibres  must  be  sufficiently  severed 
and  raised  with  the  flaps,  it  being  somewhat  more  difficult  to  separate 

^  It  has  been  ah-eady  stated  that  in  many  cases  of  depressed  fractures,  after  exposure 
of  the  fragments,  a  pair  of  dressing-forceps  and  an  elevator  may  do  all  that  is  required. 
Where  no  trephine  is  at  hand,  a  chisel  and  mallet  should  be  used.  As  soon  as  the  dura 
is  exposed,  the  proper  cranial  chisel  with  a  shoulder  (Fig.  127)  is  alwaj-s  to  be  preferred. 
That  the  trephine  itself  is  not  always  needed  should  be  clearly  understood,  as  it  is  probable 
that  elevation  of  fragments  might  often  most  wisely  have  been  performed  had  it  not  been 
for  the  absence  of  a  special  instrument,  wrongly  supposed  to  be  essential. 

2  These  anaesthetics  are  to  b?  preferred  in  cases  of  trephining,  on  account  of  the 
greater  excitement  and  congestion  which  are  usually  associated  with  ether.  But  whenever 
it  is  possible,  and  especially  when  the  pulse  and  breathing  are  falling,  anaesthetics  should 
be  dispensed  with.  \\'here  there  is  any  tendency  to  drowsiness  or  coma  "  the  anaesthetist 
should  attempt  to  secure  an  analgesic  rather  than  a  true  anaesthetic  state  "  (Hewitt 
Anaesthetics  and  their  Administration,  p.  54). 


FRACTURE  OF  TIIF  SKULL 


255 


the  periosteuiu  here,  on  account  of  its  thinness  in  tliis  region,  and  more 
intimate  adliesion  to  the  subjacent  bones.^  In  reflecting  the  flaps, 
free  haemorrhage  is  nearly  always  met  with,  especially  in  tlie  case  of  the 
chief  superheial  trunks  and  the  deep  temporal  arteries,  but  this  is 
promptly  and  easily  arrested  by  the  use  of  8pencer-Wells's  or  Lane's 
forceps,  which  act  as  most  useful  retractors,  taking  up  but  little  room, 
while  at  the  same  time  they  arrest  the  haemorrhage.  It  is  always  difficult, 
owing  to  the  density  of  the  tissues,  to  take  up  the  vessels  neatly  here. 
It  is  ([uite  permissible,  especially  in  urgent  cases,  to  take  up  the  whole 
thickness  of  the  Hap.  Owing  to  its  vascularity  it  will  not  slough.  No 
sutures  should  be  inserted  just  at  those  spots  where  the  forceps  have 


Fig.  118.      Makka's  clamps  fur  control  of  haemorrhage  from  the    scalp  during 
trephining.     On  the  right  is  figured  the  forceps  for  manipulating  the  clamps. 


been  applied.  Another  excellent  method  of  temporarily  controlling 
haemorrhage  from  the  scalp  in  these  cases  is  by  the  use  of  Makka's 
clamps  (Fig.  118).  One  blade  of  each  clamp  has  a  sharp  point 
which  is  pushed  between  the  soft  parts  of  the  bone ;  the  other  blade 
is  on  the  surface  of  the  scalp.  The  vessels  are  thus  firmly  compressed. 
If  bleeding  continues  from  any  crack  in  the  bone  which  may  now 
be  found,  it  will  only  cease  on  the  elevation  of  the  fragment,  or  on 
the  exposure  of,  and  the  dealing  with  any  subjacent  clot.  The 
fracture  being  now  in  view,  if  it  be  found  impossible  to  introduce  an 
elevator,  strong  dressing  or  sequestrum-forceps,  even  after  sawing  off 
any  projecting  angle  of  bone,  the  surgeon  must  decide  where  to  place 
his  trephine.  In  doing  so,  he  must  choose  a  spot,  if  possible,  clear  of 
a  sinus  {see  p.  252)  or  large  branch  of  the  middle  meningeal  artery  {see 
p.  273),-  and  one  which  will  at  the  same  time  support  firmly  the  pressure 
needed  in  the  working  of  the  trephine.  Thus  the  pin  and  greater  part 
of  the  trephine- crown  are  placed  on  sound  bone  (Fig.  119),  while  a  small 
part  of  the  trephine  usually  overhangs  a  depressed  fragment.  But 
if  the  surgeon  fears  that  the  fragments  are  in  contact  with  the  dura 
mater,  and  perhaps  injuring  it,  and  that  the  jarring  movement  of  the 
trephine  coming  in  contact  with  one  may  be  pernicious,  he  will  so  place 
his  trephine  that  it  rests  entirely  on  sound  bone,  any  intervening  ridge 
being  easily  cut  away. 

^  The  greater  thickness  of  the  soft  parts  which  will  here  form  the  cicatrix  will,  in  a 
measure,  make  up  for  the  difficulty  in  preserving  the  iDcriosteum. 

^  If  it  is  really  needful  to  trephine  over  one  of  these  vessels  the  remarks  at  p.  266. 
will  show  how  the  haemorrhage  should  be  met. 


256 


OPERATIONS  ON  THE  HEAD  AND  NECK 


A  spot  being  thus  chosen,  a  trephine  of  about  one  inch  in  diameter 
is  taken  with  the  centre-pin  protruded  for  about  a  tenth  of  an  inch, 
and  firmly  fixed  in  this  position,  the  trephine  being  so  grasped  in  the 
hand  that  the  index  finger  steadies  the  centre-pin  screw  when  the  bone 
is  entered.  The  instrument  is  now  firmly  applied  to  the  bone,  the 
centre-pin  being  bored  inwards,  and  as  soon  as  the  teeth  feel  the  bone 


\ 


Fig.  119.     A  shows  a  depressed  "gutter  "  fracture  in  the  right  parietal  bone. 

1'he  dotted  circle  indicates  the  disc  to  be  removed  by  the  trephine.     B,  The  disc 

has  been  removed  and  the  depressed  fragments  are  levered  into  position  by 

means  of  an  elevator. 


the  trephine  is  worked  from  left  to  right  and  then  from  right  to  left, 
care  being  taken  to  exert  equal  pressure  in  both  directions.  While 
the  first  groove  is  being  cut,  the  movements  of  the  trephine  must  be 
light  and  quick,  but  without  jerking,  the  tendency  of  the  instrument 
to  slip  being  met  by  steady  bearing  on  the  centre-pin,  and  by  keeping 
the  left  forefinger  at  first  on  the  bone  close  to  the  trephine. 

As  soon  as  a  groove  sufficient  to  keep  the  trephine  steady  has  been 
cut,  the  pin  is  drawn  upwards,  and  there  fixed.  The  rotatory  movements 
alternating  from  side  to  side  are  now  continued,  care  being  taken  to 
bear  as  evenly  as  possible  on  every  part  of  the  circle,  till  the  diploe  ^ 

1  This  is  absent  or  deficient  in  early  life  and  in  the  aged.  Also,  over  a  large  part  of 
the  squamous  bone  and  in  the  occipital  fossae,  diploe  is  never  met  with. 


FRACTURE  OF  THE  SKULL  257 

(if  this  is  present)  is  reached.  This  is  known  by  the  easier  working  of 
the  instrument  and  by  the  softer  sound.  On  the  living  body  at  least, 
owing  to  the  oozing  from  the  vascular  parts  around,  the  blood-staining 
of  the  bone-dust  described  as  taking  place  at  this  stage  is  liable  to  be 
fallacious. 

Throughout  the  operation,  but  especially  now  as  the  thinner  table 
is  being  reached,  every  care  must  be  taken  to  keep  the  circle  of  equal 
depth  :  (1)  By  pressing  on  the  saw  evenly  ;  (2)  by  making  it  bite  in 
equally  from  right  to  left  and  from  left  to  right ;  (3)  by  remembering 
that,  owing  to  the  skull  being  spheroidal  in  shape,  it  is  impossible, 
without  the  greatest  care,  to  keep  the 
groove  of  equal  depth  all  round ;  (4)  by  -^ 
bearing  in  mind  that  while  the  average 
thickness  of  the  adult  skull  is  one-fifth 
of  an  inch,  the  thickness  varies  so  much 
that  it  is  almost  always  greater  at  one 
part  of  a  trephine-circle  than  at  another. 

Thus  at  frequent  intervals  the  flat  Fio.  120.    A,  Section  of  a  depressed 
end  of  a  sterilised  trephine-probe  must  fracture.     B,  Elevation  of  the  de- 

1  ri,         .,       n^T        .      i-jv  J.   pressed   fragments    by   means    of   an 

be  carefully    mtroduced    at   different  [.i^^^^t^r  introduced  through  a  trephine 
spots,  and  when  the  circle  is  found  to  opening. 

be  deeper  on  one  side  (still  more  if  it  is 

perforated)  the  trephine  must  be  slanted  so  that  its  teeth  are  only  cutting 
on  that  part  of  the  groove  which  is  still  shallow.  When  the  groove  has 
been  made  sufficiently  deep,  and  careful  examination  finds  three  or  four 
points  of  penetration,  the  bone  may  be  removed  by  inserting  the  elevator  at 
the  deepest  part  of  the  groove  and  lifting  up  the  disc  of  bone  by  care- 
fully making  a  fulcrum  of  the  sound  bone  or  of  a  finger.  An  elevator 
is  then  gently  insinuated  between  the  depressed  bone  and  the  dura 
mater,  and  the  depressed  area  levered  into  position.  Any  loose  frag- 
ments are  removed  and  preserved  in  sterilised  saline  solution.  If  profuse 
haemorrhage  occur  on  raising  either  the  disc  of  bone  or  a  depressed 
fragment,  it  will  probably  come  either  from  a  branch  of  the  middle 
meningeal  artery  or  from  a  sinus.  The  treatment  of  the  former  is 
given  at  p.  265  :  in  the  latter  case  pressure  should  be  at  once  applied 
by  means  of  a  pledget  of  sterilised  gauze  ;  if  this  has  to  be  left  in  situ 
beneath  an  edge  of  bone  to  control  the  bleeding,  a  ligature  of  sterilised 
silk  or  catgut  should  be  fastened  on  to  it,  to  secure  its  withdrawal  in 
about  three  days'  time  {see  p.  252). 

In  the  case  of  a  punctured  fracture,  a  full-sized  inch  trephine  should 
be  applied,  so  as  to  remove  the  outer  table  around  the  immediate  neigh- 
bourhood of  the  puncture,  and  thus  expose  freely  the  damage  to  the 
inner  table. 

If  after  removing  a  crown  of  bone  more  room  is  still  required,  this 
may  be  obtained  either  by  taking  out  a  second  crown  close  by,  and 
joining  the  two,  or  by  the  use  of  a  Hey's  saw  or  the  forceps  of  De  Vilbiss 
{see  p.  312),  or  of  Hoffman's  forceps,  or  Lane's  skull  forceps. 

Sufficient  drainage  must  be  provided  in  those  cases  which  require 
it,  e.g.  where  infection  is  present,  or  where  a  large  cavity  is  left  under 
the  flap,  in  w^hich  fluid  will  collect.  Any  drainage-tube  used  should 
be  brought  through  the  lowest  part  of  the  flap,  by  puncture  if  needful, 
and  stitched  to  the  skin. 

Where  it  has  been  needful  to  remove  bone  extensively  the  question 

SURGERY  I  17 


258    OPERATIONS  ON  THE  HEAD  AND  NECK 

will  arise  as  to  the  best  means  of  diminishing  the  gap.  In  many  cases 
the  trephine-crown  or  bone  fragments,  so  long  as  these  are  not  too 
small,  unite  readily  if  they  have  been  kept  in  a  hot,  sterile  saline  solu- 
tion, the  temperature  of  which  has  been  maintained.  In  many  cases, 
often  when  their  survival  is  most  desired,  they  fail  to  unite.  They  cannot 
be  used  in  compound  fractures,  where  they  are  perhaps  infected ;  or  in 
cases  where  the  dura  mater  and  brain  have  been  injured  and  any  cavity 
or  irregular  surface  exists.  In  cases  of  trephining  for  traumatic  epilepsy 
their  replacement  would  be  injudicious,  it  being  here  desirable  to  leave 
a  safety-valve  for  the  relief  of  future  varying  tension.  Where  the 
scalp  has  been  extensively  destroyed  the  surgeon  may,  if  the  patient's 
condition  permit  of  it,  diminish  or  close  the  gap  by  means  of  one  or 
more  pedunculated  flaps. 

But,  as  a  rule,  this  will  be  left  to  a  later  stage.  German  surgeons, 
Konig  and  Mtiller,  have  advised  that  such  flaps,  for  the  better  protection 
of  the  brain,  should  be  raised  with  periosteum  and  the  outer  table,  by 
holding  the  chisel  horizontally.  This  is  a  severe  operation,  and  only 
possible  where  the  bone  is  well  developed.  It  cannot  be  employed 
in  children  owing  to  the  non- development  of  the  diploe.  Another  method 
is  the  employment  of  grafts  of  decalcified  bone,  recommended  by  Senn. 
Here  all  scar  tissue  and  the  edges  of  the  adjacent  bone  must  be  com- 
pletely removed,  so  that  the  graft  will  fit  accurately  with  the  cavities 
of  the  diploe  round  the  margin  of  the  fracture.  The  graft  must  be 
covered  with  the  scalp,  by  a  pedunculated  flap,  if  needful,  and  strict 
asepis  is  necessary  for  success. 

The  above  remarks  refer  to  conditions  which  call  for  immediate  or 
primary  trephining. 

The  following  will  be  amongst  the  intermediate  or  secondary  con- 
ditions which  may  suggest  trephining  some  days  or  weeks  after  an 
injury  to  the  skull,  where  there  is  no  definite  evidence  of  fracture.  Long 
continued  unconsciousness,  as  when  this  lasts  over  twenty-four  hours, 
no  other  cause  than  the  injury  being  present.  Convulsions,  especially 
if  localised  and  associated  with  aphasia.  Paralysis,  especially  if  marked 
and  occurring  in  adults.  Dennis^  refers  to  a  case  of  a  child  who  fell 
on  the  pavement  from  a  third  story,  sustaining  an  indented  fracture 
of  the  parietal  bone. 

The  compression  was  sufficient  to  produce  hemiplegia  of  the  opposite  side  and 
deep  coma.  Dennis  so  manipulated  the  sides  of  the  head  as  to  cause  the  indentation 
entirely  to  disappear.  As  soon  as  the  bone  sprang  back  to  its  normal  position  the 
child  passed  at  once  from  deep  coma  into  complete  consciousness,  and  the  hemiplegia 
instantly  disappeared. 

The  possibility  of  a  linear  fracture  causing  a  depression  of  the  inner 
table  has  often  been  overlooked.  Messrs.  Shield  and  Shaw  report  ^  an 
interesting  case  of  this  kind. 

The  patient,  a  healthy  man,  set.  30,  sustained  a  scalp  wound  in  the  left  frontal 
region.  No  fracture  was  found,  and  the  man  was  confined  to  bed  for  a  short  time 
for  concussion.  He  was  perfectly  well  for  some  weeks,  but  about  a  month  after 
the  injury  he  began  to  suffer  from  pain  in  the  head,  loss  of  memory,  and  sudden 
bursts  of  passion.  He  gradually  reached  a  condition  of  dementia.  There  being  no 
history  of  alcoholic  excess  or  syphilis,  the  symptoms  appeared  to  be  directly  due 
to  the  injury.  Shaw  trephined  at  the  seat  of  injury  and  found  a  healed  linear 
fracture  with  a  depression  of  the  iiuier  table.  The  operation  was  immediately 
followed  by  a  most  marked  improvement.  The  patient  ultimately  recovered. 
1  Med.  News,  March  21,  1903.  2  Lancet,  February  14,  1903. 


SEPTIC  OSTKOMVKLITIS  ()!''  THE  SKULL  259 

It  is  especially  under  the  thickness  of  the  temporal  muscle,  itself 
swollen  with  extravasated  blood,  and  the  soft  parts  over  it  bruised  and 
tender,  and  thus  interfering  with  the  accuracy  of  diagnosis,  that  the 
existence  of  a  depiessed  fracture  must  be  remembered,  when  an  altered 
mental  condition,  dulness,  &c.,  and,  if  on  the  left  side,  aphasia,  supervene 
some  time  after  an  injury. 

Traumatic  cerebral  abscess  (p.  2G1).  Su])))uration  between  the  bone 
and  the  dura  mater,  which  is  considered  in  the  next  section.  Cases  of 
ha?morrhagic  pachy-meningitis,  which  occasionally  follow  on  trauma  and 
give  rise  to  pressure  symptoms  which  demand  operative  interference. 


TREPHINING  FOR  PUS  BETWEEN  THE  SKULL  AND  DURA 

MATER 

While  the  mode  of  using  the  trephine  here  will  in  no  way  differ  from 
that  already  given,  a  few  practical  remarks  will  be  made  on  this  most 
important  condition. 

Operative  interference  here,  while  less  frequently  called  for,  owing 
to  the  improvements  of  modern  surgery,  especially  the  antiseptic  treat- 
ment of  scalp  wounds,  has  also  been  less  successful  than  it  would  appear 
to  have  been  a  hundred  years  ago,  when  Pott  drew  the  attention  of 
surgeons  to  the  need  of  trephining  when  pus  was  present  immediately 
beneath  the  skull.  For  while  Pott,  in  his  day,  saved  five  out  of  eight 
of  these  cases  in  which  he  trephined,  surgeons  of  later  days,  when  they 
have  trephined,  have  been  usually  baffled  by  the  co-existence  of  pyaemia 
owing  to  an  infective  osteo- myelitis  and  phlebitis  of  the  veins  of  the 
diploe,  or  if  this  ominous  complication  be  absent,  by  finding  the  col- 
lection of  pus  not  localised  between  the  bone  and  dura  mater  or,  if  so 
localised,  combined  with  suppurative  arachnitis  also. 

When  it  is  remembered  that  pus  does  not  form  between  the  bone 
and  dura  mater  without  a  previous  stage  of  infective  osteitis  and  phlebitis 
of  the  veins  of  the  diploe,  it  will  readily  be  understood  how  easily,  if  the 
wound  be  contaminated,  infective  osteo-myelitis  and  phlebitis,  with 
the  inevitable  result  of  pysemia,  will  follow. 

Indications  of  the  formation  of  pus  between  the  bone  and  dura  mater  ; 
question  of  trephining.  There  \vill  usually  be  a  history  of  injury  to  the 
head  with  damage  of  some  kind  to  the  outer  table.  Thus  there  is  fre- 
quently a  scalp  wound  exposing  the  pericranium,  often  opening  this  up 
though  this  may  have  escaped  observation  at  the  time ;  occasionally  the 
bone  itself  is  laid  bare  by  the  injury.  Sometimes,  however,  contusion  of 
the  soft  tissues  and  the  pericranium  alone  may  be  the  starting-point  of  a 
septic  osteo-myelitis  without  any  open  wound.  Either  now  or  later  on, 
the  wound  becomes  infected.  After  a  varying  period,  usually  in  the 
course  of  the  second  week  after  the  injury  (during  which  period  definite 
symptoms  are  often  absent),  headache,  fretfulness,  nausea,  or  vomiting 
set  in,  gradually  followed  by  drowsiness,  delirium,  twitchings,  convulsions, 
paralysis,  coma,  and  death. 

This  onrush  of  symptoms  about  the  eighth  or  tenth  day  may  be 
accompanied  by  evidence  of  pygemia,  viz.  rigors  followed  by  sweating, 
a  jactitating  temperature,  progressive  emaciation,  and  affections  of 
viscera  and  joints,  amongst  which  pleuro-pneumonia  is  one  of  the  most 
frequent  and  grave. 

The  surgeon  who  is  watching  a  case  of  this  kind,  and  who  is  also 


260  OPERATIONS  OX  THE  HEAD  AND  NECK 

not  unmindful  of  what  has  happened  and  what  is  Uable  to  be  going  on — 
the  injury  to  the  pericranium  and  bone,  the  osteitis  and  osteo-myelitis 
with  phigging  of  the  diploic  veins,  the  extension  to  the  inner  table, 
the  formation  between  the  bone  and  the  dura  mater  of  lymph  ready 
to  suppurate,  this  deep-seated  inflammation  being  only  too  ready  to 
extend  to  the  arachnoid  and  thus  become  a  difEuse  meningitis — wall 
find  it  a  matter  of  much  difficulty  to  answer  the  questions  :  How  far 
has  the  mischief  gone  ?  Is  the  case  a  hopeless  one  ?  If  the  intra- 
cranial collection  of  pus  be  a  locahzed  one  and  uncomplicated,  well- 
marked  hemiplegia  and  the  absence  of  pyeemic  symptoms  will  call 
hopefully  for  trephining.  On  the  other  hand  paralysis,  indistinct  or 
complete,  epileptiform  convulsions,  extreme  irritability,  and  especially 
any  evidence  of  involvement  of  nerves  at  the  base,  will  all  point  to 
that  form  of  meningitis  which  -u-ill  show  itself  as  a  diffuse  layer  of  pus 
and  lymph  over  one  side  of  the  arachnoid. 

Equally  pointing  to  a  fatal  issue  will  be  the  symptoms  of  pyaemia 
already  alluded  to,  and  needing  no  further  mention  here. 

What  is  to  be  done  in  these  cases  ?  Where  the  evidence  of  meningitis 
is  undoubted,  of  some  days  standing,  where  the  hemiplegia  has  been 
little  marked,  or  where  it  is  replaced  by  paraplegia,  general  convulsions, 
and  other  unfavourable  signs,  trephining  is  not  likely  to  be  successful. 

Should  evidence  of  co-existing  pysemia  be  looked  upon  as  equally 
hopeless  and  equally  negativing  the  use  of  the  trephine  ?  Every 
surgeon  knows  that,  although  pyaemia  is  usually  fatal,  it  oc- 
casionally ends  favourably.  Again,  in  treating  pysemia  resulting 
from  periostitis  and  osteo-myelitis  elsewhere,  we  are  not  deterred 
from  making  free  incisions  and  exploring  the  bone.  The  right  treat- 
ment of  these  cases  is,  of  course,  preventive,  i.e.  every  scalp  wound 
should  be  rendered  aseptic  and  kept  so  from  the  very  first,  however 
slight  it  seems  to  be.  But,  as  this  precaution  is  not  always  taken,  and 
is  occasionally  impossible,  the  condition  of  the  pericranium  and  the 
bone  should  be  explored  earlier,  at  the  very  first  warning  of  danger. 
Instead  of  treating  such  a  case  as  a  special  result  of  head  injury 
and  waiting  for  evidence  of  pus  between  the  bone  and  dura  mater,  we 
should  deal  \sTith  it  as  we  do  with  osteitis  and  periostitis  elsewhere  ; 
that  is  to  say,  that  in  cases  of  this  kind  where  there  is  reason  to  believe 
that  the  bone  has  been  injured,  especially  if  there  be  any  doubt  as  to 
the  condition  of  the  wound  throughout,  the  surgeon  should,  on  the 
very  first  appearance  of  malaise,  irritability,  headache,  nausea,  or 
chilliness  explore  the  womid.  Any  granulations  present  will  very  likely 
be  at  a  standstill.  A  piece  of  bone  will  probably  be  bare  and  perhaps 
soft,  the  pericranium  infiltrated  and  separating.  The  whole  area  of 
bone  which  is  affected  should  be  explored.  This  is  done  by  removing 
the  outer  table  and  exposing  the  diploe  with  a  gouge  or  chisel.  Wherever 
infiltration  with  pus  or  undue  reddening  is  present,  the  diseased  condition 
must  be  followed  up.  If  necessary  the  bone  must  be  freely  removed 
with  a  trephine  and  Hoffman's  forceps.  The  state  of  the  dura  mater 
must  be  ascertained  in  every  case  where  lymph  or  pus  is  present.  Free 
drainage  must  be  secured  by  removing  the  whole  thickness  of  the  bone 
over  the  diseased  membrane  as  widely  as  possible.  Where  the  patient's 
condition  admits  of  it  and  where  this  step  is  indicated  by  the  symptoms, 
any  of  the  sinuses  that  are  adjacent  to  the  area  of  operation  and  which 
can  be  reached  should  be  explored  and,  if  infected,  treated  on  the  lines 


SEPTIC  OSTEOMYELITIS  OF  THE  SKULL  261 

given  at  p.  359.  In  any  case  all  infective  granulation  tissue  must  be 
removed  and  free  drainage  must  be  provided.  The  possible  co-existence 
of  a  cerebral  abscess  must  not  be  forgotten  {see  p.  254). 

The  above  depends  on  the  fixed  conviction  that  trephining,  in  careful 
hands  and  with  due  precautions,  is  not  in  itself  a  dangerous  operation, 
and  on  the  fact,  which  is  beyond  dispute,  that,  if  these  cases  are  left 
till  hemiplegia  announces  the  existence  of  intracranial  pus,  they  will, 
too  often,  be  left  too  long,  as  this  waiting  will  give  time  for  the  onset 
of  pyemic  infection  and  for  the  arachnoid  to  be  involved  in  the 
inflammation. 

The  operation  of  trephining  here  will  in  no  way  differ  from  that 
already  described.  Pus  welling  up  from  the  diploe,  or  a  f ootid  condition 
of  this,  is  ominously  suggestive  of  impending  pycemia.  If  such  a  con- 
dition be  present,  the  bone  should  be  freely  removed  and*  disinfected 
as  far  as  possible  ;  but  the  outlook,  from  the  probable  extension  of  the 
thrombi  to  the  sinuses,  is  a  very  dark  one.  If  pus  be  present  between 
the  bone  and  the  dura  mater,  it  must  be  thoroughly  evacuated  and 
freely  drained.^  The  condition  of  the  dura  mater  should  always  be 
examined,  whether  pus  be  found  superficial  to  it  or  no.  If  it  pulsate 
freely  and  be  natural  in  appearance,  nothing  more  need  be  done.  If, 
on  the  other  hand,  it  bulge  into  the  trephine  hole  and  does  not  pulsate, 
it  should  be  punctured,  this  perhaps  giving  vent  to  a  jet  of  purulent 
fluid  from  the  arachnoid  cavity.  If  the  arachnoid  is  seen  to  be  covered 
w4th  lymph  this  is  of  the  gravest  omen.  More  bone  must  be  removed 
or  a  second  trephine  disc  removed  at  the  most  dependent  part,  the  dura 
mater  again  opened  here,  and  irrigation  employed. 

The  following  cases  are  good  examples  of  this  most  dangerous  con- 
dition of  osteitis  of  the  cranium  and  its  secjuelse  and  complications  : 
The  first  case,  one  of  Mr.  Hutchinson's,  shows  much  arachnitis  and 
no  general  pyaemic  infection.  The  second  shows  both  arachnitis  and 
pyaemia  combined.  In  both  pus  was  present  between  the  bone  and 
the  dura  mater. 

E.  S.,  a>t^  10,  was  admitted,  July  21,  into  the  London  Hospital  -ndth  extensive 
laceration  of  the  scalp  on  the  left  side,  laying  bare  the  parietal  bone.  During  the 
first  few  days  he  seemed  to  be  doing  well.  July  26  :  Bone  as  large  as  a  crowi  piece 
is  exposed  white  and  dry  above  the  left  ear.  July  29  :  A  strong  rigor  ;  wound  not 
granulating.  July  31  :  Very  restless.  Uses  all  his  limbs  at  times,  but  the  left  ones 
better  than  the  right.  August  1  :  The  skull  was  trephined  in  the  middle  of  the 
exposed  bone  two  inches  above  the  left  ear.  The  dura  mater  was  covered  with 
yellow  lymph,  but  pulsated  freely.  On  cutting  through  it  about  3j  of  thin 
purulent  fluid  escaped.  The  arachnoid  was  seen  to  be  covered  with  Ipnph. 
August  2  :  There  is  still  paralysis  of  the  right  hand.  When  the  brain,  which  bulged, 
pulsating,  into  the  wound  was  pressed  back,  pus  in  considerable  quantity  escaped 
from  the  arachnoid  cavity.  Death  took  place  on  August  3.  The  bone  around  the 
trephine  aperture  was  dry  and  green.  On  the  left  side  the  arachnoid  was  covered 
with  a  thick  deposit  of  purulent  lymph,  while  on  the  right  side  it  was  normal.  The 
superior  longitudinal  sinus  contained  puriform  fluid.  The  skull  at  the  seat  of  injury 
was  discoloured  over  an  extent  almost  as  large  as  the  palm  of  the  hand  ;  adjacent  to 
it  were  other  patches,  greenish-yellow,  and  non-vascular.  There  were  no  pyaemic 
abscesses  in  any  of  the  viscera. 

E.  S.,  aet.  40,  was  admitted  into  Guy's  Hospital  under  Sir  H.  Howse  on 
January  22,  1877,  with  a  scalp  wound  four  inches  long,  exposing  the  right  parietal 
bone.  The  discharge  became  offensive  and  eiysipelas  of  the  scalp  set  in.  At  this 
time  almost  the  entire  right  parietal  bone  was  exposed  owing  to  sloughing  of  the 

^  In  these  cases,  and  in  fact,  in  any  trephining  cases  where  the  discharges  are  infected, 
hot  boracic  fomentations,  frequently  changed,  are  preferable  to  dry  dressings  changed  less 
frequently. 


262  OPERATIONS  ON  THE  HEAD  AND  NECK 

pericranium.  Incisions  were  made  where  needful,  drainage  tubes  introduced,  and 
in  a  few  days  the  erysipelas  had  subsided  and  the  wound  was  sweet.  February  1 1  : 
She  had  a  rigor  for  the  first  time.  February  13  :  The  temperature  was  104  ;  there 
was  some  paralysis  of  the  left  side  of  the  face  and  the  left  limbs.  February  15  : 
The  hemiplegia  becoming  more  marked  the  skull  was  trephined  about  one  inch 
above  the  right  parietal  eminence.  Pus  was  found  in  the  diploe.  On  removing 
the  disc  of  bone,  abovit  5J  of  thick,  foul,  greenish  pus  welled  up.  The  inner 
surface  of  the  bone  was  rough,  the  dura  mater,  which  corresponded  to  it,  being 
covered  with  velvety  granulations.  As  the  dura  mater  did  not  pulsate  it  was 
punctured  but  without  result.  The  patient  became  more  conscious  after  the  opera- 
tion, but  soon  relapsed  into  a  semi-conscious  state.  Convulsive  seizures  of  all  the 
limbs,  with  twitchings  of  both  sides  of  the  face,  then  set  in,  and  continued  until  the 
patient's  death  on  February  17.  The  parietal  bone  was  in  a  necrotic  condition  for 
a  considerable  area,  the  diploe  being  green  and  offensive.  The  pus  seemed  to  have 
drained  from  the  extra-dural  space,  but  there  was  suppurative  arachnitis  over  the 
right  hemisphere,  reaching  to  the  falx  in  one  direction  and  towards  the  base  in  the 
other.     There  were  numerous  pya?mic  abscesses  in  the  lungs  and  liver. 

In  the  following  case  Sir  W.  MacEwen^  was  more  fortunate.  The 
case  was  one  of  extra-dural  suppuration  with  pachymeningitis,  exhibiting 
Pott's  "  puffy  tumour,"  and  originating  in  infective  bruising  of  the 
scalp  and  deeper  tissues,  but  here  the  pachymeningitis  was  fortunately 
limited  and  pygemia  absent. 

I.  R.,  set.  45,  received  from  the  shaft  of  a  cart,  a  severe  blow  on  the  left  side  of 
the  vertex,  about  an  inch  from  the  mid  line.  He  was  subsequently  able  to  work  for 
a  week  without  feeling  anything  wrong  except  slight  pain  at  the  seat  of  injury. 
Later  on  he  felt  feverish,  the  pain,  which  was  of  a  dull  character,  increased,  and  was 
accompanied  by  occasional  sharp  stabs  over  the  vertex.  He  also  had  great  head- 
ache and  prostration.  There  was  a  distinct  puffy  tumour  over  the  seat  of  the 
injury.  The  swelling,  the  patient  declared,  appeared  three  weeks  after  the  accident 
and  after  it  formed  he  had  some  relief  from  the  pain.  The  primary  swelling  f rom- 
the  bruising  had  subsided  some  weeks  before  the  puffy  swelling  appeared.  On 
incision  the  skull  was  found  bare,  a  small  quantity  of  semi-purulent  exudation 
bathing  the  bone.  The  diploe  was  filled  with  granulation  tissue,  which  could  be 
traced  in  small  portions  penetrating  the  bone,  both  through  the  external  and  almost 
through  the  internal  table  of  the  skull,  which  was  dark  in  colour.  Between  the 
internal  plate  and  the  dura  there  was  a  considerable  layer  of  freshly  formed  granula- 
tion tissue,  bathed  in  purulent  exudation.  The  patient's  symptoms  quickly  cleared 
up  after  the  operation. 

TREPHINING  FOR  MIDDLE  MENINGEAL  HiEMORRHAGE 

(Figs.  121,  122) 

Indications.  When  a  patient,  after  receiving  an  injury  to  the  head, 
has  shown  some  of  the  symptoms  given  below.  . 

It  is  noteworthy  that  the  injury  and  amount  of  violence  vary 
extremely.  While  most  frequently  serious,  as  in  falls  on  the  head, 
the  violence  may  be  extremely  slight,  for  example,  a  patient  slipping 
while  going  downstairs  and  striking  his  head  against  the  wall,  a  boy 
receiving  a  blow  from  a  cricket  ball,  or  a  child  having  a  trifling  fall 
from  a  swing.  From  this  the  following  conclusions  may  be  drawn  : 
(ft)  That  in  cases  of  severer  violence,  laceration  or  contusion  of  the 
brain  are  only  too  frequently  complications.  (6)  Where  the  violence 
has  been  slighter,  either  no  fracture  may  be  present  or,  if  one  be  present, 
it  is  often  only  a  mere  fissure,  and  may  involve  the  internal  table  only. 
It  is  a  point  of  practical  importance  that  the  slighter  the  injury  the 
less  likely  are  the  soft  parts  to  show  any  damage.  This  has  led,  in 
some  cases,  to  the  injury  being  overlooked. 

(1)  Interval  of  consciousness  or  lucidity.  Typically  the  injury  to  the 
^  Pyogenic  Diseai^es  of  the  Brain  and  Spinal  Co'd,  p.  289. 


MENINGEAL  HAEMORRHAGE  263 

head  is  followed  by  the  symptoms  of  concussion  :  These  may  be  but 
slightly  marked  and  quickly  disappear.  Then,  after  an  interval,  during 
which  symptoms  may  be  slight  or  even  absent,  the  patient  gradually 
passes  into  a  condition  of  deep  coma.  This  interval  between  the  con- 
cussion and  the  onset  of  compression  varies,  when  present,  from  a  few 
minutes  to  several  hours.  In  about  half  the  cases  it  is  well  marked. 
In  a  second  group  it  is  but  little  marked  and  may  be  easily  overlooked. 
In  a  third  and  last  set  of  cases  this  interval  is  never  present  at  all  owing 
to  (1)  the  presence  of  a  very  large  haemorrhage,  producing  compression 
symptoms  at  once  ;  (2)  co-existing  depression  of  bone  ;  (3)  co-existing 
injury  to  the  brain  ;    (4)  drunkenness  of  the  patient. 

(2)  Condition  of  the  limbs  as  to  hemiplegia,  paralysis,  rigidity,  &,c. 
Hemiplegia,  though  well  marked  in  a  large  proportion  of  cases,  must 
not  be  looked  upon  as  essential,  and  middle  meningeal  haemorrhage 
must  not  be  overlooked  because  hemiplegia  is  absent,  ill-marked,  or 
replaced  by  some  other  condition  of  the  limbs.  At  least  the  following 
seven  conditions  of  the  limbs  may  be  met  with  in  middle  meningeal 
haemorrhage  : 

(a)  Hemiplegia  present  and  well  marked,  the  leg  or  arm,  and  usually 
both,  when  taken  up  and  let  go,  dropping  without  any  resistance.  This 
condition  is  present  in  probably  one-third  of  the  cases.  It  is  note- 
worthy that  occasionally  the  hemiplegia  is  on  the  same  side  as  that 
injured,  the  extravasation  taking  place  on  the  side  opposite  to  that 
struck. 

(6)  Hemiplegia  present,  but  little  marked.  In  these  cases,  which 
are  not  uncommon,  the  extravasation  may  be  overlooked.  They  fall 
into  at  least  two  di\asions.  In  one  the  hemiplegia  is  little  marked 
throughout,  due,  perhaps,  to  some  power  of  accommodation  on  the 
part  of  the  brain  or  to  the  circulation  remaining  feeble  owang  to  co- 
existing shock  from  the  time  of  injury  to  the  moment  of  death.  In 
another  group  of  cases  the  hemiplegia  is  ill-marked  because  of  brief 
duration,  coming  on  as  it  does  in  these  cases  towards  the  close,  together 
with  coma,  giving  but  little  warning  and  leaving  but  short  time  for 
interference. 

When  there  is  any  doubt  as  to  the  existence  or  degree  of  hemiplegia, 
the  following  tests  should  be  carefully  made  use  of  :  whether  the  patient 
resists  on  the  surgeon  attempting  to  move  the  limbs  ;  the  power  of 
the  grasp  ;  the  result  of  a  needle  prick ;  whether  the  patient  moves 
either  of  his  hands,  or  which  of  them,  when  the  cornea  is  carefully 
touched,  or  the  cilia  gently  pulled. 

(c)  Hemiplegia  present,  but  temporary.  A  very  rare  condition, 
produced  probably  by  the  brain  being  able  to  accommodate  itself  to 
the  pressure  of  the  efEused  blood. 

(d)  Monoplegia,  or  the  paralysis  more  marked  in  one  limb  than  the 
other.  While  a  large  haemorrhage  generally  makes  pressure  upon  all 
the  motor  area,  von  Bergmann  and  Kronlein  point  out  that  the  opposite 
arm  is  the  part  affected  first  and  most,  the  branches  of  the  artery  having 
become  quite  small  by  the  time  they  reach  the  centre  for  the  leg. 

(e)  General  paralysis.  Another  rare  condition,  the  existence  of 
which  may  be  explained  by  a  very  large  clot — e.g.  on  the  left  side 
rapidly 'effused  and  making  pressure  through  the  left  side  of  the  brain, 
upon  the  right  as  well — or  by  co- existing  extravasation  into  the^brain 
substance  itself. 


PUP/LS     S.QUAL 


PUPil^  UfitQU/il. 


264  OPERATIONS  ON  THE  HEAD  AND  NECK 

(/)  Absence  of  any  paralysis.  A  very  rare  condition  and  one  which 
is,  perhaps,  due  to  the  blood  effused  finding  its  way  through  a  fracture 
in  the  skull  beneath  the  scalp  (see  footnote,  p.  2G5).  Another  explana- 
tion may  be  that  the  clot  is  posterior  to  the  motor  area,  of  the  rarer 
pari eto- occipital  and  not  the  more  frequent  tempero-parietal  variety. 

[g)  Limbs  rigid,  convulsed,  or  twitching.  It  is  only  too  probable 
here  that,  in  addition  to  middle  meningeal  extravasation,  contusion 
or  laceration  of  the  brain  substance  will  be  found  at  more  spots 
than  one. 

(3)  Condition  of  the  pwpils.  Whilst  this  may  vary,  there  are  at  least 
three  conditions  which  are  most  important. 

(a)  In  an  uncomplicated  case  of  compression  from  middle  meningeal 
haemorrhage  the  pupil  on  the  injured  side,  after  an  initial  transitory 
contraction,  becomes  dilated  and  fixed,  i.e.  does 
not  react  to  light.  The  pupil  of  the  opposite  side, 
which  at  first  is  normal  in  size  and  reacts  to  light, 
also  becomes  dilated  and  fixed  in  the  later  stages. 
When  present,  this  condition  of  the  pupils  is  a  most 
valuable  sign  of  the  existence  of  compression,  and 
also  affords  important  information  as  to  the  side 
affected.  Its  value  and  explanation  were  first 
pointed  out  by  Sir  Jonathan  Hutchinson.^ 

(b)  If  the  pupils  are  natural  as  regards  reaction 
to  light,  the  compression  of  the  brain  is  probably 
recoverable  if  trephining  be  immediately  performed. 
Further,  it  is  more  likely  to  be  a  case  of  com- 
pression of  the  brain  only  without  other  injury. 

(c)  If  the  pupils  are  insensitive,  often  at  the 
same  time  dilated,  the  compression  is  probably 
extreme,  and,  while   trephining  is  urgently  called 

Fig.  121.    Typical  condi- ^^r,  it  is  less  likely  that  in  these  cases  the  brain 
tion  of  pupils  in  left  middle  will  recover  itself  after  removal  of  the  clot, 
meningeal  hjemorrhage.  (4)  j^j^^   ^^Ise.     This   will   vary    according  as 

the  case  is  one  of  well-marked,  ujicomplicated 
extravasation,  or  complicated  with  contusion  or  laceration  of  the 
brain  ;  and,  if  the  concussion  stage  has  been  severe,  according  to  the 
degree  to  which  the  heart  has  recovered  from  this.  In  well-marked 
uncomplicated  compression  the  pulse  will  be  slower  than  normal,  e.g.  66, 
52,  or  even  slower,  and  usually  full  and  labouring.  If,  later,  a  pulse 
which  has  been  typically  slow  becomes  very  rapid  it  means  that 
the  final  stage  of  paralysis  of  the  vagus  has  set  in  and  that  a  fatal 
termination  is  imminent. 

(5)  Coma.  With  regard  to  this  the  following  points  should  be  borne 
in  mind  : 

(a)  The  degree  of  unconsciousness  will  vary  with  the  size  of  the 
branch  injured,  and  the  rapidity  with  which  the  blood  is  effused.  Where 
the  effusion  is  rapid  and  the  compression  great,  the  coma  may  be  as 
deep  and  complete  as  in  apoplexy.  But,  in  other  cases,  it  will  be  found 
that  though  the  coma  is  apparently  deep,  this  is  not  really  so  ;  thus 
the  patient  may  moan  constantly  or  may  move  his  limbs  feebly  when 
disturbed. 

(6)  The    commencing    coma    may    be    taken    for    natural    sleep    or 

^  London  Hospital  Reports,  1867,  vol.  iv,  p.  29. 


SOTM  PuPii^  fvu.y  i 


MENINGEAL  HAEMORRHAGE  265 

drunkenness,  in  which  condition  the  patient  may  be  allowed  to  lie  until 
it  is  too  late. 

{c)  In  a  few  cases  the  onset  of  the  coma  is  deferred  till  late  ;  its 
onset  is  here  sudden,  its  course  rapid,  and  it  generally  ends  in  death. 

(6)  Respiration.  This,  in  well-marked  cases,  is  often  stertorous  and 
somewhat  slow.  In  cases  where  stertor  has  not  supervened  to  call 
attention  to  the  existence  of  compression,  other  and  still  graver  altera- 
tions in  the  breathing  may  be  present,  alterations  which  are  warnings 
that  the  end  is  not  far  ofE  and  that,  in  the  case  of  intended  trephining, 
there  is  no  time  to  lose,  viz.  catchy,  short  respirations,  cyanosis,  and 
gasping,  irregular  breathing,  ceasing  for  intervals  of  ten  or  fifteen 
seconds  and  then  repeated. 

(7)  State  of  the  scalp.  When  the  history  is  deficient,  or  when  the 
signs  of  compression  are  not  well  marked,  ecchymosis  or  contusion  of 
the  parietal  and  temporary  regions,  giving  rise  to  a  pulpy  or  puffy  feel, 
are  of  great  value.  This  condition  will  be  especially  marked  when  the 
haemorrhage  from  the  middle  meningeal  artery  is  finding  its  way  through 
some  fissure  into  the  tissues  of  the  scalp. ^ 

Treatment.  Early  trephining  should  be  performed  as  follows  :  The 
scalp  should  be  shaved  widely  as  much  bone  may  require  removal. 
No  anaesthetic  should  be  given  if  the  patient  is  unconscious  or  the 
respiration  failing.  If  any  be  employed  the  greatest  care  must  be 
taken  on  account  of  the  risk  of  vomiting  and  aspiration-pneumonia.  The 
head  being  supported  on  sand  bags  or  a  firm  pillow,  the  middle  meningeal 
area^  on  the  side  which  is  bruised,  and  on  the  side  opposite  to  the  hemi- 
plegia, is  explored  by  turning  down  a  semilunar  flap,  the  centre  of  which 
is  one  and  a  half  inches  behind  the  external  angular  process  and  one 
inch  above  the  zygoma — roughly  speaking,  two  fingers'  breadth  above  the 
zygoma  and  about  the  same  behind  the  external  angular  process  (Fig.  122, 
p.  273).  Kronlein  distinguishes,  according  to  the  point  of  rupture, 
three  haematomata — an  anterior,  fronto-temporal ;  middle,  temporo- 
parietal ;  and  posterior,  or  parieto-occipital.  He  advises  trephining 
first  at  the  usual  place  ;  if  no  haematoma  be  found  here,  a  second  per- 
foration should  be  made  further  back,  a  little  above  and  behind  the  ear, 
or,  more  accurately,  at  the  inter-section  of  a  line  drawn  backwards  from 
the  upper  margin  of  the  orbit  with  a  vertical  one  carried  up  directly 
behind  the  mastoid  process.     Enlargement  of  either  of  these  openings 

^  There  is  a  good  specimen  of  this  in  the  St.  George's  Hospital  Museum,  figured  by  Mr. 
Holmes  in  his  Surgery,  4th  ed.,  p.  140.  It  shows  the  parietal  bone  of  a  child,  in  which  a 
gaping  fissure  crosses  the  middle  meningeal  artery,  producing  considerable  extravasation 
inside  the  skull  and  still  more  externally. 

^  L.  B.  Rawlings  (surface  markings)  gives  the  following  useful  account  of  the  surface 
anatomy  of  the  middle  meningeal  artery.  "  The  middle  meningeal  artery  enters  the 
skull  through  the  foramen  spinosum,  and  divides  after  a  short  and  variable  course  across 
the  middle  fossa  into  two  main  trunks.  The  seat  of  bifi],rcation  usually  corresponds  to  a 
point  just  above  the  centre  of  the  zygorna^^  The  anterior  branch  is  not  only  the  larger 
of  the  two,  but  it  is  also  more  liable  to  injury,  since  it  is  protected  in  the  temporal  region 
only  by  a  thin  osseous  barrier.  The  danger  zone  in  the  course  of  this  may  be  mapped  out 
by  taking  three  points.  ( 1 )  One  inch  behind  the  external  angular  process  of  the  frontal 
bone  and  one  inch  above  the  zygoma.  (2)  One  and  a  half  inches  behind  the  external 
angular  process  and  one  and  a  half  inches  above  the  zygoma.  (3)  Two  inches  behind 
the  external  angular  process  and  two  inches  above  the  zygoma.  A  line  uniting  these 
three  points  indicates  therefore,  that  part  of  the  anterior  branch  which  is  most  liable  to 
injury.  The  anterior  division  of  the  vessel  will  be  exposed  by  trephining  over  any  of  these 
three  points,  but  it  is  generally  preferable  to  choose  the  highest  point,  as  in  this  way  the 
posterior  border  of  the  great  wing  of  the  sphenoid  is  avoided  ;  as  an  additional  reason  it 
should  be  added  that,  in  the  position  of  points  1  and  2,  the  artery  frequently  runs  in  an 
osseous  canal." 


266  OPERATIONS  ON  THE  HEAD  AND  NECK 

will  enable  the  surgeon  to  deal  with  a  middle  or  parietal-temporal 
haematoma.  The  brisk  hsemorrhage  which  takes  place  from  the  scalp 
may  be  controlled  by  the  use  of  Spencer-Wells  forceps  and  Lane's 
tissue  forceps,  the  latter  acting  as  retractors  also  :  Makka's  clamps  may 
also  be  employed  for  compressing  the  base  of  the  flap.  The  pericranium 
is  then  carefully  separated,  and  any  fissure  or  fracture  looked  for  in  the 
bone.  Whether  one  be  found  or  no,  a  disc  of  bone  is  next  removed  with 
a  full-sized  trephine.  When  this  has  been  exposed  the  clot,^  hsemorrhage 
may  still  be  going  on,  warning  of  which  will,  perhaps,  be  given  by  the 
pulsation  of  the  clot.  This  having  been  removed  by  a  small  scoop, 
by  one  of  Volkmann's  spoons,  or  better  still  by  irrigation  with  sterile 
saline  solution,  the  hsemorrhage  may  cease,  or  it  may  continue  profusely, 
welling  up  from  a  point  quite  out  of  reach.  In  such  cases  the  surgeon 
may,  after  saving  his  patient  from  the  dangers  of  compression,  have  to 
face  those  of  most  serious  hsemorrhage.  In  such  a  contingency  much 
will  depend  on  the  accessibility  of  the  bleeding-point,  whether  it  is 
in  the  wall  of  the  skull  or  in  the  foramen  at  the  base  ;  the  following 
steps  may  be  made  use  of  after  the  free  exposure  of  the  interior  of  the 
cranium  by  the  removal  of  sufficient  bone  by  Hoffman's  forceps  (p.  312). 
A  good  light  is  essential,  an  electric  head  lamp  being  often  of  the  greatest 
use. 

(1)  Ligature  of  the  artery  after  removal  of  sufficient  bone  to  expose 
the  site  of  injury.  (2)  Crushing  together  with  forceps  the  edge  of  the 
bone  from  which  bleeding  comes.  (3)  Underrunning  the  artery  in  the 
dura  mater  with  a  fine  curved  needle.  (4)  The  use  of  Horsley's  wax. 
This  is  a  mixture  of  beeswax  7  parts,  almond  oil  1  part,  and  carbolic 
acid  or  salicylic  acid  1  part.  Its  use  is  especially  indicated  when  the 
artery  is  ruptured  in  the  bony  canal,  the  wax  being  forced  into  the 
opening  wdth  a  probe.  (5)  Another  method  of  checking  the  bleeding 
when  the  vessel  is  damaged  in  a  bony  canal  is  to  plug  this  canal  with 
a  tiny  boiled  and  aseptic  wooden  peg.^  (6)  Forcipressure  by  means  of 
a  pair  of  Spencer-Wells  forceps  left  in  situ  for  twelve  hours.  (7)  The 
above  means  failing,  which  is  unlikely,  ligature  of  the  external  or  common 
carotid  had  better  be  resorted  to.^  If  such  a  step  be  really  needful, 
a  temporary  closure  of  the  common  carotid  (q.v.)  will  perhaps  suffice. 
It  is  always  to  be  remembered  that  local  hsemostasis  is  greatly  to  be 

^  Perhaps  more  bone  must  be  removed  by  skull  forceps  satisfactorily  to  expose  the 
clot. 

2  This  was  suggested  by  Sir  T.  Smith,  and  used  successfully  by  Mi".  Willett  and 
Mr.  H.  Marsh,  at  St.  Bartholomew's  Hospital  in  cases  of  haemorrhage  from  the  descending 
palatine  artery  {Clin.  Soc.  Trans.,  vol.  xi,  p.  71. 

^  Ligature  of  the  common  carotid  is  justified  by  a  successful  case  by  Dr.  Liddell  (Amer. 
Journ.  Med.  Sci.,  vol.  Ixxxi,  p.  344),  in  which  secondary  hsemorrhage  from  the  middle 
meningeal  artery,  three  weeks  after  a  shell  wound  in  the  temporal  region,  was  successfully 
arrested  by  ligature  of  the  common  carotid.  If  the  condition  of  the  patient  be  very 
grave,  ligature  of  the  common  and  not  the  external  carotid  will  generally  be  resorted 
to,  as  being  more  quickly  done.  More  recently  Dr.  E.  L.  Robinson,  of  Guernsey  (Brit. 
Med.  Journ.,  Dec.  31,  1904)  reports  a  successful  case  with  several  points  of  interest.  The 
patient,  a  woman  set.  20,  had,  in  falling  from  a  shop  counter,  struck  her  head  against  a 
shelf.  She  had  walked  home  and  there  vomited  blood.  While  telling  her  story  to  a 
medical  man,  an  hour  later,  she  suddenly  became  unconscious  with  left  hemiplegia,  and 
widely  dilated  right  pupil.  A  fracture  was  found  in  the  anterior  third  of  the  temporal 
fossa,  running  down  to  the  base.  The  bone  when  trephined  was  very  thin.  Fresh 
arterial  blood  and  clot  welled  up  into  the  opening  as  soon  as  this  was  made,  and  as  it  was 
impossible  to  see  the  source  of  the  bleeding,  the  right  common  carotid  was  tied.  This  was 
successful  at  once.  As  the  patient  came  round  from  the  anaesthetic  it  was  seen  that  the 
hemiplegia  had  disappeared.  Save  for  rather  tardy  disappearance  of  paralysis  of 
the  third^nerve  the  recovery  was  uneventful. 


^lEXIXCiKAL  H/EMORRHAGE  267 

preferred,  and  that,  of  the  methods  given  above,  ligature  of  the   middle 
meningeal  artery  itself  is  the  safest. 

Dr.  8h('])herd,  of  Montreal,  records  ^  an  instructive  case  of  middle 
meningeal  luemorrhage  in  which  ligature  of  the  common  carotid  was 
successfully  resorted  to.  That  the  ha-morrhage  was  not  severe  at  first, 
and  pressure  symptoms  from  the  slowly  spreading  clot  were  not  marked 
until  the  day  after  the  accident,  is  explained  in  Dr.  Shepherd's  opinion, 
by  the  fact  that  the  rupture  of  the  artery  was  low  down,  where  the  dura 
mater  was  closely  attached  to  the  base  of  the  skull,  and  where  it  needed 
considerable  force  to  separate  it  from  the  bone. 

A  large  and  very  tliick  clot  having  been  exposed  by  the  removal  of  two  trcpliine 
crowiis  in  tlie  line  of  a  fissured  fracture  in  the  anterior  part  of  the  left  parietal,  the 
empty  meningeal  artery  could  be  seen  ramifying  on  the  dura  mater,  while  blood 
was  freely  welling  up  from  below.  A  large  piece  of  bone,  three  inches  long  by  two 
inches  wide,  was  chiselled  away  in  the  hope  of  reaching  the  bleeding-point.  After 
a  large  amount  of  clot  had  been  removed  there  was  furious  bleeding  from  below. 
The  brain  and  dura  mater  being  held  aside  by  a  broad  retractor  it  was  seen  that  the 
fracture  ran  through  the  foramen  spinosum,  and  then  across  the  body  of  the  sphenoid. 
The  artery  was  evidently  torn  in  the  foramen.  It  was  decided  to  tie  the  common 
carotid  which  immediately  stopped  the  free  haemorrhage.  All  the  blood  clot  ha\nng 
been  washed  out,  the  space  at  the  base  of  the  skull  was  packed  with  iodoform  gauze. 
The  patient  soon  recovered  consciousness.  Two  days  later  as  the  gauze  was  being 
removed,  there  was  a  tremendous  spurt  of  blood  as  the  last  piece  came  away.  The 
wound  was  therefore  again  packed.  Three  days  after,  the  patient  had  a  rigor,  a 
temperature  of  l()2-5  ,  and  paralysis  of  the  left  side  and  motor  aphasia.  These 
gradually  disappeared  and  the  gauze  was  removed  without  any  bleeding  ten  days 
after  the  second  plugging.     The  patient  made  an  excellent  recovery. 

Dr.  Shepherd  considered  that  the  paral}'sis  and  aphasia  were  due 
to  the  compression  affected  by  the  large  quantity  of  firmly  packed 
iodoform  gauze,  and  not  to  ligature  of  the  carotid,  for  these  signs  came 
on  only  after  the  second  packing  and  were  veiy  temporary  in  duration. 
The  compression  would  have  been  rendered  still  greater  w^hen  the  gauze 
became  soaked  w4th  blood.  Dr.  Shepherd  resorted  to  ligature  of  the 
common  carotid  instead  of  plugging  the  foramen,  because  this  might 
have  separated  the  fracture  in  the  base  of  the  skull.  As  in  all  operations 
on  the  head  and  brain,  where  the  patient's  condition  is  a  grave  one, 
infusion  of  saline  fluid  should  be  resorted  to  when  the  artery  has  been 
secured. 

How  far  the  surgeon  should  remain  satisfied  with  partial  removal 
of  the  clot,  or  proceed  to  remove  the  skull  freely,  and  then  the  clot, 
more  extensively,  must  depend  partly  on  the  conditions  under  which 
the  operation  is  carried  out,  but  chiefly  on  the  state  of  the  patient,  the 
size  of  the  clot,  and  w'hether  the  depression  in  the  dura  mater  begins 
quickly  to  pulsate  and  to  rise  up.  If  these  last  points  are  in  doubt, 
there  should  be  no  hesitation,  the  condition  of  the  patient  admitting 
it.  in  removing  more  bone,  and  any  clot  which  seems  firm  and  dense, 
till  all  cause  of  depression  in  the  membrane  is  removed. 

Prognosis.  With  reference  to  this  point,  the  following  remarks  from 
a  paper  by  Mr.  Jacobson  in  the  Guy's  Hospital  Reports,  vol.  xliii,  maybe 
quoted  :  "  The  chief  points  on  which  this  depends  are  whether  the  middle 
meningeal  extravasation  is  probably  complicated  with  such  injuries  as 
extensive  fractures  and  brain  injury  and,  secondly,  upon  the  date  of 
trephining,  and  whether,  at  this  time,  the  brain  recovers  itself  quickly  or 
not.  With  regard  to  the  former,  or  the  existence  of  complications,  the 
1  Brit.  Med.  Journ.,  1896,  vol.  i,  p.  905. 


268  OPERATIONS  ON  THE  HEAD  AND  NECK 

surgeon  will,  if  asked  to  state  the  probable  result,  base  his  opinion  on  the 
history  of  the  case,  the  severity  of  the  violence,  e.cj.  height  of  fall,  whether 
any  interval  of  lucidity  has  been  present  and,  if  so,  for  how  long  and  how 
far  has  this  been  well  marked,  how  far  the  symptoms  of  compression, 
well-defined  hemiplegia,  the  failing  pulse,  the  stertorous  breathing,  &c., 
are  present  or  replaced  by,  or  complicated  with,  those  symptoms  which 
are  believed  to  point  rather  to  laceration  or  contusion  of  the  brain  or 
its  membranes,  viz.  restlessness,  convulsive  movements  or  twitchings, 
pulse  quick  and  sharp,  or  pyrexia,  which  show  that  inflammation  of  the 
brain  has  probably  supervened  upon  the  injury  to  its  substance." 

The  seventy  cases  upon  which  the  above  paper  was  based  appeared 
to  fall  into  the  three  following  groups  : 

A.  The  most  hopeful  cases  for  trephining.  Violence  comparatively 
slight ;  laceration  of  the  middle  meningeal  artery  or  its  branches ; 
fracture  of  skull,  if  present,  slight  and  localized  to  one  side,  i.e.  not 
implicating  the  base  ;  compression  present,  but  little  or  no  contusion 
or  laceration  of  brain.     Twenty-seven  cases. 

B.  Less  hopeful  cases.  Violence  greater ;  laceration  of  middle 
meningeal  or  its  branches  ;  fracture  implicating  middle  fossa  ;  some 
injury  to  brain,  but  this  only  trivial.     Twenty  cases. 

C.  Cases  probably  hopeless  from  the  first.  Violence  very  great ;  lacera- 
tion of  the  middle  meningeal  or  its  branches  ;  fracture  of  skull  extensive  ; 
perhaps  implicating  several  bones  and  sutures  both  in  the  vault  and 
base  ;    injury  to  brain  very  severe.     Twenty-three  cases. 

Sub-dural  haemorrhage.  This  obscure  and  difficult  subject  has  had 
much  light  thrown  upon  it  by  a  paper  by  Mr.  W.  H.  Bowen.^  The 
differential  diagnosis  of  extra-dural  haemorrhage,  intracranial  suppura- 
tion, uraemia,  idiopathic  epilepsy,  cerebral  haemorrhage,  and  meningeal 
haemorrhage  is  carefully  considered.  Mr.  Bowen  is  inclined  to  rely 
upon  (1)  the  long  duration  of  lucid  intervals.  (2)  The  presence  of  a 
scalp  wound,  or  bruise,  recent  or  remote.  (3)  The  presence  of  Hutchin- 
son's pupil  {see  p.  264),  which  is  however  rarely  present.  The  only 
treatment  is  early  trephining.  The  following  points  of  practical  import- 
ance are  brought  out  by  Mr.  Bowen  in  his  paper  :  («)  No  fracture  may 
be  present  in  these  cases  of  sub-dural  haemorrhage.  Operators  who 
may  be  inclined  on  exploring  a  case  to  close  the  wound  because  the 
bones  are  found  uninjured,  should  bear  this  in  mind.  (6)  If,  on  opening 
the  dura  at  more  than  one  place,  no  clot  is  found  and  the  brain  bulges 
through,  pulsating,  the  following  possibilities  must  be  borne  in  mind  : 
(1)  The  diagnosis  may  be  wrong  and  a  cerebral  abscess  be  present. 
If  this  is  excluded,  and  if  the  passage  of  a  curved  director  into  the 
arachnoid  cavity  for  the  purpose  of  exploring  neighbouring  areas  proves 
negative,  the  opposite  side  of  the  skull  should  be  trephined  and  a  careful 
search  made  there.  (2)  As  in  the  case  of  middle  meningeal  haemorrhage 
it  may  be  a  case  of  contre-coup.  (3)  Where  sub-dural  haemorrhage 
is  present,  tenseness  and  non-pulsation  of  the  dura  mater  are  far  more 
valuable  than  the  colour  of  this  membrane.  "  If  colour  be  relied  upon, 
two  conditions  at  least  may  lead  to  error,  one  being  that  the  compressing 
agent  is  not  always  blood,  but  may  be  blood  and  serum,  or  serum  alone, 
when  there  will  be  no  discoloration,  notwithstanding  the  presence  of 
pronounced  compression  ;  the  other  that  a  thin  layer  of  blood  over 
the  surface  of  the  brain,  associated  with  severe  contusion,  yet  incapable 
^  Gtiy's  Hospital  Reports,  vol.  lix. 


TRAUMATIC  CEREBRAL  ABSCESS  269 

of  compression,  may  cause  discoloration,  and  this  may  also  appear  to 
be  present  when  caused  by  the  very  distended  veins  on  the  surface  of 
the  brain  pressed  against  the  membrane."  (4)  With  regard  to  the 
removal  of  the  clot  tliere  is  nothing  to  be  added  to  the  account  given 
at  p.  2()G.  (5)  Ha'morrhage  may  be  difficult  to  stop  and  may  recur 
dangerously.  In  such  cases  it  is  possible  that  a  sinus  has  been  opened 
by  a  fracture  running  into  the  base.  Cerebral  vessels  may  require 
ligature.  (())  As  to  the  advisability  of  drainage  no  rule  can  be  laid 
down.  Only  when  it  is  certain  that  all  clot  has  been  removed  and  that 
the  field  of  operation  is  sterile,  should  the  w^ound  be  entirely  closed. 
The  following  case,  under  the  care  of  the  late  Mr.  H.  W.  Allingham,^ 
is  a  most  interesting  one,  the  bleeding  having  apparently  come  from  a 
laceration  of  the  frontal  lobe.  The  length  of  the  "  latent  "  interval 
will  be  noted. 

A  man,  set.  40,  was  admitted  to  the  Great  Northern  Hospital,  having  fallen  off 
a  tramcar  while  half  drunk.  He  complained  of  pain  in  the  left  shoulder  ;  there  was  no 
evidence  of  injury  to  the  head.  The  next  four  days  the  patient  was  very  drowsy 
and  irritable  when  disturbed.  There  was  no  jiaralysis.  A  week  later  the  patient  was 
seized  with  convulsions.  These  began  in  the  left  side  of  the  face,  the  mouth  being 
drawn  up,  and  the  eyelids  moved  in  clonic  spasm.  The  muscles  of  the  neck  were 
next  affected,  and  subsequently  the  left  arm  and  leg.  The  breatliing  was  stertorous. 
A  large  flap  was  turned  down  in  the  right  parietal  region  and  a  disc  of  bone  was 
removed  over  the  right  fissure  of  Rolando — i.e.  about  two  and  a  half  inches  behind 
and  one  and  a  half  inches  above  the  external  angle  of  the  orbit.  The  posterior 
branch  of  the  middle  meningeal  ran  across  the  exposed  dura  mater.  This  mem- 
brane did  not  pulsate,  and  showed  a  black  mass  beneath  it  ;  the  artery  being 
secured,  the  dura  mater  was  incised  and  a  large  clot  exposed.  About  three  ounces 
of  this  having  been  removed  chiefly  by  irrigation,  a  large  cavity  could  be  felt  as  far 
as  the  finger  could  reach  ;  the  brain  appeared  to  be  much  lacerated  over  the  frontal 
lobe.     The  patient  made  a  good  recovery. 

TREPHINING  AND  EXPLORATION  OF  CEREBRAL  ABSCESS 
DUE  TO  INJURY 

Indications  for  exploring  ;  symptoms  and  diagnosis  of  traumatic 
cerebral  abscess.  Many  of  these  are  given  at  somewhat  fuller  length  in 
reference  to  that  form  of  cerebral  abscess  which,  as  one  of  the  results 
of  otitis  media,  is  discussed  at  p.  352.  To  begin  with  there  is  often  the 
history  of  an  injury. ^  This  may  have  been  a  stab- with  a  knife,  a  graze 
of  the  head  with  brief  concussion,  a  fracture,  especially  a  compomid 
one,  a  blow  with  a  stone  or  a  glancing  bullet.  Occasionally  an  abscess 
may  follow  a  trifling  superficial  septic  injury,  such  as  the  bite  of  an 
insect,  the  infection  reaching  the  brain  through  some  of  the  emissary 
veins.  Again  the  nasal  fossae  must  not  be  forgotten,  as  shown  by  the 
case  mentioned  at  p.  461.  Dr.  Carson^  mentions  the  case  of  a-  child 
where  the  infection,  starting  in  a  nasal  catarrh  the  result  of  an  injury, 
extended  through  the  cribriform  plate  to  the  brain  and  led  to  an  abscess 
which  terminated  fatally.  Often,  but  not  always,  follows  a  latent 
period  devoid  of  brain  symptoms,  which  may  last  from  a  few — e.g.  four- 
days  to  three  or  four  weeks  or  much  longer.  This  latent  period  is 
succeeded  by  brain  symptoms  increasing  in  severity  and  going  on  to 

^  Clin.  Soc.  Trans.,  vol.  xxii,  p.  220. 

*  But  the  help  which  a  history  of  injury  gives  is  not  always  present,  and  this  is  an 
indication  for  always  examining  for  any  wound  or  scar,  and  exploring  it,  however  un- 
important it  may  seem  to  be,  in  these  cases. 

*  New  York  Med.  Journ.,  April  27,  1905. 


270  OPERATIONS  OX  THE  HEAD  AND  NECK 

those  of  compression,  viz.  headache  felt  over  the  side  injured,  but  not 
necessarily  most  intense  at  the  injured  spot ;  nausea  or  vomiting ; 
some  pyrexia,  although  the  temperature  usually  rises  slowly,  if  it  rises 
above  the  normal  at  all.^     Optic  neuritis  may  be  present. 

Other  symptoms  are  mental  dulness  (the  answers  long  delayed,  but 
intelligent  when  they  come),  a  slow  pulse,  perhaps  rigors,  progressive 
emaciation,  perhaps  accompanied  by  vomiting.  Whether  local  nerve 
symptoms — e.g.  disturbances  of  sensation  and  motion — are  present 
must  depend  on  the  position  of  the  abscess.  If  the  injury  has  been 
over  the  motor  area  (Figs.  122  and  123)  nerve  symptoms  may  be  clearly 
marked,  but  if  over  the  anterior  part  of  the  frontal  or  temporo-sphenoidal  ^ 
lobes,  they  may  be  entirely  absent.  Thus  hemiplegia,  a  paralysis  limited 
— e.g.  of  upper  limb  and,  later  on,  gradually  increasing — epileptic 
seizures,  spasms,  spastic  rigidity,  all  have  been  met  with,  but  must 
by  no  means  be  relied  upon  ;  and  even  when  paralysis  is  present  it  may 
escape  observation,  as  when  there  is  slight  paralysis  of  the  muscles  of 
the  lower  half  of  the  left  side  of  the  face,  and  some  loss  of  power  in  the 
left  hand  and  arm,  but  only  temporary.^  Here,  as  in  otitis  media, 
there  is  but  one  rule,  and  that  is,  that  in  all  cases  where  an  abscess  of 
the  brain  may  be  present,  exploration  should  be  undertaken,  and  that 
this  step  should  not  be  deferred. 

For  the  surgeon,  who  is  watching  what  he  believes  to  be  a  cerebral 
abscess,  must  always  remember  that  after  a  period  of  latency,  which 
may  last  weeks  or  more,  acute  symptoms  may  set  in  suddenly  and 
quickly  close  in  death. 

Operation  of  trephining  Jor  traumatic  cerebral  abscess.  As  the 
fatality  of  cerebral  abscess,  if  left  to  itself,  is  so  high — 90  to  100  per 
cent. — trephining  is  abundantly  justified.  The  chief  difficulty  is,  of 
course,  hitting  off  the  seat  of  the  abscess,  especially  in  cases  where  there 
are  no  definite  nerve  symptoms  to  guide  and  where  the  history  of  the 
part  of  the  head  injured  is  indefinite  also. 

To  ob\'iate  the  neces.sity  of  multiple  trephining,  Dr.  Fenger  and  Dr.  Lee,  of 
Chicago,  have  recommended,*  as  easier  and  safer,  exploratory  puncture  and  aspira- 

^  On  this  and  other  points  reference  may  be  made  to  p.  352,  Prof.  Xancrede  (loc. 
supra  cit.,  p.  9.j)  writes  thus  :  '•  I  beheve  that  an  abscess  involvmg  the  cerebral  tissue 
alone  will  be  accompanied,  in  most  cases,  by  a  subnormal  or,  at  least,  a  normal  tempera- 
ture. Where  a  high  temperature  is  noted,  either  the  pus  collection  is  a  locahsed  suppura- 
tive arachnitis  limited  by  adhesions,  or  there  is  a  meningitis  in  addition  to  the  abscess." 

2  With  regard  to  the  large  collection  of  pus  found  here,  Dr.  Yeo  (loc.  supra  cit.,  p.  885) 
quotes  as  follows  from  Huguenin  {Ziemssen'-s  Cyclopedia,  vol.  xii)  :  ''  The  difficulty  of 
diagnosis  is  increased  by  the  circumstance  that  no  bands  of  fibres,  which  are  direct 
conductors  of  sensibihty  or  motion,"  pass  through  this  lobe  ;  and,  therefore  an  abscess 
here  ••  may  attain  a  considerable  size,  and  may  cause  general  symptoms  of  compression, 
before  any  distinct  symptoms  of  local  disease  arouse  the  suspicion  of  a  localised  affection 
of  the  brain." 

3  The  value  of  accurately  noting  symptoms  which,  though  of  but  brief  duration,  may 
be  very  important  guides  in  treatment,  is  weU  shown  by  a  case  of  Sir.  W.  Macewen's 
(Lancet,  1881,  vol.  ii,  p.  582). 

A  boy,  aged  11,  was  admitted  into  the  Glasgow  Royal  Infirmary,  two  weeks  after  a  fall 
upon  his  head,  with  a  partially  healed  wound  and  bare  bone  over  the  left  e\-ebrow.  A 
week  later  he  had  a  rigor.  Five  days  later,  or  twenty-.six  days  after  the  injury,  the  patient 
had  a  convulsion  confined  to  the  right  side ;  when  this  had  passed  ofE,  he  was  distinctly 
aphasic.  The  seat  of  the  abscess  now  seemed  to  be  the  third  left  frontal  convolution, 
and  trephining  was  proposed.  The  friends,  however,  refused  to  permit  this,  as  the 
patient  had  recovered  consciousness,  though  they  were  warned  that  the  improvement 
would  only  be  temporary.  Thirty  hours  later,  the  convulsions  of  the  right  side  recurred, 
the  temperature  rose  quickly  from  101'  to  104^,  and  the  patient  died  before  the  operation 
could  be  performed.     The  situation  of  the  abscess  was  verified  after  death. 

*  Trans.  Amc.  Surg.  Assoc,  vol.  ii,  j).  78. 


TRAUMATIC  CEREBRAL  ABSCESS  271 

tion.  Tliis  must  b(>  done  mothodically,  witli  a  needle,  four  inches  long,  set  in  an 
exploring  syringe.  The  needle  shonki  not  be  too  tine,  and  the  gauge  should  be 
powerfulenough  to  make  suffieient  suction,  as  a  tine  needle  is  readily  plugged  with 
brain  substance.  This  may  be  easily  taken  for  pus.  The  needle,  sterilised,  is 
pushed  tlu-ough  a  trepliine-hole,  straiglit  in,  in  a  definite  direction,  for  half  an  inch 
or  one  inch  ;  the  piston  is  then  withdra\vn  a  little  and,  if  no  pus  follows,  the  needle 
is  pushed  half  an  inch  further  and  the  piston  again  withdrawn.  The  depth  to 
which  it  will  be  permissible  finally  to  push  the  needle  will,  of  course,  vary  with 
the  position  of  the  trephine-opening  and  the  direction  of  the  pimcturc,  the  surgeon 
being  guided  by  the  anatomy  of  the  brain.  The  ])unctures  are  to  be  repeated  at 
intervals  of  half  an  inch  or  one  inch,  the  utmost  care  being  taken  to  push  the  needle 
in  straight  and  to  avoid  all  lateral  movements.  The  loss  of  resistance  and  the 
sensation  tliat  the  point  moves  in  a  cavity  are  to  be  carefully  watched  for.  If, 
after  a  reasonable  number  of  punctures,  no  pus  is  withdrawn,  the  operator  may 
feel  convinced  that  none  is  preseiit.  Ail  abscess  in  the  brain  is  usually  as  large  as 
a  walnut,  often  much  larger.     More  details  are  given  at  p.  357. 

Puncturing  healthy  brain  tissue  with  a  fine,  perfectly  aseptic  needle  can  do  but 
little  mischief. 

The  needle  should  be  kept  as  a  guide  till  the  abscess-cavity  is  definitely  opened 
either  by  inserting  a  pair  of  Lister's  sinus-forceps  or  a  sharp  straight  bistom-y.  The 
abscess  must  be  thoroughly  drained  and  made  to  close  from  the  bottom. 

A  drainage  tube  should  be  used  and  should  be  kept  in  position  by 
stitch  securing  it  to  the  margin  of  the  skin. 

The  following  cases  of  traumatic  cerebral  abscess,  in  addition  to 
those  given  at  p.  261  and  in  the  footnotes  to  p.  270,  are  good  instances 
of  the  disease  and  also  of  its  successful  treatment  : 

A  labourer,  aged  60,  was  admitted  into  the  ]\Iiddlesex  Hospital,  under  the  care  of 
the  late  Mr.  J.  W.  Hulke.  a  fortnight  after  being  struck  a  glancing  blow  on  the  right 
temple  by  a  falling  ladder,  which  stunned  him  for  a  few  minutes  and  caused  consider- 
able bruise.  He  continued,  nevertheless,  to  work  as  usual  imtil  the  middle  of  the 
third  day,  when  headache,  which  he  had  from  the  time  of  the  accident,  became  very 
severe — -so  severe  that  his  wife  feared  that  he  would  go  out  of  his  mind.  On  admission 
the  pulse  was  56,  and  the  temperature  slightly  below  the  normal.  The  patient's  mind 
was  unclouded.  About  one  week  later,  in  the  night,  he  became  insensible,  and  in 
the  morning  the  right  upper  and  lower  limbs  were  found  absolutely  palsied  as  regards 
motion,  and  nearly  so  as  regards  sensation.  When  the  arm  or  thigh  was  severely 
pinched,  he  gave  scarce  any  sign  of  consciousness  of  it,  but  shrank  slightly  when  the 
left  limbs  were  pinched  similarly.  Two  days  later,  spastic  rigidity  of  the  left  arm 
supervened.  A  small  disc  of  bone  cut  out  beneath  the  bruised  bone  on  the  right 
temple  appeared  uninjured.  The  dura  mater  bulged  up  so  tensely  that  pulsation 
could  neither  be  seen  nor  felt ;  its  exposed  sturface  appeared  healthy.  A  needle 
connected  with  an  exhausting  syringe  was  pushed  through  it  to  a  depth  of  one  and  a 
quarter  inches.  A  brownish  turbid  fluid  rose  up  into  the  receiver,  and  continued 
to  flow  after  the  needle  was  withdrawn.  The  minute  opening  was  enlarged  with  a 
scalpel,  and  a  considerable  quantity  of  fluid  escaped.  The  flaps,  which  had  been 
reflected,  were  replaced.  Next  morning  the  spastic  rigidity  of  the  left  arm  had 
gone.  On  the  second  day  slight  return  of  power  was  noticed  in  the  right  Hmbs, 
and  before  the  end  of  a  week  their  palsy  had  disappeared.  For  a  very  few  days  after 
the  operation  the  dressing  was  wetted  and  discoloured  by  the  fluid  which  continued 
to  ooze,  but  the  wound  soon  healed,  and  two  months  after  the  operation  the  patient 
appeared  quite  well. 

It  is  interesting  to  note  in  the  following  case  that  the  hemiplegia 
which  followed  the  operation  was  only  transitory.  It  also  shows  that 
grave  symptoms  may  be  latent  for  as  long  as  five  months  if  a  skull 
wound  remains  unhealed. 

A  child,  aged  4i,  had  sustained  a  severe  compound  fracture  of  the  right  frontal 
bone.  The  removal  of  some  portions  of  necrosed  bone  led  subsequently  to  a  slight 
hernia  cerebri.  The  sinus  persisted,  but  the  child  seemed  well  in  other  respects 
until  about  five  months  after  the  accident,  when  left-sided  convulsions  (chiefly  of 
the  muscles  of  the  face  and  arm)  came  on,  and  an  alarming  condition  rapidly 
developed.     The  sinus  was  opened  up  and  a  director  passed  for  a  distance  of  one  inch 


272  OPERATIONS  ON  THE  HEAD  AND  NECK 

into  the  right  frontal  lobe  downwards  and  backwards.  A  free  flow  of  fetid  pus 
occurred,  and  after  the  cavity  had  been  washed  out  ^vith  carbolic  lotion  (1  in  40),  a 
drainage-tube  was  inserted.  The  latter  was  removed  at  the  end  of  a  fortnight. 
Left  hemiplegia  followed  the  operation,  but  it  passed  oflE  some  twenty-four  hours 
subsequently.     Recoveri-  was  rapid  and  complete. 

TREPHINING  FOR  EPILEPSY  AND  OTHER  LATER  RESULTS 
OF  A  CRANIAL  INJURY 

This  is  one  of  the  advances  in  cranial  surgery,  the  results  of  which 
have  not  come  up  to  the  expectations  formed  of  it.  The  operation — 
one  of  the  most  ancient  in  the  history  of  surgery — after  being  almost 
abandoned  for  centuries,,  has  been  again  taken  up  in  recent  years,  wdth 
all  the  advantages  of  modern  surgery,  especially  in  those  cases  where, 
after  an  injury,  epileptiform  con\^ilsions  beginning  in  the  leg,  arm,  or 
face  are  due  to  lesions  of  the  corresponding  parts  of  the  motor  area. 
This  form  of  con\"ulsion  forms  a  large  part  of  the  epilepsy  which  bears 
Dr.  Hughhngs  Jackson's  name.  It  is  to  be  feared  that  any  candid 
inquirer,  weighing  fairly,  unsuccessful  as  well  as  successful  cases,  and 
attaching  due  importance  to  the  facts  that  many  of  the  latter  have  been 
pubhshed  prematurely  as  to  final  result — -i.e.  before  they  have  been  sub- 
mitted to  the  time  test — will  come  to  the  conclusion  that  the  result  of 
trephining  for  traumatic  epilepsy  is  a  disappointing  one.  It  "^411  be  worth 
while  to  go  a  little  into  detail  with  regard  to  the  grounds  which  lead  to 
these  conclusions  : 

Results  of  operation.  Later  collections  of  cases  and  (what  is  of 
paramount  importance)  keeping  cases  more  carefuUy  under  after- 
observation,  have  shown  that  the  operation  for  traumatic  epilepsy  has 
not  come  up  to  the  expectations  formed  of  it.^  One  of  the  most  exten- 
sive of  cases  with  careful  analysis  of  results  is  by  Graf.- 

Graf  ha.s  collected  146  cases.  Of  these  71  were  trephined,  and  though  the  dura 
was  incised  in  some  of  these,  the  brain  was  not  incised.  In  the  remaining  75  the 
operative  procedure  was  extended  to  the  cortex  cerebri.  In  56  of  the  latter  group 
there  was  removal  of  spicules  or  fragments  of  bone,  or  incision  or  excision  of  a  cyst 
or  removal  of  a  cicatrix,  while  in  the  remaining  19  the  cortical  centre  was  excised. 
Of  the  total  number  there  was  an  operation  mortality  of  6-1  per  cent.  Fifty- 
three  of  the  cases  were  imder  observation  for  too  short  a  period  to  estimate  the 
result  of  the  operation.  Of  the  remainder.  35,  or  29-9  per  cent,  were  free  from  recur- 
rence at  the  end  of  six  months,  22,  or  15-1  per  cent,  were  improved,  while  36,  or 
27 "6  per  cent,  were  failures.  Graf  found  that  successful  cases  without  recurrence 
at  the  end  of  three  years  were  at  the  most  only  6-5  per  cent. 

This  want  of  success  can  be  readily  understood  from  a  consideration 
of  the  possible  pathological  conditions  {see  p.  274).  It  is  of  course 
quite  possible  to  remove  spicules  or  depressed  portions  of  bone,  or  to 
remove  any  cyst  or  mass  of  connective  tissue.     As  the  result  of  the 

^  Agnew  {Trans.  Amer.  Surg.  Assoc,  1891)  gives  results  in  57  cases  operated  upon  at 
Philadelphia.  Of  these  4  died,  4  were  cured,  4  were  operated  upon  too  recently  to  venture 
an  opinion,  4  passed  out  of  observation,  32  experienced  temporary  benefit,  and  9  obtained 
no  relief.  Of  those  reported  as  cured  2  had  been  under  observation  for  only  10  months — 
too  short  a  period  to  be  sure  of  a  permanent  cure.  Dr.  E.  G.  Mason,  of  New  York, 
tabulates  {Med.  News,  vol.  i,  1896,  p.  313)  70  cases  in  a  paper  which  is  especially  valuable 
because  he  refuses  to  accept  any  cases  as  "  cures  "  unless  the  patients  have  been  under 
observation  for  three  years,  and  have  had  no  return  of  fits.  Starting  with  this  sound 
proviso  he  finds  8  cases,  or  6'3  per  cent,  can  be  accepted  as  cures;  6  (or  4*2  percent.) 
showed  improvement  of  more  than  a  year's  duration  ;  in  14  (20  per  cent.)  there  was  no 
improvement  ;  in  three  cases  death  was  due  to  the  operation. 

2  Arch.  J.  Klin.  Chir.,  Bd.  Ivi,  quoted  by  Oppenheim,  Textbook  of  Nervous  Diseases, 
p.  1229. 


TRAUMATIC  EPILKPiSY 


273 


operation,  however,  some  scarring  or  adhesion  is  certain  to  take  place 
which  too  frequently  keeps  up  the  cerebral  irritation.  Still  more  is  it 
useless  to  break  down  adhesions  between  the  dura  and  pia  or  between 
the  pia  and  brain,  because  they  will  inevitably  re-form  after  the  opera- 
tion. Even  excision  of  a  portion  of  the  cortex  is  certain  to  be  followed 
by  a  cicatrix,  which,  in  turn,  will  act  as  an  irritant.  It  is  usually  im- 
possible to  determine  the  exact  pathological  condition  present  before- 
hand, and  it  must  be  remembered  that  in  some  cases  an  injury  to  the 
head  may  cause  contusion  of  the  brain  and  subsequent  sclerotic  changes 
in  the  cortex  without  any  fracture  or  depression  of  the  bone.     In  some 


Fig.  122. 

of  these  cases,  even  when  the  initial  lesion  or  portions  of  the  cortex  are 
removed,  the  slowly  established  habit,  created  by  years  of  excitation, 
will  remain.^ 

The  treatment  of  traumatic  epilepsy  should,  to  a  certain  extent,  be 
preventive.  All  depressed  fractures,  however  small,  should  be  elevated, 
for  though  no  symptoms  may  be  present  at  the  time,  such  injuries  are 
apt  at  a  later  date  to  produce  epileptic  convulsions. 

The  surgical  treatment  of  epilepsy  is  thus  summed  up  by  Professor 
Oppenheim  :  ^  (1)  The  operative  treatment  of  non- traumatic  true 
epilepsy  is  not  justifiable.  (2)  The  operative  treatment  of  Jacksonian 
epilepsy  of  non-traumatic  origin  is  admissible  under  certain  conditions, 
e.g.  if  an  operable  cortical  affection  (cyst,  tumour,  or  abscess)  is  probably 

^  See  the  remarks  of  Prof.  Nancrede  {Ann.  of  Surg.,  1896,  vol.  ii,  p.  122).  Also 
Sachs  and  Gerster  {Amer.  Journ.  Med.  Sci.,  Oct.  1896).  For  an  expression  of  the  opinion 
of  German  surgeons  see  the  proceedings  of  the  German  Surgical  Congress  {Ann.  of  Surg., 
December  1903). 

2  Textbook  of  Nervous  Diseases, -p.  \22Q. 
SURGERY  I  1 8 


274  OPERATIONS  ON  THE  HEAD  AND  NECK 

present.  Should  this  not  be  so  the  prospects  of  a  successful  operation 
are  slight.  (3)  Operation  is  indicated  in  cases  of  cortical  epilepsy 
following  injury,  especially  if  the  cicatrix  practically  corresponds  to  a 
motor  area.  If  at  a  distance  from  the  Rolandic  area  the  point  for 
trephining  should  be  that  indicated  by  the  attack.  (4)  In  all  cases 
scars,  spicules  of  bone,  &c.,  should  be  removed.  In  many  cases  it  is 
advisable  also  to  excise  the  cortical  centre. 

But  while  it  is  authoritatively  proved  that  the  value  of  trephining 
for  traumatic  epilepsy  has  been  greatly  exaggerated,  owing  to  many 
operations  ha^^ng  been  ill-advised,  and  also,  what  is  less  excusable, 
to  premature  reporting  of  "  successes,"  it  by  no  means  follows  that  this 
operation  is  to  be  abandoned.  It  is  to  be  employed  on  careful  and 
scientific  hnes.  We  should  be  more  careful  in  promising  success  save 
in  cases  of  recent  date,  where  there  has  not  been  time  for  the  changes 
to  occur  which,  as  we  have  seen,  must  render  recurrence  of  the  con- 
vulsions after  a  time  a  matter  almost  of  certainty.  In  other  cases  it 
will  be  only  honest  not  to  hold  out  much  hope  of  cure,  but  to  explain 
to  the  patient  and  his  friends  that  the  operation  more  or  less  must  be 
uncertain ;  that  its  dangers  are  slight  in  experienced  hands ;  that 
while  cure  in  the  truthful  sense  of  the  word  is  unlikely,  some  relief  will 
almost  certainly  be  granted  in  the  number  and  severity  of  the  fits  ; 
that  as  to  any  headache,  &c.,  from  which  the  patient  suffers,  it  is 
impossible  to  state  what  the  amount  of  relief  will  be  till  the  parts  have 
been  explored  ;  and,  ha^^ng  said  this,  we  shall  be  wise  if  we  leave  the 
decision  in  the  hands  of  the  patient  or  his  friends. 

For  as  we  know  nothing  of  the  actual  causation  of  epilepsy  in  these 
cases,  so  we  must  rest  uncertain  as  to  the  relief  which  a  trephine- opening 
on  wide  hnes  may  give.  If  headache  or  optic  nemitis  is  present,  these 
will  be  relieved.  As  to  convulsions,  we  may  hope  that,  in  cases  which 
are  not  of  too  long  standing,  the  relief  to  tension  may  help  towards 
recovery  the  impaired  A^itaUty  of  cells  so  delicately  constituted  as  those 
of  the  brain.  In  other  cases  the  opening  may  allow  of  the  intracranial 
circulation  undergoing  fluctuations,  to  which  it  is  inevitably  exposed, 
without  the  imstable  cortical  centres  becoming  congested  and  irritated 
and  prone  to  explosions,  as  would  otherwise  be  the  case. 

Condition  of  the  parts  which  may  be  met  with  during  the  operation 
and  which  may  have  originally  caused  the  epilepsy.  (1)  The  scalp. 
Shaving  often  reveals  scars  known  or  undiscovered.  When  operation 
was  again  resorted  to  in  this  disease,  some  years  ago,  it  was  hoped  that 
tenderness  of  such  scars  would  be  a  valuable  guide  and  characteristic 
of  cases  to  be  benefited  by  operation.  Thus  Mr.  Walsham^  found  that, 
of  eighty-two  cases,  the  scar  or  spot  was  sensitive,  tender,  or  painful 
in  forty-two.  Pressure  in  some  caused  vertigo,  convulsions,  rigidity, 
or  spasmodic  twitchings  of  certain  groups  of  muscles.-  Larger  col- 
lections of  cases  have  shown  that  these  instances  are  fewer  than  was 
hoped,  the  share  taken  in  epilepsy  by  tender  scalp  scars  being  a  small 
one.  In  eight  out  of  the  forty-two  cases  collected  by  Mr.  Walsham 
a  sinus  was  present  leading  down  to  bare  bone. 

(2)  The  'periosteum.  This  may  be  found  extremely  thickened,  and 
very  closely  adherent  to  the  bone.  Excess  of  vascularity  may  also  be 
met  with.     Osteophytic  deposits  have  not  been  observed. 

^  St.  Bartholomew's  Hospital  Heports,  1883,  vol.  xix,  p.  127. 

^  It  is  especially  in  those  cases  in  ■which  pressure  on  a  tender  scar  produces  convulsive 
movements  on  the  same  side,  that  the  surgeon  may  be  content  with  removing  the  scar. 


TRAUMATIC  EPILEPSY  275 

(3)  The  skull.  Lesions  of  all  kinds  have  been  present.  Depressions, 
fractures,  fissures,  are  common.  From  the  inner  table  a  spicule  ^  may- 
project  inwards.  With  regard  to  these  last  conditions  it  is  very  note- 
worthy that  in  one  of  the  cases  collected  by  Mr.  Walsham,  though 
nothing  was  detected  at  the  operation,  a  spicule  was  found,  at  the 
necropsy,  not  far  from  the  trephine- hole. 

Another  point  which  is  of  great  importance  with  regard  to  the 
indications  for  trephining  as  given  by  the  state  of  the  skull  is  <;his. 
Several  cases  have  been  recorded  which  prove  that  it  is  not  always  safe 
in  trephining  for  epilepsy  to  rely  on  the  position  of  a  fracture,  unless 
that  fracture  coincides  very  closely  with  the  spot  selected  for  trephining 
from  the  character  of  the  fit.  Thus,  in  two  cases  related  by  Dr.  Starr, 
depressed  fractures  existed,  epileptic  attacks  had  developed  subse- 
quently to  them,  but  the  fit,  which  in  both  patients  began  in  the  arm, 
indicated  disease  in  the  middle  third  of  the  motor  area,  while  the  position 
of  the  fracture  was  upwards  of  two  inches  away  from  this  spot.'^  In 
another  case  where  the  surgical  indication  or  position  of  the  fracture 
was  put  aside  in  favour  of  the  medical  one,  or  the  evidence  given  by 
the  fits,  the  latter  proved  to  be  the  correct  one,  as  on  raising  the  button 
of  bone  a  splinter  from  the  internal  table  was  found  penetrating  the 
dura  mater  and  brain,  though  at  the  spot  selected  there  was  no  evidence 
of  fracture. 

(4)  The  membranes.  Before  opening  the  membranes  the  surgeon 
should  remember  that  it  is  at  this  stage  that  danger  begins.  Aseptic 
trephining  in  experienced  hands  entails  no  risk,  but  it  is  another  matter 
when  the  membranes  are  opened  and  the  brain  itself  is  interfered  with. 
The  risks  of  hsemorrhage,  sudden  cessation  of  breathing,  shock,  infec- 
tion, hernia  cerebri,  have  now  to  be  faced.  Both  the  dura  and  pia  mater 
may  be  found  much  thickened,  blended  with  each  other,  and  adherent 
to  the  cortex.  In  some  cases  they  form  respectively  the  outer  and  inner 
wall  of  a  cyst. 

(5)  The  brain.  When  pathological  changes  are  present  in  the  part 
explored,  the  cortex  may  be  found  compressed  or  indented,  stained, 
sclerosed  or  softened.  Cysts  in  the  cortex,  perhaps  the  result  of  old 
hsemorrhage,  are  not  uncommon  lesions,  and  are  amongst  the  most 
hopeful  for  treatment.  If  removal  of  the  cyst  is  impracticable  incision 
and  drainage  should  be  employed.  Any  blood  clot  must  be  removed 
by  curetting  or  carefully  cut  away.  If  old,  it  may  resemble  yellowish 
scar  tissue.     If  the  dura  has  been  opened  to  get  at  it,  the  edges  of  this 

^  The  term  exostosis  is  soirietimes  applied  to  the  depressed  bone  ;  this,  when  circum- 
scribed, is  easily  dealt  with.  An  allied  condition  rarer,  and  one  much  more  difficult  to 
deal  with,  is  described  by  Dr.  Echeverria  {Arch.  Gen.  de  Med.,  1878,  t.  ii,  p.  5.33).  A 
conical,  irregular  projection  of  bone,  measuring  2  x  2i  inches,  here  compressed  the  dura 
mater  and  brain,  being  situated  very  close  to  the  superior  longitudinal  sinus,  just  to  the 
left  of  the  occipital  protuberance.  In  trephining,  the  crown  entered  into  this  exostosi.s, 
the  removal  of  it  proving  most  laborious,  the  operation  lasting  three  and  a  haK  hours. 
The  patient  recovered.  A  case  of  Kochler's,  of  Berhn  {Deutsche  Med.  Woch.,  No.  46, 
1889),  illustrates  a  less  localised  condition.  A  sword-cut  had  injured  the  bone,  without 
depression.  Epileptic  fits  followed  in  six  weeks.  About  a  year  later  trephining  was 
successfully  performed.  The  dura  mater  was  adherent,  the  bone  much  thickened  and 
covered  with  thorn-like  processes  pressing  on,  but  not  perforating,  the  dura.  Before 
deciding  whether  any  diffuse  thickening  of  the  bone  is  really  morbid  the  varying  thickness 
of  the  skuU  in  different  parts  must  be  remembered.  Good  illustrations  of  a  blunt  spicule 
from  the  internal  table  are  given  by  Dr.  Williamson  and  Mr.  Jones  {Brit.  Med.  Journ., 
vol.  ii,  1899,  p.  919). 

2  Such  cases  emphasise  the  need  of  sweeping  a  probe  around  the  margins  of  the 
trephine-hole,  so  as  to  explore  the  neighbourhood  thoroughly. 


276    OPERATIONS  ON  THE  HEAD  AND  NECK  " 

membrane  must  be  drawn  together  with  sutures,  drainage  being  employed 
if  needful. 

Before  cutting  through  thickened  membranes,  especially  if  adherent 
to  the  brain,  the  surgeon  should  remember  the  following  case,  which 
occurred  in  the  experienced  hands  of  Dr.  Gerster  himself  : 

The  patient,  set.  17,  had  been  operated  on  twice  before.  The  epilepsy  continuing 
and  the  patient  being  anxious  for  a  third  operation,  an  attempt  was  made  to  lessen 
the  tension  caused  by  a  scar  at  the  site  of  the  first  operation,  over  the  left  arm- 
centre.  Cutting  through  this  scar,  the  surgeon  found  an  enormously  thickened 
membrane  between  the  dura  and  the  scalp.  In  the  attempts  to  separate  adhesions 
and  cut  through  thickened  membrane,  excessive  ha?morrhage  occurred,  which  it 
was  impossible  to  check  for  some  time.  The  patient  did  not  recover  from  the  shock 
of  the  operation,  and  died  in  collapse  three  days  later. 

If  nothing  be  found  when  the  dura  is  opened,  the  surgeon  may, 
before  deciding  to  interfere  with  the  brain  itself,  explore  the  neighbour- 
hood of  the  wound  within  the  dura  with  a  blunt-pointed  instrument, 
e.g.  a  curved,  flexible,  sterilized  director.  By  this  means  a  clot  or  cyst, 
which  would  otherwise  have  been  missed,  may  be  detected,  and  dealt 
with  by  enlarging  the  opening. 

But  even  when  clots  and  cysts  may  seem  to  have  been  satisfactorily 
dealt  with,  and  the  fits  cease  at  once,  mischief  in  the  brain  may  co-exist 
(especially  if  the  case  be  one  of  long  standing)  and  lead  to  their  recurrence 
{vide  infra). 

The  majority  of  lesions  of  the  brain  will  however  be  found  to  be  much 
less  amenable  to  treatment.  How  varied  they  are  is  shown  by  the 
following  list  enumerated  by  Dr.  Starr  :  ^  "  Any  affection  of  the  meninges, 
whether  pachymeningitis  or  leptomeningitis,  of  traumatic  or  syphilitic 
or  tubercular  origin  ;  or  new  growths  upon  or  in  the  cortex  of  the  brain  ; 
or  cysts  formed  as  the  result  of  small  circumscribed  haemorrhages,  or 
of  spots  of  softening  from  embolism  or  thrombosis  of  a  cerebral  artery  ; 
or  circumscribed  encephalitis  or  sclerotic  patches,  may  act  as  centres 
of  irritation  in  the  cortex  of  the  brain.  The  majority  of  these  forms 
of  disease,  when  exactly  localised  in  a  small  area,  appear  to  be  traceable 
to  traumatism,  either  to  a  blow,  a  fall  on  the  head,  or  to  a  fracture  with 
or  without  depression." 

But  it  is  not  only  the  variety  of  the  lesions  of  the  brain  which  may, 
after  an  injury,  produce  Jacksonian  epilepsy,  that  is  worthy  of  careful 
note  ;  it  is  their  nature  which  makes  the  majority  of  cases  recurrent 
after  any  operation,  however  skilfully  performed.  At  first  sight  haemor- 
rhage and  cysts  would  appear  capable  of  being  dealt  with  by  careful 
curetting,  drainage,  &c.  {vide  supra).  But  going  with  these  coarser  lesions 
there  is  almost  always  present  some  meningo-encephalitis,  circum- 
scribed or  diffuse.  Coen,^  van  Gieson,^  Starr  {vide  supra) — the  latter 
especially — have  shown  the  frequency  of  the  occurrence  of  adhesions 
between  the  pia  and  the  cortex,  of  a  chronic  degeneration  of  the 
pyramidal  cells,  and  of  an  increase  in  neuroglia.  The  bearing  of  this 
on  excision  of  the  cortex  will  be  alluded  to  later  (see  p.  280). 

Operation.  To  begin  with,  a  painful  cicatrix^  may  be  freely  excised. 
This  may  be  done  with  some  hope  that  nothing  further  in  the  way  of 

1  Brain  Surg.,  p.  25.        ^  Zieghfs  Beitr.  z.  Path.  Anat.  u.  Physiol.,  1888,  Bd.  ii,  s.  107. 

3  New  York  Med.  Record,  April  24,  1893. 

4  In  one  of  Dr.  Echeverria's  cases  (loc.  supra  cit.),  convulsions,  vertigo,  &c.,  were  cured 
by  the  removal  of  a  small  fibroma  adherent  to  the  frontal  periosteum  and  supra-orbital 
nerve,  Dr.  Starr's  opinion,  on  the  other  hand,  is  much  less  favourable  :    "  From  my 


TRAUMATIC  EPILEPSY  277 

operation  will  be  required  in  cases  where  the  scar  is  constantly  painful, 
tender,  or  hot ;  where  it  corresponds  to  the  course  of  some  known 
nerve  ;  and  in  any  case  where  the  original  wound  lacerated,  or  contused, 
and  slow  in  healing,  and  where  there  is  any  chance  of  a  splinter  of  wood 
or  metal  being  embedded  in  the  scar.^ 

If  it  be  necessary,  as  it  usually  is,  to  remove  a  crown  of  bone,  an 
appropriate  semiluniir  flap  {see  p.  309)  must  be  reflected,  with  the  aseptic 
and  other  precautions  already  given.  Haemorrhage  is  next  arrested, 
and  the  flap  retracted  by  Spencer-Wells  forceps,  the  pericranium  being 
carefully  turned  off  the  bone,  and  its  condition  noted  as  to  thickening 
and  other  evidence  of  old  inflannnation.  The  bone  being  thoroughly 
exposed,  the  surgeon  must  be  prepared  for  the  following  conditions, 
viz.  the  line  of  an  old  fracture,  necrosis  (indicated  by  a  sinus  with 
prominent  granulations),  hypertrophic  sclerosis,  depressed  fragments 
of  the  internal  table,  spurs,  or  nodules  of  bone.  Any  sequestrum  will, 
of  course,  be  removed.  For  dealing  with  the  bone  the  surgeon  will 
select  out  of  those  methods  described  at  p.  310  the  one  with  wdiich  he 
is  most  familiar.  In  trephining  the  surgeon  will  use  the  precautions 
given  at  p.  256,  remembering  that  here  he  is  especially  likely  to  be 
dealing  with  a  disc  of  bone  of  varying  density  at  different  points  of  its 
circumference. 2  It  must  be  elevated  with  particular  caution,  as  a 
spicule  may  have  made  its  way  through  the  dura  mater  and  be  pressing 
on  the  brain,  or  be  in  close  contact  with  one  of  the  sinuses. 

If  the  first  crown  show  nothing  abnormal,  a  probe  should  be  gently 
inserted  between  the  bone  and  dura  mater  and  carefully  swept  around, 
so  as  to  give  information  of  the  condition  of  the  inner  surface  of  the 
surrounding  bone.  If  the  crown  show  changes  which  are,  however, 
not  localised  to  it,  more  bone  must  be  taken  away,  by  one  of  the  methods 
described  at  p.  312,  till  all  that  is  thickened  and  capable  of  exerting 
pressure  on  the  brain  and  its  membranes  is  removed. 

If  no  change  can  be  found  in  the  crown  removed,  or  in  the  sur- 
rounding bone,  what  more  should  be  done  on  this  occasion  ?  If  there 
be  reason  to  suspect  the  presence  of  an  excess  of  cerebro- spinal  fluid 
or  of  an  abscess  in  the  brain,  because  the  symptoms  of  this  condition 
(pp.  269  and  352)  are  present,  or  because  the  dura  mater  bulges  up 
w^ithout  pulsation  into  the  trephine- hole,  the  treatment  should  be  as 
directed  at  p.  356. 

Directions  as  to  dealing  with  any  cysts,  and  how  far  it  is  wise  to 
go  in  attacking  the  thickened  membranes,  have  been  given  at  p.  275. 
These  details  of  the  operation  would  not  be  complete  wdthout  some 
reference  to  the  question  of  excising  fortions  of  the  cortex  tohere  no  lesion 
sufficient  to  account  for  tfie  epilepsy  lias  been  found  more  super jiciallij . 
This  is  not  to  be  lightly  undertaken.  Professor  Nancrede,  of  Michigan,-'* 
has  with  great  candour  recorded  three  cases  in  which  he  took  this  step  ; 

experience  I  consider  that  true  reflex  epilepsy  from  scars  in  the  scalp  is  a  very  rare 
occurrence." 

^  Dr.  Johnson  {Clin.  Soc.  Trans.,  vol.  vi,  p.  35)  records  a  case  where  trismus,  facial 
neuralgia,  and  paralysis,  with  a  recurrence  of  epilepsy  (the  patient,  aged  44,  had  been  free 
from  fits  for  twelve  years),  were  caused  by  a  sharp,  angular  piece  of  flint  embedded  in  a 
painful  cicatrix  of  the  cheek,  the  removal  of  which  was  followed  by  complete  recovery. 

2  Free  and  most  embarrassing  hiemorrhage  may  be  met  with  in  sawing  through  altered 
diploe  traversed  by  large  sinus-like  venous  channels,  requiring  firm  pressure  during  and 
after  the  operation,  plugging  with  a  tiny  sterilised  wooden  peg,  or  crushing  the  bone 
together  with  forceps  at  the  bleeding- point. 

3  Ann.  of  Surg.,  1896,  vol.  ii,  p.  122. 


278  OPERATIONS  ON  THE  HEAD  AND  NECK 

in  all  the  fits  recurred,  though  in  one  case  not  for  two  and  a  half  years, 
while  in  another  "  somewhat  over  three  years  "  had  elapsed.  And  this 
candour  is  the  greater,  as  Professor  Nancrede  allows  that  formerly  he 
thought  well  of  this  procedure..  Dr.  Sachs  and  Dr.  Gerster  ^  have  given 
this  a  full  trial,  having  employed  it  in  five  cases.  Their  experience 
leads  them  to  the  conclusion  that,  in  epilepsy  of  long  standing,  the 
excision  of  cortical  tissue  does  no  good,  and  such  excision  is  hereafter 
to  be  restricted  to  epilepsies  of  short  duration.  And  again  :  "  Since 
such  cortical  lesions  are  often  of  a  microscopical  character,  excision 
should  be  practised  even  if  the  tissue  appears  to  be  perfectly  normal 
at  the  time  of  operation  ;  but  the  greatest  caution  should  be  exercised 
to  make  sure  that  the  proper  area  is  removed." 

Not  only  may  this  step  cause  severe  haemorrhage,  shock,  and  open 
the  door  to  infection,  but  is  impossible  to  see  how  it  can  do  otherwise 
than  lead  to  fusing  of  the  scalp  membranes  and  cortex  in  a  scar  which 
will  become  increasingly  dense  wath  time,  and  bring  about  "  anchoring 
of  the  brain,"  with  its  grave  disadvantages  {see  p.  276)  and  sclerosis 
of  the  cortex,  leading  inevitably  to  a  recurrence  of  the  trouble.  To 
put  it  briefly,  it  seems  certain  that  when  taking  this  step  the  surgeon 
is  almost  sure  to  replace  one  traumatic  epilepsy  by  another,  which, 
supervening  somewhat  later,  is  traumatic  also,  but  in  addition,  unhappily, 
surgical  as  well.^ 

What  is  needed  is  to  prevent  the  adhesion  of  brain,  membranes,  and 
scalp,  and  at  present  none  of  the  methods  are  reliable.  Possibly  trans- 
planting a  flap  of  scalp,  bone,  and  membrane  might  succeed,  but  such 
a  step  is  too  severe  to  be  undertaken  at  the  close  of  an  operation  already 
severe  and  prolonged,  and  if  deferred  for  some  days  its  object  would 
probably  be  defeated.  The  use  of  gold  and  other  pliable  metal  plates 
between  the  dura  and  the  skull  will  not  prevent  the  formation  of  adhesions 
between  the  dura  and  the  brain.  A  case  of  Dr.  Gerster's  proves  this. 
Having  removed  a  cerebral  cyst,  this  surgeon  placed  a  gold  plate  between 
the  dura  and  the  skull.  Two  years  and  nine  months  after  the  first 
operation  it  was  necessary  to  perform  a  second,  and,  while  the  gold 
plate  was  found  lying  exactly  as  it  had  been  introduced,  the  best  result 
attained  was  "  that  the  surrounding  tissue  had  undergone  fewer 
changes  than  would  have  been  the  case  if  the  ordinary  scar  had  formed." 
Other  materials  have  been  suggested  by  the  ingenuity  of  American 
surgeons.^ 

Another  objection  to  the  removal  of  motor  centres  (except,  of  course, 
in  cases  where  they  are  involved  by  a  growth)  is  that  this  step  may 
merely  replace  one  inconvenience  by  another.  It  is  true  that  in  most 
cases  the  loss  of  power  has  been  temporary,  but  in  some  this  has  not 
been  the  case.     Certainly  not  every  patient  would  choose  to  lose  his 

^  Loc.  supra  cit. 

2  After  mere  incision  of  the  dura  or  meninges,  the  cicatrix  left  will  no  doubt,  be  linear 
and  small,  and  the  inner  surface  of  the  skull  smooth  and  adhesions  absent,  but  the 
condition  present  after  removal  of  one  or  more  centres  will  be  very  different. 

3  Beach  has  used  gold-foil.  Abbe  rubber  tissue  ;  but  these  substances  have  been  proved 
to  have  the  disadvantages  of  causing  formation  of  adhesions  and  scar  tissue,  of  disintegra- 
ting, and  of  causing  suppuration.  Dr.  L.  Freeman,  of  Denver  (Ann.  Surg.  October  1898), 
having  tried  gold-foil  in  a  case  of  trcphming  for  cerebellar  tumour,  and  found,  three 
months  later,  that  '•  considerable  new  connective  tissue  had  formed,"  recommends  the 
use  of  egg-membrane,  as  being  inexpensive,  readily  obtainable,  strong  in  spite  of  its 
thinness,  and  durable,  and  not,  in  the  full  sense  of  the  word,  a  foreign  bod3\  The  above 
claims  are  based  upon  two  experiments  on  animals. 


TRAUMATIC  EPILEPSY  279 

epilepsy  at  the  cost  of  having  a  right  arm  or  leg  permanently  paralysed. 
Furtlierinore,  it  is  easy  to  understand  that  in  inexperienced  hands 
permanent  damage  may  be  readily  inflicted  on  the  centres  grouped 
about  the  motor  area,  bringing  about  a  condition  by  which  one  form 
of  distress  will  merely  be  exchanged  for  another. 

If  it  be  decided,  owing  to  the  gravity  and  frequency  of  the  attacks — 
especially  where  the  condition  amounts  to  the  patient  being  practically 
in  what  is  a  status  epilepticus — their  limitation  to  one  or  two  centres, 
the  absence  of  any  other  extra-cerebral  cause,  and  perhaps  also  the 
failure  of  a  previous  operation,  to  remove  one  of  the  motor  centres, 
this  should  be  accurately  localised  by  electricity.  To  trust  to  measure- 
ments of  the  skull  is  not  enough.  Sufficient  of  the  motor  area  having 
been  exposed,  the  dura-arachnoid  is  opened  and  all  hemorrhage  is 
arrested.  By  means  of  two  aseptic  platinum  electrodes,  different  parts 
of  the  motor  area  are  examined,-  the  results  most  carefully  noted,  and 
when  that  spot  is  reached  which  causes  motion  in  that  particular  part 
of  the  body  first  affected  in  the  fit,  that  particular  spot,  and  that  only, 
should  be  excised  (Keen).  Its  limits  having  been  determined,  any  large 
veins  which  enter  the  field  of  operation  are  first  tied  with  fine  sterilized 
catgut  passed  under  them  by  Sir  V.  Horsley's  needle-director.  The 
area  of  the  centre  is  then  marked  out  by  a  sharp  knife  held  vertically 
to  the  surface  and  penetrating  to  the  white  matter.  The  centre  is  then 
excised  by  a  sharp  knife  or  scissors  going  to  the  same  depth,  about 
three  millimetres,  or  a  quarter  of  an  inch.  Haemorrhage  is  best  arrested 
by  ligature  of  any  bleeding-points  if  possible,  hot  aseptic  lotions,  or 
compression  with  gauze  wrung  out  of  hot  lotion,  or  sterihsed  adrenalin 
chloride.  The  cautery  should  never  be  resorted  to  if  it  can  possibly 
be  avoided.  It  introduces  sepsis  and  suppuration,  and  may  lead  to  a 
hernia  cerebri.  It  prevents  the  surgeon  bringing  together  the  flaps 
of  dura  mater  over  the  excised  centre.  Drainage  will  usually  be  required 
on  account  of  the  oozing. 

After  the  removal  of  the  centre,  to  make  sure  that  this  has  been 
effectual,  it  will  be  well  to  again  make  use  of  the  electric  test  (Keen). 

The  strictest  aseptic  precautions  should  be  taken  before  and  during 
the  operation  ;  sufficient  drainage  should  be  provided  and,  in  bringing 
the  wound  together,  the  drainage-tube  must  not  be  pressed  upon  or 
closed.  Great  care  must  be  taken  to  keep  the  wound  sterile  later  on, 
infection  leading  to  infective  softening  and  hernia  of  the  brain.  Only 
if  it  has  been  needful  to  remove  much  bone  should  any  of  this  be 
preserved  and  replaced,  with  the  precautions  given  at  p.  258.^ 

In  cases  where  during  the  operation  there  has  been  any  escape  of 
cerebro-spinal  fluid,  th£  dressings  will  soon  need  to  be  repacked  or 
changed. 

Causes  of  failure  after  trephining  for  traumatic  epilepsy.  These  may 
be  summed  up  as  follows  : 

^  Prof.  Kocher,  of  Bern  {La  Sem.  Med.,  April  12,  1899,  p.  121),  is  of  opinion  that  not 
only  should  the  bone  disc  not  be  replaced,  but  that  the  dura  mater  itself  should  be  widely 
excised.  He  holds  that  one  of  the  chief  causes  of  epilepsy  consists  in  an  exaggeration, 
local  or  general,  of  the  intracranial  pressure.  He  believes  that,  in  a  number  of  cases  of 
excision  of  cerebral  centres,  except  in  those  where  the  excision  has  been  sufficiently  com- 
plete to  bring  about  a  definite  paralysis,  the  success  should  be  attributed  rather  to  the 
opening  of  the  dura  mater,  which  estabhshes  a  sort  of  safety-valve  susceptible  of  regulating 
the  intracranial  pressure. 

Kocher  would,  therefore,  only  put  back  the  di&c  where  a  very  definite  lesion,  such  as  an 
exostosis  or  growth,  has  been  removed  ;  in  aU  others  the  skull  should  be  left  open. 


280  OPERATIONS  ON  THE  HEAD  AND  NECK 

(1)  Not  hitting  off  the  right  spot.  A  bony  spicule,  undetected  at  the 
operation,  has  been  found,  at  the  necropsy,  not  far  from  the  trephine- 
hole.  To  meet  this  contingency,  or  to  find  a  clot,  it  has  been  ad\ased 
to  sweep  a  probe  or  wire-loop  carefully  round  the  ^^cinity  of  the  trephine- 
opening. 

(2)  A  general  and  diffuse  thickening  of  the  bone  round  the  site  of  injury. 

(3)  Membranes  too  much  thickened  and  too  adherent  to  the  cortex 
to  admit  of  their  being  safely  detached. 

(4)  Owing  to  the  long  continuance  or  to  the  amount  of  the  irritation, 
the  brain  may  be  permanently  affected.  Thus,  in  Dr.  Gunn's  words 
already  quoted  {see  p.  2.50).  there  are  cases  of  depressed  fracture  in 
which  "  the  constant  irritation  has  begotten  a  permanent  impression 
upon  the  brain  and  nervous  system  which  remains  after  the  offending 
point  of  bone  has  been  removed."  The  grosser  and  more  localised 
the  lesion  the  more  speedy  will  be  the  rehef.  As  long  as  the  fits  are 
diminished  in  number  and  severity,  the  prognosis  is  still  hopeful.  The 
fits  may  be  very  slow  in  disappearing. 

(.5)  While  marked  relief  has  been  given  in  some  cases  of  violent 
temper,  delusions,  and  melancholia,  whether  associated  or  not  with 
local  epilepsy,  the  same  rule  holds  with  the  former  as  with  the  latter, 
i.e.  if  the  interval  between  the  injury  and  trephining  has  been  a  long 
one,  the  cure  is  very  likely  to  be  imperfect. 

(6)  Neglect  of  after-treatment,  both  medical  and  surgical,  but  chiefly 
the  former.  Professor  Xancredes  words  ^  are  worthy  of  remembrance  : 
"  The  operation,  indeed,  removes  the  most  important  cause  of  the 
epilepsy,  but  only  one  cause.  The  disturbed  circulation  in  the  nervous 
centres,  and  the  excessive  mobility  of  the  nervous  system,  can  only 
disappear  with  time  ;  and  if  all  other  sources  of  peripheral  irritation 
are  not  most  carefully  guarded  against,  the  patient  may  be  slightly, 
if  at  all,  benefited,  whereas  judicious  after-treatment  will  sometimes 
relieve  an  apparent  operative  failure."  Judicious  after-treatment 
should  especially  refer  to  alcohol,  exposure  to  the  sun,  overheated  small 
rooms,  and,  generally  speaking,  the  patient  should  lead  a  healthy  fife. 

(7)  TreiDhining  for  fits  not  belonging  to  traumatic  epilepsy  in  character. 
There  is  no  doubt  that  the  glamour  of  a  new  operation  and  "  the  chance 
of  finding  something  "  have  led  to  this  operation  being  performed  in 
unsuitable  cases,  which  have  not  been  published.  It  cannot  be  too 
strongly  laid  down  that  no  operation  is  justifiable  in  other  epilepsies 
save  the  Jacksonian,  of  which  so  many  are  traumatic  in  origin.  That 
is  to  say,  that  in  ordinary  idiopathic  epilepsy  the  conditions  justifsdng 
operation  must  be  of  the  very  rarest.  They  would  be  something  of  this 
kind  :  Epilepsy  with  intense  local  headache  ;  epilepsy  in  which,  after 
the  general  con\T.ilsions,  paralysis  or  paresis  of  any  group  of  muscles 
follows.  Those  who  trephine  an  idiopathic  epilepsy  because  it  is 
impossible  always  to  exclude  traumatism  in  idiopathic  cases,  or  because 
there  is  a  bare  possibility  that  a  haemorrhage,  the  origin  of  irritation, 
may  be  met  with  on  the  surface  of  the  brain,  are  likely  to  meet  with 
disappointment. 

(8)  An  infected  condition  of  the  wound,  almost  invariably  occurring 
during  the  operation,  and  bringing  about  (a)  meningitis  ;  (b)  hernia 
cerebri ;    (c)  cerebral  abscess. 

(9)  Shock. 

^  Inter.  Enc.  Surg.,  vol.  v,  p.  102. 


BULLET  WOUNDS  OF  BRAIN  281 

Finally,  in  cases  of  honest  doubt,  and  in  those  where  a  well-considered 
operation  has  failed,  the  interference  of  the  surgeon  will  be  justified 
by  the  fact  that  traumatic  epilepsy  tends  to  grow  worse,  and  is  little 
affected  by  medical  treatment.  In  the  words  of  Echeverria,^  once 
declared,  traumatic  epilepsy,  due  to  injury  to  the  head,  leads  to  early 
insanity  or  to  feebleness  of  intellect. 

OPERATIVE  INTERFERENCE  IN  THE  CASE  OF  FOREIGN 
BODIES  IN  THE  BRAIN 

Under  the  above  heading  such  bodies  as  bullets,  knife-points,  &c., 
are  included.  Depressed  and  isolated  fragments  of  bone  may  come 
within  the  meaning  of  foreign  bodies,  but  have  already  been  considered 
[see  p.  253). 

A.  Bullets.  The  following  questions  will  suggest  themselves  when 
a  surgeon  is  called  to  a  case  of  bullet  wound  of  the  skull  : 

(1)  Has  the  bullet  penetrated  the  skull  at  all  ? 

(2)  It  may  have  'passed  between  the  bone  and  the  dura  mater,  ivithout 
penetrating  the  latter,  and  reached  a  spot  quite  out  of  sight.  Probably  in 
most  hands  a  second  application  of  the  trephine,  if  needful,  at  some 
distance  from  the  wound,  so  as  to  extract  the  bullet  there,  would  be 
preferable  to  attempts  at  removing  it  from  the  original  wound. 

(3)  Has  the  ball  split  into  two  or  more  pieces  ?  Balls  elongated  as  well 
as  round  are  liable  to  split  when  impinging  on  sharp  angles  of  bone. 
Thus,  when  the  ball  splits  upon  the  outer  table,  part  may  pass  beneath 
the  scalp,  while  the  rest  may  drive  on  before  it  some  of  the  internal 
table,  causing  pressure  on  the  dura  mater,  or  even  reach  the  brain. 

(4)  Has  the  bullet  penetrated  the  brain  ?     If  so,  where  does  it  lie  ? 

(5)  Ought  any  exj>loration  to  be  performed  at  once  and  if  so,  how  far 
is  the  surgeon  to  go  ? 

If  the  last  question  be  answered  in  the  affirmative,  an  answer  will 
be  given  to  most  of  the  others. 

While,  owing  to  the  rarity  of  gunshot  injuries  of  the  head  in  civil 
practice  in  this  country,  it  is  very  difficult  to  give  a  dogmatic  answer, 
the  following  reasons  are  in  favour  of  exploring  in  all  cases  in  which 
it  is  clear  that  the  injury  is  not  going  to  be  quickly  fatal : 

(a)  The  fact  that  only  by  exploring  will  the  surgeon  be  able  to  answer 
the  question  certain  to  be  put  to  him  by  the  friends,  whether  the  brain 
is  injured  or  no  ? 

(b)  Whether  the  bullet  has  split,  whether  the  internal  table  is 
shattered  and,  if  so,  how  far  it  resembles  a  punctured^  fracture,  are 
points  which  alone  can  be  cleared  up  by  trephining. 

(c)  Disinfection  of  the  wound  and  good  drainage  are  almost  hopeless 
unless  this  be  opened  up  and  explored  by  trephining  if  needful. 

The  following  case  is  not  only  a  good  instance  of  the  kind  of  gunshot 
injury  to  the  head  w^hich  may  be  met  with  in  civil  practice,  but  it  shows 
how  slight  may  be  the  injury  which  actually  originates  the  fatal 
mischief.     It  was  brought  before  the  Clinical  Society  ^  by  Mr.  Lucas  : 

The  patient,  aged  21,  had  shot  himself  with  a  small  revolver.  "  Almost  in  the 
centre  of  his  forehead  were  two  small  circular  holes,  with  slightly  inverted  edges. 
The  surrounding  skin  was  raised  into  a  rounded  prominence.  There  was  some 
bleeding  from  the  nose  as  well  as  from  the  womids.    On  turning  back  flaps,  a 

^  Loc.  supra  cit.,  p.  277.  ^  Trans.,  vol.  xii,  p.  5. 


282    OPERATIONS  ON  THE  HEAD  AND  NECK 

blackened  cavity  was  opened  beneath  the  skin,  formed  by  the  expansion  of  the 
powder  after  it  had  penetrated  the  integument.  At  the  bottom  of  this  cavity,  a 
somewhat  cruciform  aperture  was  seen  in  the  bone,  and  lying  upon  the  internal 
table  were  two  flattened  bullets.  The  internal  table  was  driven  back  so  as  to  give 
the  appearance  of  a  sinus,  in  which  the  bullets  were  lying  loose  ;  and  at  the  time 
we  were  under  the  impression  that  the  man  had  very  large  frontal  sinuses,  which 
had  been  opened  by  the  bullets.  After  removing  numerous  fragments  belonging 
to  the  external  table  and  diploe,  the  splintered  internal  table  forming  the  posterior 
wall  of  the  cavity  was  also  removed. 

This  came  away  in  large,  sharp-edged,  angular  fragments,  two  of  which  were 
grooved  by  the  longitudinal  sinus.  When  the  internal  table  had  been  removed,  the 
dura  mater  was  seen  at  the  bottom  of  the  wound  and  pulsating.  The  membrane 
was  entire  except  at  one  spot,  where  there  was  a  small  aperture  just  such  as  might  be 
made  by  stabbing  the  point  of  a  penknife  into  a  sheet  of  paper.  But  for  that  small 
puncture  it  is  not  improbable  that  he  would  have  recovered.  Infective  meningitis 
came  on  in  about  forty-eight  hours,  followed  by  death  early  on  the  sixth  day. 

If  the  surgeon  decides  to  explore  the  wound  he  does  so  with  the 
intention  of  rendering  the  wound  as  sterile  as  possible,  removing  all  dirt, 
hair,  and  splinters  in  the  cortex,  if  accessible,  \vithout  making  the  condition 
of  the  patient  worse  than  it  already  is.  He  will  have  warned  the  friends 
that  removal  of  the  bullet  may  be  found  impracticable  on  this  occasion 
owing  to  the  patient's  condition.  We  will  suppose  that  no  cerebral 
symptoms  are  present,  either  focal  ones  to  guide  him,  or  such  grave  ones 
as  coma,  stertor,  paralysis  of  the  sphincters,  which  would  lead  him  to  stay 
his  hand.  Lastly,  the  injury  is  not  of  that  destructive  character,  so 
shattering  the  skull  and  ploughing  up  the  brain,  especially  in  a  direction 
towards  the  basal  ganglia,  as  is  certain  to  prove  quickly  fatal. 

Localisation.  This  can  be  accurately  ascertained  by  a  radiographic 
examination.  Surgeon- General  Stevenson^  thus  sums  up  the  question 
of  localisation  : 

It  is  not  the  bullet  so  much  as  the  fragments  of  bone  driven  in  which  will 
cause  infection.  This  is  borne  out  by  the  military  experience  in  South  Africa.  Here 
also  while  suppuration  was  rare  after  bullet  injuries,  it  was  the  rule  in  womids  due  to 
fragments  of  shell.  "All  exploring  instruments,  electrical  and  other,  for  the  detection 
of  lodged  missiles  may  nowadays  be  set  aside  as  out  of  date,  and  dependence  placed 
entirely  on  the  use  of  X-rays  for  this  purpose.  By  their  means,  using  Mackenzie 
Davidson's  cross-thread  localiser,  the  exact  position  of  any  foreign  body  within  the 
tissue  can  be  ascertained  to  a  millimetre,  or  stereoscopic  photographs  may  be  taken 
which  will  afford  means  of  sufficiently  exact  estimation  of  the  position  of  an  object 
as  large  as  a  bullet  to  warrant  the  surgeon  in  operating  for  its  removal  without 
more  accurate  localisation.  When  using  this  method,  small  pieces  of  wire  should 
be  fastened  on  to  the  skin  above  and  below  the  bullet,  so  that  its  relative  position 
to  known  points  on  the  skin  may  be  shown  in  the  stereoscope,  and  thus  a  clear 
indication  obtained  for  the  operative  procedure  to  be  carried  out.  Before  proceeding 
to  locahse  the  bullet,  or  to  skiagraph  it  stereoscopically,  its  general  position  should 
be  ascertained  by  means  of  the  fluorescent  screen  or  by  a  single  skiagraph  so  that 
part  of  the  limb  or  body  in  which  it  is  situated  may  be  placed  in  the  proper  position 
over  the  photograj^hic  plate  while  these  methods  are  being  carried  out." 

Mr.  E.  W.  H.  Shenton,  Surgical  Radiographer  to  Guy's  Hospital,  writes  as 
follows  :  "  It  is  possible  by  means  of  the  Rontgen  Rays  to  estimate  the  size  of,  and 
to  exactly  locate  bullets  or  other  bocUes  which  have  become  lodged  in  the  cranial 
cavity.  The  simplest  method,  perhaps,  is  that  where  two  radiograms  are  taken — 
one  in  an  antero-posterior  direction,  and  the  other  in  the  lateral.  Another  system, 
and  a  far  more  accurate  one,  is  that  now  in  common  use  at  Guy's  Hospital.  It  is 
a  system  whereby  the  exact  distance  from  any  given  point  may  be  fomid,  and  the 
principle  upon  which  it  is  based  as  follows  :  When  an  image  is  being  viewed  upon 
the  screen  and  the  tube  moved,  the  shadows  of  the  various  parts  of  the  object 
viewed  will  move  iipon  the  screen  at  different  rates  according  to  their  distance  fiora 
the  screen  ;   that  is,  the  nearer  to  the  screen  the  less  their  shadows  will  travel  in  a 

^  Report  on  Surgical  Cases  noted  in  the  South  African  War. 


BULLET  WOUNDS  OF  BRAIN  283 

given  time.  Quite  superficial  objects,  those  almost  touching  the  screen,  will  hardly 
move  at  all.  By  a  suitable  mechanism  exact  measurements  are  easily  obtaiiied 
and,  in  all  cases  where  the  foreign  body  can  be  seen  upon  the  screen,  this  can  bo 
aceom{)lished  without  the  em|)loyment  of  any  photographic  process.  If  considered 
desirable  in  the  ease  of  bullets  in  the  head,  a  skull  may  be  taken  and  a  bullet  arranged 
in  it,  by  the  aid  of  the  measurements  obtained,  to  correspond  in  situation  to  the 
original  bullet.  Such  a  device  will  prove  of  great  value  to  the  surgeon  at  an 
operation  for  the  removal  of  the  foreign  body.  When  exact  localisation  has  been 
obtained,  radiogia])hy  can  go  no  further,  miless  the  practice  of  operating  with  the 
rays  to  hand  is  adopted.  By  such  a  metliod  the  surgeon  is  enabled  to  see  the 
position  of  the  fori'ign  body  from  time  to  time,  and  any  metal  instrument  he  may 
be  using.  Until  tubes  of  greater  power  are  forthcoming  this  method  cannot  be 
advised  for  cases  of  bullet  in  the  head." 

Though  probes  should  not  be  used  for  localising  the  position  of  the 
bullet  unless  it  is  very  superficially  situated,  they  are  of  use  in  identifying 
it  when  its  position  has  been  determined  by  a  radiographic  examination. 
Some  blunt  instrument  should  be  employed,  such  as  Nelaton's,  which 
is  provided  with  a  rounded  porcelain  knob  at  its  extremity. 

Treatment.  This  may  be  considered  under  two  headings.  (1)  The 
opening  up  of  the  wound  for  the  purpose  of  removing  fragments  of 
bone  and  bruised  tissues,  and  for  cleaning  the  wound  and  providing 
drainage.  (2)  The  removal  of  the  bullet.  This  may  be  immediate  or 
late  and  will  depend  on  the  condition  of  the  patient  and  the  situation 
of  the  bullet. 

The  following  remarks  by  Mr.  G.  H.  Makins^  are  of  twofold  interest, 
first  from  their  recent  date  and  their  bearing  on  the  effect  of  modern 
small  projectiles  of  high  velocity  and,  secondly,  from  the  wide  practical 
experience  and  weight  with  which  the  writer  speaks. 

"  Operative  interference  is  necessary  in  every  case  in  which  recovery  is  judged 
possible.  The  injuries  are,  without  exception,  of  the  nature  of  punctured  wounds 
of  the  skull,  and  the  ordinary  rule  of  surgery  should  under  no  circumstances  be 
deviated  from.  An  expectant  attitude,  although  it  often  appears  immediately 
satisfactory,  exposes  the  patient  to  future  risks  wliich  are  incalculable.  .  .  .  Cases 
of  a  general  character,^  or  in  which  the  base  has  been  directly  fractured  other  than  in 
the  frontal  region,  are  seldom  suitable  for  operation,  since  surgical  skill  is  in  these 
of  no  avail ;  but  in  all  others  an  exjjloration  is  indicated.  I  use  the  word  '  explora- 
tion,' since  what  may  be  called  the  formal  operation  of  trephining  is  seldom  neces- 
sary except  in  the  case  of  the  small  openings  due  to  wounds  received  from  a  very 
long  range  of  fire  ;  in  all  others  there  is  no  difficulty  in  making  such  enlargement 
of  the  bone  opening  as  is  necessary  with  Hoffmann's  forceps. 

"  The  scalp  should  be  first  shaved  and  cleansed  ;  if  for  any  reason  an  operation 
is  impossible,  this  procedure  at  least  should  be  carried  out,  with  a  view  to  ensuring 
as  far  as  possible,  future  asepsis,  infection  in  head  injiu-ies  being  almost  the  only 
danger  to  be  feared.  The  scalp  having  been  cleaned  with  all  care,  a  flap  is  raised, 
of  which  the  bullet  opening  forms  the  central  point,  and  the  wound  explored.  In 
slight  cases  the  entry  wound  is  the  one  of  chief  importance,  and  the  exit  may  be 
simply  cleansed  and  dressed.  The  flap  having  been  raised,  if  the  wound  be  a  small 
perforation,  a  half -inch  trephine  crown  may  be  taken  from  one  side  ;  but  it  is  rare 
for  the  opening  to  be  so  small  that  the  tip  of  a  pair  of  Hoffman's  forceps  cannot  be 
inserted.  The  trephine  is  more  often  useful  in  cases  of  non -penetrating  gutter 
fractures  where  space  is  needed  for  exploration,  and  the  elevation  or  removal  of 
fragments  of  the  inner  table.  Loose  fragments  may  have  to  be  removed  from 
beneath  the  scalp,  but  the  important  ones  are  those  within  the  cranium.  These 
may  either  be  of  some  size,  or  fine  comminuted  splinters  of  either  table,  often  at  as 

^  Surgical  Experiences  in  South  Africa,  1899-1900. 

2  Under  this  heading  are  included  extensive  sagittal  tracts  passing  deeply  through  the 
brain,  and  vertical  wounds  passing  from  base  to  vertex  or  vice  versa,  in  the  posterior 
two-thirds  of  the  skull.  For  their  production  the  retention  of  a  considerable  degree  of 
velocity  on  the  part  of  the  bullet  was  always  necessary,  and  the  results  were  consei^uently 
both  extensive  and  severe. 


284  OPERATIONS  ON  THE  HEAD  AND  NECK 

great  a  distance  as  two  inches  or  more  from  the  surface.  The  cavity  must  be 
thoroughly  explored  and  all  splinters  removed.  I  have  seen  more  than  fifty  ex- 
tracted in  one  case  of  open  gutter  fracture.  The  brain  pulp  and  clot  should  then  be 
gently  removed  or  washed  away,  and  the  wound  closed  without  drainage.  Frag- 
ments of  bone,  as  a  rule,  are  better  not  replaced,  but  complete  suture  of  the  skin  flap 
is  always  advisable  in  view  of  the  great  importance  of  primary  union,  and  the  fact 
that  a  drainage  opening  exists  at  the  original  wound  of  entry,  and  that  the  wound  is 
readily  reopened  to  its  whole  extent,  should  such  a  steji  become  desirable. 

"  The  detection  of  fragments  is  most  satisfactorily  done  with  the  finger,  and  in 
all  but  simple  punctures  the  opening  should  be  large  enough  to  allow  thoroughly 
effective  digital  exploration.  The  determination  of  the  amount  of  brain  pulp  which 
should  be  removed  is  somewhat  more  difficult  ;  all  that  washes  away  readily  should 
be  removed,  and  its  place  is  usually  taken  up  by  blood. 

"  Few  fractures  of  the  base  are  suitable  for  operative  treatment  ;  the  only  ones 
I  saw  were  those  of  direct  fractures  of  the  roof  of  the  orbit  or  nose,  produced  by 
bullets  passing  across  the  orbits.  Here  the  advisability  of  interfering  with  the 
injured  eye  led  to  opening  of  the  orbit,  and  sometimes  exposed  the  fracture. 

"  As  to  the  most  satisfactory  time  for  the  performance  of  these  operations  ...  in 
head  injuries  the  advantages  of  early  interference  were  more  evident  than  in  any 
other  region.  This  depended  on  the  fact  that,  as  in  civil  practice,  the  scalp  is  one  of 
the  most  dangerous  regions  as  far  as  the  auto-infection  of  the  wound  is  concerned,  and 
one  of  the  most  difficult  to  cleanse  except  by  thorough  shaving."  With  regard  to 
the  treatment  of  retained  bullets  which  are  stated  to  have  been  distinctly  rare, 
Mr.  Makins  advises  that  the  ojjeration  should  not  be  undei'taken  until  "  the 
patient  can  be  placed  under  the  best  conditions  which  can  be  secured.  .  .  .  Sucli 
operations  need  the  infliction  of  an  additional  wound,  require  great  delicacy,  and 
may  be  very  prolonged  in  performance."  Earlier  interference  is  only  indicated 
where  the  bullet  has  tried  to  escape  or  secondary  symptoms  develop  pointing  to 
irritation. 

Operation.  A.  The  position  of  the  bullet  has  not  been  determined, 
either  on  account  of  the  condition  of  the  patient  or  the  radiographic  exami- 
nation may  have  been  inconclusive.  While  the  head  is  being  shaved 
and  preparations  for  the  operation  made,  the  surgeon  will  take  note 
of  any  superficial  lesions,  such  as  blackening  of  the  skin,  burning,  the 
presence  of  grains  of  powder,  and  the  original  characters  of  the  external 
wound,  both  for  medico-legal  purposes  and  for  future  guidance,  all 
these  lesions  being  soon  liable  to  alteration.  It  is  rare,  supposing  the 
patient  to  have  recovered  consciousness,  that  any  localiisng  symptoms 
are  present,  which  can  point  to  the  lodgment  of  the  bullet  in  a  definite 
part  of  the  cortex,  e.g.  the  motor  or  the  speech  area.^  In  a  few  cases, 
as  soon  as  the  whole  head  is  shaved,  the  surgeon  may  gain  evidence 
of  the  position  of  the  bullet  by  finding  on  the  opposite  side  of  the  skull 
a  contusion  of  the  scalp,  an  elevation  of  the  bone,  or  even  a  tender 
spot,  beneath  which,  after  incision,  some  fine  fissures  may  be  detected 
(Phelps). 2  The  surgeon,  having  raised  an  appropriate  flap,  enlarges 
the  wound  in  the  skull  with  Hoffmann's  forceps  and  removes  any  dirt, 
soft  parts  which  will  certainly  die,  and  superficially  lying  splinters. 
In  order  thoroughly  to  remove  any  powder,  dirt,  or  lead  splashes  from 
the  external  wound  in  the  skull,  even  after  this  has  been  enlarged  with 
Hoffmann's  or  other  forceps  {see  p.  -'312),  it  may  be  needful  to  resort 
to  rubbing  with  sterilised  gauze,  or  even  to  use  the  gouge.  The  wound 
in  the  dura  should  be  sufficiently  enlarged  to  give  exit  to  any  blood 
or  cerebral  debris.  If  uninjured,  or  very  slightly  injured,  the  bullet 
having  been   deflected,   the  dura  should  be  most  carefully  examined 

^  Any  such  lesions,  which  may  be  noted  immediately,  are  due  to  the  passage  of  the 
bullet ;  if  occurring  later  on  they  will  mark  certain  secondary  morbid  conditions. 

2  <SVe  '"Traumatic  Injuries  of  the  Brain  and  its  Membranes,"  by  Dr.  Phelps,  of  New 
York,  p.  343. 


BULLET  WOUNDS  OF  lUl AIN  285 

before  it  is  taken  for  granted  that  the  parts  beneath  have  not  been 
impHcated.  If  this  membrane,  though  uninjured,  is  bulging,  it  is 
always  to  be  opened.  Fragments  of  bone  accessible  within  the  cortex 
should,  after  the  wound  has  been  enlarged,  be  sought  for  with  a  probe 
or  even  with  the  finger  and,  when  found,  removed  with  dressing  forceps 
or  a  small  scoop.  The  bullet  may  be  discovered  in  the  course  of  these 
manipulations  but,  unless  it  is  soon  met  with,  its  extraction  should 
be  postponed  to  a  future  operation  when  its  exact  position  has  been 
localised.  The  opening  in  the  dura  should  be  sufficiently  large  to  give 
exit  to  any  blood  or  cerebral  debris.  If  irrigation  of  the  bullet-track 
is  practised,  with  the  view  of  removing  infected  clots  or  sloughs,  it 
will  be  well  to  plug  round  the  opening  in  the  skull  with  strips  of  gauze 
lest  the  fluid  carry  infected  particles  into  the  arachnoid  or  sub-arachnoid 
spaces.  Dr.  Phelps  is  of  opinion  that  drainage-tubes  are  to  be  employed 
with  much  reserve,  and  only  in  cases  where  there  is  great  and  widespread 
damage  to  the  central  regions  of  the  brain.  If  used  at  all,  drainage- 
tubes  should  be  withdrawn  and  abandoned  at  a  very  early  period, 
usually  on  the  second  day. 

The  following  objections  to  the  employment  of  drainage  tubes  must 
be  remembered:  (1)  That  they  are  irritant  foreign  bodies.  (2)  That 
they  are  likely  to  jjecome  filled  with  clot,  and  thus  act  as  plugs  rather 
than  as  drains.  (3)  That  they  are  media  for  the  deep  implantation  of 
infective  elements  when  the  surface  is  no  longer  sterile. 

If  the  surgeon  fails  to  find  the  bullet  he  will,  in  the  majority  of  cases, 
do  well  to  wait  for  an  improved  condition  of  his  patient  and  careful 
localisation  by  the  use  of  the  Rontgen  rays.  If  already  localised  he 
must  consider  whether  the  state  of  the  patient  justifies  further  inter- 
ference. While  profound  unconsciousness  and  deepening  coma  or  a 
marked  condition  of  shock  contra-indicate  any  prolonged  operation, 
it  will  be  better  if  the  site  of  the  bullet  is  known  with  anything  like 
certainty,  to  remove  it  at  once,  and  so  minimize  as  much  as  possible 
the  risks  of  infection.  Before  inflicting  this  additional  injury  and 
running  the  risk  of  causing,  perhaps,  further  severe  loss  of  blood  from 
incisions  in  scalp,  dura  mater,  and  brain,  the  surgeon  will,  accordingly, 
take  into  careful  consideration  the  condition  and  vitahty  of  his  patient. 

B.  The  removal  of  the  bullet.  Whether  this  is  done  at  the  same  time 
as  the  cleaning  of  the  wound  or  later,  when  the  condition  of  the  patient 
has  improved,  it  may  be  effected  through  the  original  wound  or  by 
counter-trephining.  The  advisability  of  the  latter  operation  will  depend 
upon  the  position  of  the  bullet.  The  course  of  the  projectile  within  the 
skull  is  often  very  erratic,  as  it  may  be  deflected  by  coming  into  contact 
either  with  the  dura,  or  with  some  bony  prominence.  A  radiographic 
examination  may  therefore  show  it  to  be  in  an  easily  accessible  position 
at  some  distance  from  the  wound  of  entry.  It  will  now  be  necessary 
to  consider  those  cases  where,  after  careful  exploration,  the  patient  has 
been  saved  from  the  risks  of  infection,  but  though  the  bullet  has  not 
been  found  the  wound  has  healed.  The  question  then  arises  as  to 
whether  the  bullet  should  be  removed  or  allowed  to  remain.  Where 
headache  or  any  local  symptoms  are  present,  we  will  say  two  or  three 
months  after  the  injury,  the  course  to  follow  is  clear,  especially  when  a 
radiographic  examination  clearly  localises  the  bullet.  But  it  is  not 
so  easy  to  give  an  answer  in  those  cases  where,  after  healing  of  the 
wound,  cerebral  symptoms  are  absent,  or  extremely  slight,  and  perhaps 


286  OPERATIONS  ON  THE  HEAD  AND  NECK 

the  Rontgen  rays  are  unable  clearly  to  define  the  position  of  the  bullet. 
On  the  one  hand,  any  honest  surgeon  knows  that  by  operating  he  may, 
in  spite  of  all  his  care,  expose  his  patient  to  dangers  greater  perhaps 
than  those  entailed  by  leaving  the  bullet  alone.  On  the  other  hand, 
the  evidence  is  strong  that  if  a  large  number  of  cases  of  recovery  without 
removal  of  the  bullet  were  accurately  watched  for  long  periods,  many 
would  be  found  to  be  cases  of  incomplete  recovery. 
'  The  evil  results  of  allowing  a  foreign  body  to  remain  in  the  brain 
are  usually  manifested  sooner  or  later,  even  as  long  as  fifteen  years 
after  the  injury.  Inflammation,  slow  or  rapid,  sometimes  involving 
large  portions  of  the  brain  tissue,  or  yellow  softening,  is  apt  to  be  set 
up  around  the  foreign  substance,  either  spontaneously,  or  from  the 
most  trivial  exciting  causes.  The  usual  termination  is  cerebral  abscess, 
this  condition  having  been  found  in  fifty-three  cases  in  which  a  necropsy 
was  performed.  Apoplexy  is  an  occasional  cause  of  death,  as  is  pressure 
of  the  foreign  body  on  the  venous  trunks,  inducing  ventricular  effusion 
and  consequent  compression  of  the  cranial  nerves.  The  probable 
explanation  of  those  cases  in  which  no  symptoms  have  been  present 
for  long  periods,  but  in  which  death  has  rapidly  followed  upon  the 
sudden  development  of  brain  symptoms,  is  that  quoted  by  _Wharton 
from  Flourens.  This  observer  found  that  bullets  introducednhTo" 
different  portions  of  the  upper  parts  of  the  hemispheres  and  the  cere- 
bellum gradually  penetrated  the  brain  substance,  ultimately  reaching 
the  basis  cranii,  the  bullet  tracks  healing  after  them.  "  There  is  probably 
no  authenticated  case  of  recent  Anglo-American  record  in  which  a 
bullet  left  in  the  brain  substance  has  failed  to  work  mischief,  nor  has 
the  mischief  been  often  long  procrastinated.  There  have  been  occasional 
instances  in  which  it  has  remained  harmless  for  a  number  of  years  in 
the  cranial  cavity,  but  the  brain  has  not  been  penetrated.  The  fact 
that  epilepsy  has  developed  so  late  as  fifteen  years  after  injury  must 
make  even  apparently  exceptional  cases  doubtful."^ 

The  following  detailed  case  by  Mr.  W.  Sheen,  of  CardifE,^  which  is 
an  instance  of  removal  of  the  bullet  by  counter-trephining  at  a  second 
operation,  will  be  found  extremely  instructive  : 

The  patient,  a  man  set.  23,  had  been  struck  by  a  revolver  bullet  about  2  cm.  to 
the  left  of  the  mid-frontal  line,  and  the  same  distance  above  the  supra-orbital  arch. 
Owing  to  the  depth  of  the  bullet,  about  12  cm.  from  the  point  of  entrance,  it  was  not 
considered  advisable  to  extract  it  at  first.  Ten  weeks  later  there  were  still  attacks 
of  left  parietal  and  frontal  headache,  some  motor  aphasia,  and  weakness  in  the  right 
leg.  The  position  had  been  localised  with  the  Rontgen  rays  by  Dr.  Martin, 
whose  remarks  are  quoted  below,  at  a  depth  of  6'5  cm.  from  the  lateral  surface  of 
the  head.  A  flap  was  turned  down  behind  the  left  ear,  and  a  one-inch  disc  removed 
above  and  behind  the  meatus.  This  opening  was  enlarged  downwards  and  for- 
wards, the  dura  mater  opened,  and  the  bullet  searched  for  "  by  entering  a 
probe  3'5  cm.  above  the  meatus,  and  2-5  cm.  behind  the  intermeatal  line,  and 
passing  it  in  the  horizontal  plane  of  the  head  to  a  depth  of  6"5  cm.  The  bullet  not 
being  felt,  Hedley's  telephone  probe  was  passed  in  the  same  line,  and  after  feeling 
a  moment  a  rather  doubtful  tap  was  felt.  The  probe  was  withdrawn,  and  a  pair 
of  ordinary  dressing  forceps  passed  in  felt  the  bullet,  which  bobbed  about  in  an 
elusive  way,  suggesting  the  possibility  of  its  being  in  a  cavity."  At  the  second 
attempt  the  bullet  was  removed,  with  a  little  brain  substance  adhering.  The  length 
of  forceps  introduced  measured  6'5  cm.  from  the  skull  surface.  As  there  was  con- 
siderable increase  of  intracranial  tension,  some  of  the  brain  substance  had  to  be 
removed  before  the  dura  could  be  closed.     The  disc  of  bone  was  replaced  and  the 

y    ^  "  Traumatic  Injuries  of  the  Brain  and  its  Membranes." 
2  Lancet,  vol.  ii,  1904,  p.  825. 


BULLET  WOUNDS  OF  BRAIN  287 

wound  closed  without  drainage.  The  after-progress  was  uneventful,  but  there  was 
still  some  weakness  in  the  right  arm  and  leg  and  dimness  of  vision  in  the  right  eye. 
About  five  months  after  the  operation  the  patient  resumed  work  as  a  stoker, 
and  is  believed  to  have  continued  it  since. 

Such  cases  as  the  above  are  the  ones  hkely  to  be  met  with  in  civil 
practice.  In  a  case  like  this,  revolver  bullets,  with  comparatively- 
low  velocity,  indict  damage  largely  limited  to  their  track.  On  the  other 
hand,  as  pointed  out  by  Mr.  Makins,^  a  high  velocity  bullet  of  the  modern 
small  arm  type  not  only  fissures  the  skull  extensively,  but  as  it  rushes 
into  the  brain,  scatters  waves  of  destruction  in  different  directions. 
The  exact  course  of  the  bullet,  as  in  Mr.  Sheen's  case,  above  the  ventricles 
and  basal  ganglia,  helps  also  to  determine  the  result.  With  regard  to 
the  justifiability  of  the  operation,  all  will  agree  with  Mr.  Sheen's  remarks  : 
"  The  man  was  nearly  free  from  symptoms  and  apparently  on  the  road 
to  complete  recovery.  There  were,  however,  certain  symptoms,  viz. 
intermittent  headache,  pain  on  moving  the  head,  and  at  least  one  severe 
attack  of  headache,  with  temporary  remission  of  symptoms.  Then  one 
realises  that  the  heavy  bullet  may  change  its  position ;  its  being  felt 
as  if  in  a  cavity  at  the  second  operation  supports  this  possibility." 

The  remarks  of  Dr.  W.  Martin  on  the  result  of  the  radiographic 
examination  are  of  equal  interest : 

"  When  the  question  of  removing  the  bullet  was  brought  forward,  radiograms 
were  taken  laterally  and  antero-posteriorly,  and  localisation  was  effected  by  the 
double  impression  on  the  single  plate,  and  the  Mackenzie-Davidson  cross  thread 
localiser.  By  these  means  it  was  found  that  the  depth  of  the  bullet  from  the  plate 
was  6-9  cm.  About  '5  cm.  was  allowed  for  scalp,  &c.,  intervening  between  the  plate 
and  the  external  surface  of  the  skull,  so  that  it  was  calculated  that  the  centre  of  the 
bullet  approached  on  the  horizontal  plane  of  the  head  from  a  point  3"5  cm.  above 
the  left  meatus,  and  2'5  cm.  behind  the  intermeatal  line,  would  be  found  at  a  depth 
of  6-4  cm.  This  distance  was  checked  by  the  antero-posterior  view,  which  placed  the 
centre  of  the  bullet  between  6'4  and  6"5  cm.  Stereoscopic  views  were  also  obtained 
the  night  before  the  operation.  Such  views,  however,  for  foreign  bodies  lying  deep 
in  the  cranial  cavity  do  not  give  a  very  clear  idea  of  the  exact  depth,  owing  to 
the  absence  of  intervening  landmarks,  in  the  same  way  that  distances  at  sea  are 
so  difficult  to  estimate." 

A  number  of  interesting  cases  of  bullet  wounds  of  the  skull  are 
recorded  by  Surgeon- General  Stephenson  in  the  Report  on  Surgical 
Cases  noted  in  the  South  African  War.  In  the  following  case  complete 
recovery  is  stated  to  have  resulted,  though  the  time  the  patient  was 
under  observation  after  the  operation  is  decidedly  short.  The  bullet 
appears  to  have  been  in  a  very  inaccessible  position. 

Trooper  M.,  Canadian  Contingent,  admitted  13  General  Hospital  April  5,  1902, 
with  small  scab  over  frontal  bone  due  to  gunshot  wound.  No  brain  symptoms — 
seemed  perfectly  well.  Wound  probed,  probe  passed  into  skull  ;  dry  gauze  dressing. 
Six  days  after  temperature  rose  and  brain  symptoms  appeared  ;  restless  ;  quite 
unaccountable  for  his  actions.  Next  day  trephined  ;  spicules  of  bone  removed  ; 
dura  found  lacerated ;  drained.  On  the  seventeenth  day  brain  symptoms  again 
appeared,  and  he  was  explored  th3  day  following.  Pus  under  scalp  above  right  ear 
evacuated ;  it  was  found  to  be  issuing  from  a  fracture  here,  from  abscess  in  the 
brain  three  inches  deep  ;  trephined,  and  abscess  drained.  Completely  recovered  in 
two  months  ;  invalided  ;  X-rays  showed  bullet  at  base  of  brain.  The  man  returned 
to  Canada  September  4, 1902,  from  Royal  Victoria  Hospital,  Netley.  (Civil  Surgeon 
Malcolm.) 

B.  Other   foreign  bodies  besides  bullets  which  may  penetrate  the 
^  Loc.  supra  cit.,  p.  248. 


288    OPERATIONS  OX  THE  HEAD  AND  NECK 

brain  are   Jcyiife- points.     These,  with  their   tendency  to   form    cerebral 
abscess,  have  already  been  alluded  to. 

C.  Another  class  of  foreign  body  which  may  be  met  with  by  the 
surgeon  in  civil  practice  is  shown  in  the  following  case  of  Mr.  Couper's  : 

A  house  painter  fell  twelve  feet  from  a  ladder,  irapaling  the  right  side  of  his  skull 
on  the  spike  of  an  iron  palLsade.  When  brought  into  hospital  there  was  a  clean  cut 
wound  three  quarters  of  an  inch  long  immediately  under  the  right  ear.  partly 
overlapped  by  its  lobule.  In  this  the  end  of  a  large  rough  piece  of  metal,  corre- 
sponding to  a  freshly  broken  spike,  could  be  felt,  and  its  direction  could  be  inferred 
to  be  upwards,  inwards  and  a  httle  forwards  from  the  outer  wound,  which  was 
situated  half  an  inch  under  the  external  meatus  between  the  mastoid  process  and 
the  ramus  of  the  jaw.  There  was  some  bleeding  from  the  ear.  but  no  facial  or  other 
paralysis.  The  patient  was  put  under  chloroform,  and  Mr.  Courier  succeeded, 
after 'much  forcible  wrenching,  in  extracting  the  iron.  During  these  efforts 
about  three  ounces  of  blood  oozed  from  the  wound  ;  the  hfemotrhage  ceased 
as  soon  as  the  iron  was  out,  but  a  small  quantity  of  semi-fluid  brain  substance 
then  escaped.  Right  facial  paralysis  came  on  two  days  after  the  injurj%  then 
delirium,  restlessness,  and  on  the  seventh  day  left  hemiplegia,  followed  by  con- 
vulsive attacks  afEeeting  the  right  limbs  and  the  right  half  of  the  face.  Two  days 
later,  or  nine  davs  after  the  accident,  the  patient  died.  At  the  necropsy  the  surface 
of  the  right  hemisphere  showed  well-marked  sub-arachnoid  meningitis.  The 
posterior  part  of  the  right  middle  cerebral  lobe  had  been  deeply  wounded  :  the  brain 
substance  at  this  spot  softened  and  streaked  with  pus,  elsewhere  was  healthy.  The 
spike  had  entered  just  under  the  apex  of  the  mastoid  process,  traversed  the  internal 
ear,  and  driven  several  irregular  masses  of  petrous  bone  through  the  dura  mater. 

In  a  similar  case  the  careful  use  of  chisel  or  gouge  would  loosen  the 
foreign  bodv,  while  opening  up  of  the  wound  would  facilitate  drainage 
and  cleansing  the  parts  damaged,  including  the  brain  itself  and  its 
membranes. 

^  London  Hospital  Reports,  vol.  ii ;  Hutchinson's  Clinical  Surg.,  vol.  i.  p.  91.  pi.  xvii. 


CHAPTER  XV 

CEREBRAL  LOCALISATION  IN  REFERENCE  TO  OPERATIONS. 
OPERATIONS  FOR  TUMOUR  OF  THE  BRAIN 

Motor  Area.  The  motor  area,  or  that  part  of  the  cortex  in  which 
lesions  cause  paralysis  on  the  opposite  side  of  the  body,  lies  beneath  the 
anterior  half  of  the  parietal  bone.  It  is  situated  immediately  in  front 
of  the  fissure  of  Rolando,  occupying  the  precentral  convolution.  Formerly 
it  was  thought  that  the  motor  area  extended  behind  the  fissure  of 
Rolando  into  the  post-central  convolution.  It  is  now  recognised  that 
the  latter  convolution  is  concerned  with  muscular  and  tactile  sense. 

Speaking  succinctly,  but  perhaps  with  sufficient  accuracy  for  practical 
purposes,  paralysis  or  conxTilsions  hmited  to  one  lower  extremity  mean 
that  the  lesion  is  situated  in  the  upper  third  of  the  opposite  motor  area 
and  will  call  for  removal  of  bone  in  this  situation  ;  paralysis  of  the  arm 
points  to  a  lesion  in  the  middle  third  of  the  area  ;  while  paralysis  of  the 
face  indicates  a  lesion  of  the  lower  third.  The  centre  for  speech  hes  (on 
the  left  side)  a  little  below  and  in  front  of  the  latter  area  and  is  situated  in 
the  first  frontal  convolution.  Where  lesions  are  combined  a  more  or  less 
extensive  removal  of  bone  over  the  corresponding  areas  will  be  called  for. 

It  will  be  seen  that  a  simple  method  of  marking  out  the  fissure  of 
Rolando  is  of  great  importance  to  the  surgeon.  This  may  be  fairly 
accurately  marked  out  as  follows  :  Draw  a  line  between  the  root  of  the 
nose  (nasion)  and  the  external  occipital  protuberance  (inion)  :  bisect  this 
hne  and  take  a  point  half  an  inch  behind  its  centre.  This  will  give  the 
upper  extremity  of  the  fissure,  i.e.  where  it  meets  the  mesial  longitudinal 
fissure  of  the  brain.  From  this  point  a  Une,  four  inches  in  length,  is  drawn 
downwards  and  forwards  making  an  angle  of  67-5°  with  the  first  line. 
This  angle,  which  is  three  quarters  of  a  right  angle,  is  easily  measured. 
The  second  hne  indicates  the  fissure  of  Rolando,  so  that  the  motor  area  is 
just  in  front  of  it. 

Sir  R.  Godlee,  in  the  classical  case  mentioned  on  p.  293,  used  the  follow- 
ing simple  method  of  marking  out  this  fissure.  A  very  similar  method 
was  employed  by  Mr.  Makins  and  the  late  Mr.  Anderson. 

(1)  A  line  was  drawn  between  the  nasion  and  the  inion  as  described 
above. 

(2)  At  a  right  angle  to  this  a  second  Hne  was  drawn  vertically  down- 
wards through  the  front  of  the  external  auditory  meatus. 

(3)  Parallel  to  the  last  another  hne  was  drawn  vertically  upwards 
at  the  level  of  the  posterior  border  of  the  mastoid  process,  reaching  the 
first  or  longitudinal  line  (1)  about  two  inches  behind  the  second. 

(4)  From  the  junction  of  lines  1  and  3,  one  was  drawn  diagonally  down- 
wards, reaching  the  second  about  two  inches  above  the  external  auditory 
meatus.     This  corresponds  to  the  direction  of  the  fissure  of  Rolando. 

SURGERY  I  289  19 


290 


OPERATIONS  ON  THE  HEAD  AND  NECK 


With  regard  to  all  surface  markings  of  the  cerebral  convolutions  it  may 

here  be  pointed  out  that  the  eminences  and  sutures  of  the  skull,  and  the 

J  relations  of  the  sulci  and 

convolutions  beneath   to 

the    cranial    surface    are 

liable  to  variations. 

Position  of  the  chief 
sutures  (Fig.  123).  The 
coronal  suture,  the  an- 
terior limit  of  the  parietal 
bone,  may  thus  be  traced. 
The  point  where  it  leaves 
the  sagittal  suture,  the 
bregma,  may  be  found  by 
drawing  a  line  from  a 
point  just  in  front  of  the 
external  auditory  meatus 
straight  upwards  to  the 
vertex ;  from  this  point 
the  coronal  suture  runs 
downwards  and  forwards, 
speaking  roughly,  to  the 
middle  of  the  zygomatic 
arch,  or  more  exactly,  to 
join  the  temporal  part  of 
the  great  "^dng  of  the 
sphenoid,  which  it  meets 
an  inch  and  a  half  above 
the  middle  of  the  zygoma, 
and  not  quite  an  inch  be- 
hind the  external  angular 
process  of  the  frontal 
bone. 

Under  this  suture  lie 
the  posterior  extremities 
of  the  three  frontal  con- 
volutions, for  the  frontal 
lobe  hes  not  only  under 
the  frontal  bone,  but  ex- 
tends backwards  under 
the  anterior  part  of  the 
parietal,  the  fissure  of 
Rolando,  which  forms  the 
anterior  boundary  of  the 
frontal  lobe,  lying  from 
one  and  a  half  to  two 
inches  behind  the  coronal 
suture. 

The  occipito-parietal 
or  lambdoid  suture,  the 
posterior  limit  of  the  parietal  bone,  will  be  marked  out  by  a  line  which 
starts  two  and  a  half  inches  above  the  external  occipital  protuberance, 
and  runs  forwards    and  downwards  to  its  termination,  which  is  on  a 


Fig.  123  A,  Showing  relations  of  chief  cerebral  sulci 
to  surface  of  skull.  B,  Showing  chief  sulci  and  their 
relations  to  surface  of  head. 
1.  The  nasion.  2.  The  inion.  3.  Mid  point 
between  nasion  and  inion.  4.  Fissure  of  Rolando. 
5.  Superior  temporal  crest.  6.  Inferior  temporal 
crest.  7.  Sylvian  point.  8,  9,  10.  The  thi-ee  limbs 
of  the  Sylvian  fissure.  11.  The  parietal  eminence. 
12.  The  malar  tubercle.  13.  The  lambda.  14. 
First  tempore  -  sphenoidal  sulcus.  15.  External 
parieto  -  occipital  sulcus.  16.  Lateral  sinus. 
17.  Level  of  the  base  of  the  cerebrum.  18.  Ex- 
ternal auditory  meatus.     19.  Reid's  base  line. 


GROWTHS  OF  THE  BRAIN  291 

level  with  the  zygoma,  an  inch  and  a  quarter  behind  the  meatus.  As 
the  occipital  lobe  is  not  limited  to  the  upper  portion  of  the  occipital 
bone,  but  extends  forwards  under  cover  of  the  posterior  part  of  the 
parietal,  the  parieto-occipital  fissure  lies  about  three-quarters  of  an  inch 
in  front  of  the  apex  of  the  lanibdoid  suture.  But  this  varies  a  good 
deal  according  to  the  ossification  of  the  tabular  part  of  the  occipital. 

The  squamous  suture  is  not  easy  to  mark  out,  owing  to  the  irregularity 
of  its  curve.  Its  highest  point  is  usually  an  inch  and  three-quarters 
above  the  zygoma. 

The  Sylvian  fissure,  which  separates  the  temporo-sphenoidal  lobe 
from  the  parietal,  passes  obliquely  upwards  and  backwards  across  this 
suture  near  its  middle,  the  temporo-sphenoidal  lobe  lying  beneath  the 
lower  part  of  the  parietal  as  well  as  under  the  squamous  and  the  great 
wing  of  the  sphenoid. 

To  mark  out  the  fissure  of  Sylvius  it  is  necessary  to  find  first  of  all 
the  Sylvian  point,  which  represents  the  site  of  divergence  of  the  three 
limbs  of  the  fissure.  This  point  is  situated  an  inch  and  a  quarter  behind 
the  external  angular  process  of  the  frontal  and  an  inch  and  a  half  above 
the  zygoma.  "  The  main  posterior  horizontal  limb  of  the  Sylvian  fissure 
passes  backwards  and  upwards  from  this  point  to  a  point  situated  three 
quarters  of  an  inch  below  the  most  prominent  part  of  the  parietal  bone. 
The  vertical  limb  is  directed  upwards  for  about  three-quarters  of  an  inch, 
whilst  the  anterior  horizontal  limb  passes  forwards  for  about  the  same 
distance.".^ 

The  following  practical  points  are  given  by  Prof.  Nancrede,  following 
M.  Lucas-Championniere.^ 

(1)  Monoplegia,  or  spasms  limited  to  one  limb,  or  a  portion  of  one 
limb,  indicate  limited  lesions.  If  the  lower  limb  be  affected,  the  upper 
portion  of  the  ascending  parietal  convolution  (Fig.  124)  is  involved.  Bone 
must  therefore  be  removed  over  the  upper  part  of  the  motor  area. 

(2)  With  paralysis  of  the  arm  and  leg,  the  lesion  probably  involves  the 
upper  two-thirds  of  the  area  with  possibly  the  paracentral  lobule  on  the 
mesial  aspect  of  the  hemisphere.  The  trephine  should  thus  be  placed 
at  the  upper  part  of  the  area,  and  the  opening  enlarged  upwards  or  down- 
wards as  required. 

(3)  Paralysis  of  the  upper  extremity  alone  probably  indicates  a 
lesion  at  the  middle  third  of  the  ascending  frontal  convolution,  and  the 
trephine  should  be  applied  a  little  in  front  of  the  middle  third  of  the 
fissure  of  Rolando. 

(4)  Paralysis  of  the  lower  part  of  the  face  points  to  a  lesion  in  the 
lower  third  of  the  motor  area. 

(5)  In  simple  aphasia  a  disc  of  bone  should  be  removed  lower  down  still. 
in  front  of  and  below  the  lower  extremity  of  the  left  fissure  of  Rolando. 

(6)  In  most  cases  more  than  one  centre  is  affected,  and  consequently 
a  considerable  extent  of  bone  may  require  removal.  Lesions  which 
irritate  a  localised  area  of  the  cortex,  e.g.  a  spicule  of  bone,  a  meningeal 
haemorrhage,  a  localised  meningitis,  or  a  growth,  produce  spasms  in  the 
corresponcUng  groups  of  muscles  on  the  opposite  side  of  the  body  which 
are  supplied  by  the  cortical  centres  irritated  (Jacksonian  epilepsy).  The 
irritation  may  involve  adjacent  centres,  causing  widespread  and  even 
general  convulsions.  Lesions  which  destroy  any  area  of  the  cortex  pro- 
duce paralysis  on  the  opposite  side  of  the  body  corresponding  to  the 

^  Rawlings,  '•  Surface  Markings."  ^  Intern.  Encycl.  Surg.,  vol.  v,  p.  90. 


292 


OPERATIONS  ON  THE  HEAD  AND  NECK 


position  and  extent  of  the  area  destroyed.  A  few  special  cortical  centres 
must  be  remembered.  Broca's  convolution,  in  the  posterior  extremity  of 
the  left  inferior  frontal  convolution,  corresponds  to  a  point  three  fingers' 
breadth  vertically  above  the  middle  of  the  zygomatic  arch.  This  centre 
governs  the  muscular  movements  concerned  in  speech,  and  lesions  of 
it  cause  "  motor  aphasia."  The  auditory-speech,  or  word-hearing  area, 
the  function  of  which  is  the  perception  of  spoken  words,  hes  in  the  middle 
of  the  first  temporo-sphenoidal  convolution.  Lesions  here  produce 
"  word  deafness,"  the  patient  being  unable  to  understand  spoken  words. 
The  visual  speech  or  word-seeing  centre,  by  which  written  words  are 


Fiti.  124.     Outer  surface  of  brain,  showing  localisation  of  chief  cerebral  centres. 


appreciated,  lies  in  the  angular  gyrus  at  a  point  higher  up  and  behind  the 
last  (Fig.  124).  If  this  centre  be  destroyed  power  to  read  words  is  lost. 
All  the  above  are  situated  on  the  left  side  in  right-handed  patients. 

The  cortical  centres  for  vision  lie  near  the  calcarine  fissure  on  the 
inner  aspect  of  the  occipital  lobes,  below^  the  level  of  the  parieto-occipital 
fissure  (Fig.  124).  Each  is  a  half -vision  centre  and  receives  fibres  from 
the  same  side  of  each  retina.  Lesions  of  one  centre  produce  "  homony- 
mous hemianopsia  "  or  inability  to  see  objects  situated  on  the  side  opposite 
to  the  lesion. 

PRACTICAL  VALUE  OF  CEREBRAL  LOCALISATION 

A  few  instances  will  be  given  under  the  foUoTvdng  headings  :  (a)  In 
head  injuries  ;   (6)  In  brain  growths. 

(a)  Cerebral  Localisation  in  the  Diagnosis  and  Treatment  of  Injuries  to 
the  Head.  (For  examples  see  also  pp.  301-308.)  A  typical  case  in  which 
localisation  may  help  the  surgeon  in  trephining,  would  be  one  in  which  the 
injury  is  limited  to  the  cranium,  and  is  followed  immediately  by  paralysis. 
Secondary  or  late  paralysis  may  be  the  result  of  later  inflammatory 
processes. 

M.  Lucas-Championniere  ^  gives  this  interesting  case  : 

A  man  was  found  in  the  street  with  slight  paralysis  of  the  right  arm,  but  with 
perfect  sensibility.  There  was  a  small  superficial  cut  half  an  inch  long  over  the  left 
parietal  eminence.     Five  or  six  days  later  the  patient  became  stupid  and  miable  to 

^  La  Trepanation  guidee  par  les  Localisations  cerebrates,  p.  107. 


GROWTHS  OF  THE  BRAIN 


293 


swallow,  and  convulsions,!  increasing  in  violence  and  involving  all  the  hody  save 
tlu' right  forearm  and  hand,  set  in.  Suspecting  a  fracture  of  the  inner  table,  M.  Lucas- 
Chanipionniere  tre])hined  at  the  site  of  the  woiuid,  and  found  a  fine  fissure  just 
in  front  of  this  ;  there  was  a  slight  depression  of  the  fragments,  which  were  wedged 
tightly  together.  After  the  o])eration  the  convulsions  ceased  and  a  good  recovery 
took  place,  with  use  of  the  right  arm.  The  fracture  was  proved  by  mcasuremnts 
to  be  over  the  middle  and  lower  part  of  the  fissure  of  Rolando,  considerably  in 
front  of  the  scalp  wound. 

The  following  is  a  case  of  traumatic  aphasia  successfully  treated 
by  removing  blood  clot  from  the  interior  of  the  cerebrum.^ 

The  patient  had  been  struck  on  the  head  with  a  penknife  six  days  before  admis- 
sion. At  that  time  he  had  difficulty  in  speaking  correctly,  which  had  increased 
somewhat,  and  ])ain  in  the  left  side  of  the  head, 
but  no  paralysis  or  loss  of  sensation.  A  small 
scar  was  found  over  the  left  squamous  bone 
two  inches  from  the  external  angle  of  the 
orbit  and  three-quarters  of  an  inch  above  the 

zygoma.     Both  forms  of  aphasia  (motor  and         /i  /    ^^.K  \  0 

sensory  word-blindness)  were  to  a  certain  ex- 
tent present.      Five  days  later  the  scar  was 
explored,  and  a  wound  of  the  squamous  bone, 
in  size  and   shape  likely  to   have   been  pro- 
duced by  a  small   penknife,  found,   and  cut 
out  in  a  trephine  disc.     The  knife  had  pene- 
trated the  dura  and  brain,  the  large  posterior 
branch  of  the  middle  meningeal  just  escaping. 
The  dura  being  opened,  a  sinus  forceps  was 
gently  passed  along  the  brain  wound,  and  on 
sepai'ating  the  blades  a  blood  clot  presented, 
and  was  gradually  extruded  by  brain  pres- 
sure.    More  clot  was  then  washed  away  by  '"">-.  % 
a    stream    of    weak    perchloride    lotion.      A                       •: 
drainage-tube  was  inserted.     On  the  evening                              Fig.  125. 
of  the  same  day  the  aphasia  was  much  im- 
proved.    Next  morning  the  patient  was  again  more  aphasic,  and  it  was  found  that 
the  tube  had  become  blocked.     On  freeing  it,  much  fluid  with  broken-down  clot 
escaped,  and  the  power  of  speech  improved.     The  patient  recovered  uninterruptedly, 
regaining  completely  Ms  power  of  writing,  reading  and  speaking.     Sir  C.  Ball  believed 
that  the   knife  had  penetrated  the  superior  temporo-sphenoidal  gyrus,  traversed 
the  Sylvian  fissure,  and  probably  injured  Broca's  convolution. 

(6)  Cerebral  Localisation  iii  the  Diagnosis  and  Removal  of  Cerebral  Groivtlis. 
The  following  case,  trephined  by  Sir  R.  Godlee  for  Dr.  Hughes  Bennett 
in  1884,3  is  of  great  interest,  partly  because  it  was  one  of  the  first  cases 
of  removal  of  a  tumour  from  the  brain  in  this  country,  and  also  on  account 
of  the  completeness  of  the  details  and  the  accuracy  of  his  reasoning. 

A  man,  aged  twenty-five,  had  four  years  before  suffered  from  slight  concussion 
from  a  blow  on  the  left  side  of  the  head.  A  year  later  there  first  set  in  twitchings 
in  the  left  side  of  the  mouth  and  tongue,  paroxysmal  and  irregular  in  occurrence. 
Some  months  after  fits  began,  with  loss  of  consciousness  and  general  convulsions. 
This  condition  lasted  two  and  a  half  years  ;  and  six  months  before  admission, 
twitchings  of  the  left  hand,  followed  shortly  by  weakness  of  the  left  fingers,  hand 
and  forearm,  were  noticed.  For  three  months  these  had  prevented  his  using  his 
tools.  During  this  last  period  there  had  been  twitchings  of  the  left  leg,  which 
had  also  been  getting  weak.  There  was  nothing  abnormal  in  the  skull  or  scalp 
Vision  was  normal,  but  optic  neuritis  was  present  on  both  sides,  most  marked  on 
the  right.  Hearing  was  less  acute  in  the  right  ear.  There  was  now  complete 
paralysis  of  the  left  fingers,  thumb, and  hand,  the  elbow  movements  were  very 

^  Convulsions  in  themselves  are  only  an  indication  for  interference  when  they  are 
localised  and  persist,  and  especially  if  they  alternate  with  paralysis  of  the  same  muscles, 
^  Sir  C.  B.  Ball,  Trans.  Roy.  Acad,  of  Med.,  Ireland,  vol.  vi,  p.  155. 
^  Med.  Chir.  Trans.,  vol.  Ixviii,  p.  244. 


294    OPERATIONS  ON  THE  HEAD  AND  NECK 

limited,  those  of  the  shoulder  impaired.  There  was  no  rigidity  or  wasting  of 
muscles.  The  toes  of  the  left  leg  did  not  clear  the  ground  in  walking.  There  was 
persistent  vomiting  and  retching,  with  attacks  of  lancinating  headache,  rendering 
life  intolerable.     Large  doses  of  the  iodides  were  fruitless. 

An  operation  being  decided  on,  the  motor  area  and  the  fissure  of  Rolando  were 
mapped  out.  Theoretically,  in  order  to  hit  the  middle  of  the  fissure  of  Eolando, 
the  centre  of  the  trejjhine  should  have  been  placed  about  half  an  inch  behind  the 
diagonal  line  and  about  an  inch  and  a  half  from  the  median  longitudinal  line.  As, 
however,  there  was  a  tender  sjwt  on  the  scalp  two  inches  anterior  to  this,  the  first 
trephine  opening  was  made  between  the  two.  The  dura  mater  was  normal ;  after 
a  crucial  incision  was  made  in  it,  the  brain  was  thought  to  bulge  abnormally,  and 
to  be  rather  more  yellow  than  usual.  A  second  disc  was  removed  with  the  trephine, 
overlapping  the  first,  external  to  and  slightly  in  front  of  it,  and  tlie  angles  of  bone 
uere  rounded  off  with  a  gouge.  These  two  openings  were  then  joined  by  one  posterior 
to  them,  so  that  an  aperture  measuring  two  inches  by  an  inch  and  three-quarters 
was  made.  The  dura  mater  was  opened  and  a  sm-face  of  brain  exposed  nearly 
equal  in  size  to  that  of  the  skull-opening.  Occupying  most  of  this  space  and  crossing 
it  obliquely  from  above  and  behind,  clownwards  and  forwards,  was  a  convolution, 
into  the  centre  of  which  an  incision  was  made.  From  an  eighth  to  a  c^uarter  of  an 
inch  below  the  surface  lay  a  transparent,  lobulated,  solid  tumour,  thinly  encajisuled 
but  quite  isolated  from  the  surrounding  brain  substance.  The  incision  into  the 
cortex  being  prolonged,  the  sides  of  the  growth  were  easily  separated  by  a  steel 
spatula.  The  superficial  sm-face  of  the  growth  being  thus  isolated,  this  portion 
was  removed  with  the  finger.  As  part  now  broke  away,  the  deeper  part  was 
enucleated  with  a  sharp  six)on,  the  scraping  being  continued  till  apparently  only 
healthy  brain  matter  remained.  The  ca\-ity.  about  the  size  of  a  pigeon's  egg, 
filled  up  -with  blood,  and  sponge  pressme  failing,  the  haemorrhage  was  eventually 
checked  by  the  electro  cautery.  A  di-ainage  tube  was  inserted  beneath  the  dura 
mater,  which  elsewhere  was  ckawn  together  by  sutvires.  The  skin  wound  was  closed 
and  an  antiseptic  dressing  applied. 

The  wound  was  not  dressed  till  the  third  day,  when  the  scalp  near  the  wound 
was  somewhat  cedematous.  The  next  day  wet  boracic  di-essings  were  applied,  but 
a  hernia  cerebri  as  large  as  half  an  orange  was  protruding  through  the  lips  of  the 
wound.  There  were  no  twitchings  of  limbs  or  face,  no  headache.  The  patient  was 
bright  and  cheerful,  with  a  good  appetite.  The  hernia  cerebri,  however,  increased, 
and  on  the  eighth  day,  having  reached  the  size  of  half  a  cricket  ball,  was  snipped 
away  with  scissors,  the  parts  removed  consisting  chiefly  of  granular  matter  and 
clot,'  with,  apparently,  little  true  cerebral  structure.  The  hernia  cerebri  again 
increased  somewhat,  but  all  seemed  to  be  doing  well,  when,  on  the  twentj^-first  day, 
a  rigor  occurred,  headache  and  vomiting  followed,  then  restlessness,  sleeplessness, 
and  gradual  sinking  about  four  weeks  after  the  operation. 

At  the  autopsy  extensive  araclmitis  was  found.  The  parietal  area  appeared  to 
have  fallen  in  ;  in  its  centre,  and  occupying  the  position  of  the  fissure  of  Rolando, 
was  the  wound  in  the  brain.  The  destruction  of  the  cerebral  cortex  involved  nearly 
all  the  ascending  parietal  convolution,  the  upper  part  of  the  ascending  frontal,  and 
the  anterior  tliird  of  the  supramarginal  g^Tus.  The  extent  of  softening  was  not 
great,  but  it  was  difficult  to  tell  this  accurately,  as  the  brain  had  undergone  the 
proce-ss  of  hardening.     The  growth  was  a  glioma,  of  the  size  of  a  walnut. 

In  the  comments  on  the  case,  most  interesting  remarks  are  grouped 
mider  the  following  heads:  (1)  diagnosis,  (2)  sm-gical  treatment,  (3)  chni- 
cal  phenomena  after  the  operation,  (4)  revelations  of  the  necropsy 
physiologically  and  pathologically  considered. 

These  will  repay  most  carefiil  perusal ;  only  the  chief  points  can  be 
given  here. 

(1)  Diagnosis.  A  brain  growth  on  the  right  side  was  diagnosed  in  this 
case  on  the  following  grounds  :  slow  progress,  uncontrollable  vomiting, 
violent  pains,  double  optic  neuritis. 

It  was  thought  to  occupy  the  cortex  because  certain  motor  tracts 
were  imphcated  in  definite  order,  because  paralysis  was  present  without 
loss  of  sensibility,  and  above  all  because  of  certain  paroxysmal  seizures 
of  local  con\nilsions  occurring  without  loss  of  consciousness,  eminently 
suggestive  of  irritation  of  the  grey  matter. 


GROWTTTS  OF  THE  BRAIN  205 

Til  this  case  tlioro  was  coinplete  paralysis  of  tho  fingers  and  hand,  with 
inahiHtvto  proiiate  and  supinate  tlie  forearm;  there  was  partial  paresis 
of  tlie  luovements  of  tiie  elhow,  and  weakness  of  those  of  the  shouhU'r  joint. 
There  was  also  shght  paresis  of  the  leg  and  one  sich;  of  the  face.  Accom- 
panying all  these  there  were  paroxysmal  convulsions  in  all  these  regions, 
occm'ring  either  singly  or  in  definite  order  one  after  the  other.  These 
phenomena  were  to  be  accounted  for  by  an  extensive  but  not  absolutely 
complete  destruction  of  the  motor  centres  of  the  fingers,  hand,  and  fore- 
arm, with  slight  encroachment  on  and  irritation  of  those  of  the  face,  upper 
arm,  and  leg.  A  very  definite  localisation  was  thus  permitted,  and  the 
tumour  was  pronounced  to  have  occupied  the  whole  thickness  of  the 
middle  two-fourths  of  the  ascending  parietal  convolution,  and  a  portion 
of  the  adjoining  upper  half  of  the  ascending  frontal  convolution.  The 
growth  was  })r()verl  to  be  limited  by  the  fact  that  the  centres  of  the  leg 
above,  of  the  face  and  tongue  below,  of  sight  behind,  and  of  the  movement 
of  the  eyeballs  in  front,  were  not  seriously  involved.  As  to  the  probable 
nature  of  the  tumour,  the  age  of  the  patient,  the  absence  of  syphilis, 
and  the  slow  progress,  suggested  glioma. 

(2)  The  Operation.  One  convolution  only  being  exposed  during 
the  operation,  there  w^as  at  the  time  some  question  as  to  whether  it 
w^as  the  ascending  frontal  or  parietal.  This  doubt  arose  from  the 
circumstance  that  in  the  attempt  to  approach  the  tender  spot  the 
theoretical  position  had  been  slightly  departed  from.  After  death, 
however,  it  was  apparent  that  the  convolution  which  had  been  incised 
was  that  in  which  from  the  first  the  disease  had  been  diagnosed  to  exist, 
viz.  the  ascending  parietal.  There  was  no  external  appearance  of 
disease  about  this  part  except  that  it  seemed  sw^ollen,  less  glossy,  and 
less  vascular  than  natural.  An  incision  into  it  showed  the  morbid  growth 
to  be  immediately  under  the  surface,  and  almost  completely  involving 
the  entire  thickness  of  the  cortex. 

It  may  be  questioned  whether  it  w^as  advisable  to  arrest  the  haemor- 
rhage from  the  interior  of  the  W'Ouncl  by  means  of  the  galvano-cautery,  as 
the  bleeding  was  not  severe  and  would  no  doubt  have  become  arrested 
by  natural  means.  The  use  of  this  instrument  appears  to  have  brought 
about  the  sloughing  which  was  the  cause  of  the  inflammation  and  conse- 
quent hernia  cerebri.  It  was  remarkable  that  the  discharge  continued 
for  so  long  to  be  so  copious  and  so  watery,  as  to  suggest  the  idea  of  its 
being  cerebro-spinal  fluid. ^ 

(3)  Clinical  Phenomena  following  the  Operation.  The  patient  lost 
his  headache,  vomitings,  and  violent  twitchings  in  the  Kmbs  ;  even  the 
double  optic  neuritis  markedly  diminished.  The  only  change  which 
followed  the  operation  w'as  completion  of  the  paresis  of  the  upper 
extremity,  evidently  due  to  the  unavoidable  destruction  of  the  remaining 
arm-centres  in  the  removal  of  the  tumour.  Coincident  also  with  the 
formation  of  the  hernia  cerebri  came  fresh  symptoms,  in  the  shape  of 
paresis  of  the  left  leg  and  partial  angesthesia  of  one  half  of  the  body. 
These  were  probably  due  to  the  effects  of  simple  pressure,  and  possibly 
to  the  subsequent  secondary  softening  of  the  conducting  fibres  caused 
by  it. 

(4)  Revelations  of  the  Necropsy.  The  brain  was,  practically,  every- 
where healthy  except  over  the  area  injured  by  the  operation  and  in  the 

1  It  was  not  conclusively  shown  at  the  necroi^sy  if  tho  lateral  ventricle  had  been 
opened. 


296  OPERATIONS  ON  THE  HEAD  AND  NECK 

membranes  in  the  immediate  neighbourhood.  The  meningitis  was  due 
to  irritating  matter  from  the  interior  of  the  womid  flo^^'ing  doAMiwards 
between  the  layers  of  the  arachnoid,  and  accumulating  at  the  base  of  the 
brain.  The  local  inflammation  of  the  wound  had  opened  out  the  parts, 
and  separated  the  adhesions  so  as  to  allow  the  discharge  to  make  its 
way  into  the  cranial  cavity,  but  not  till  three  weeks  after  the  operation. 

The  following  case,  quoted  from  a  paper  by  Dr.  Risien  Russel,  read 
before  the  British  Medical  Association  in  1907,^  is  an  example  of  a  case  in 
•which  the  position  of  the  tumour  could  be  ascertained  with  practical 
certainty,  and  in  which  it  was  successfully  removed  by  operation. 

M.  B.,  a  woman  aged  40,  complained  of  increasing  weakness  of  the  right  foot  of 
two  months"  duration.  She  next  noticed  twitchings  of  the  right  toes  in  attacks 
which  lasted  for  a  minute  or  two  and  which  occm-red  once  or  twice  in  the  twenty- 
foiu'  hours.  These  clonic  movements  and  the  motor  weakness  gradually  ascended 
the  limb,  until  six  weeks  after  the  commencement  of  her  illness  they  culminated 
in  a  Jacksonian  fit,  which,  commencing  in  the  foot,  subsequently  involved  the 
right  arm  and  face,  without  loss  of  consciousness.  A  similar  fit  occurred  three 
days  later.  Seven  weeks  from  the  onset  of  the  illness  she  began  to  notice  progressive 
loss  of  power  in  the  right  upper  limb.  She  had  been  entirely  free  from  headache, 
and  at  no  time  did  she  become  aphasic.  When  she  came  under  observation  there 
was  hemiparesis  of  the  right  side  :  the  face  was  only  slightly  affected,  the  arm  much 
more  so,  and  the  leg  most  of  all.  Indeed,  no  movement  of  the  ankle  or  toes  was 
possible.  A  diagnosis  of  a  tumour  in  the  leg  area  of  the  left  motor  region  was  made. 
Sir  Victor  Horslej'  operated,  with  the  result  that  a  tumour  the  size  of  a  walnut 
was  removed  from  about  half  an  inch  beneath  the  cortex  of  the  leg  area.  As  an 
immediate  effect  of  the  operation  there  was  marked  increase  of  the  hemiplegia,  but 
the  paralysis  subsequently  improved  so  that  before  the  patient  left  the  hospital, 
seven  weeks  after  her  operation,  feeble  movements  could  be  made  in  the  right 
toes  and  at  the  ankle,  in  which  parts  no  movements  had  been  possible  before  the 
operation. 

QUESTIONS  ARISING  BEFORE  OPERATION  ON  A  CEREBRAL 

GROWTH 

The  chief  of  these  are  :  (A)  The  existence  of  a  growth ;  (B)  The 
site  of  the  growth  ;  (C)  The  depth  of  the  growth  ;  (D)  Is  it  single  or 
multiple  ?  (E)  Its  nature  ;  (F)  The  conditions  which  justify  operative 
interference  and  the  probable  results  of  this  step. 

The  above  points,  and  the  five  first  especially,  must  be  decided  ^vith  the 
help  of  a  physician  ;  and  it  is  to  be  hoped  that  in  futm-e  physicians  will 
invoke,  at  least,  the  opinion  of  the  surgeon  at  an  early  stage  of  the  disease. 
In  too  many  cases  of  cerebral  growth  the  operation  has  only  been  resorted 
to  as  a  forlorn  hope,  a  fact  Avhich  is  always  to  be  considered  when  the 
mortahty  from  operation  in  these  cases  is  estimated.  Information  with 
regard  to  questions  (A)  to  (D)  -^-ill  be  obtained  by  referring  to  some  standard 
work  on  medicine.  The  surgical  aspect  and  treatment  of  these  cases 
necessitate  the  discussion  here  of  questions  (E)  and  (F)  at  some  length. 

(E)  The  nature  o£  the  growth.  Before  deahng  with  growths  of  the 
brain  itself  it  will  be  necessary  to  allude  to  those  springing  from  the  dura 
mater  {see  also  p.  245). 

Prof.  Keen-  published  a  case  of  fibroma  weighing  over  three  ounces,  attached  to 
the  dura  mater,  which  he  removed  successfully  in  a  patient  aged  27  in  1887.  The 
growth  dated  probably  from  an  injury  in  childhood.     It  caused  epilepsy,  aphasia, 

^  See  Brit.  Med.  Journ.,  1907,  vol.  ii,  p.  1122.  This  paper  and  the  discussion  which 
followed  contain  much  useful  information  as  to  the  localisation  of  cerebral  tumours,  and  of 
its  practical  value  as  regards  operative  treatment. 

^  Armr.  Journ.  Med.  Sci.,  1888. 


GROWTHS  OF  THE  BRAIN  297 

conipk'te  hoiniplogia,  intense  neuralgia,  deafness,  and  great  inipairnient  of  vision. 
After  tlie  operation,  save  for  the  eye  and  ear  symptoms,  all  the  otliers  had  passed 
away  exeept  slowness  of  speeeli  and  the  epilepsy,  and  the  last  was  much  improved. 
In  the  same  periodieal  for  189G  (vol.  cxii,  p.  5G3),  I'rof.  Keen  gives  the  state  of  this 
patient  nine  years  after  the  operation:  "Eyesight  still  imperfect.  Epilejrtiform 
attacks  recur  now  at  intervals  of  about  a  year.  Patient  still  very  nervous  and 
unable  to  do  any  work." 

Sir  W.  Macewen  1  has  ]iul)lished  a  case  in  -which  a  growth  of  the  dura  mater 
caused  irritative  lesions  of  the  left  frontal  lobe.  The  patient  was  restored  to  perfect 
health  after  the  operation,  and  died  eight  years  later  of  Bright's  disease. 

In  the  above-mentioned  case  the  growth  was  Hniited  to  the  dura.  A 
detailed  account  of  a  case  in  which  a  growth  originating  in  the  dura 
involved  the  cortex  of  the  brain  is  recorded  by  Dr.  Bremer  and  Dr. 
Carson,  of  St.  Louis. ^ 

The  growth  was  an  endothelioma.  Owing  to  the  characteristic  spread  of  the 
paralysis  from  one.  the  shoulder  centre,  to  the  others  of  the  upper  extremity,  the 
diagnosis  of  growth  in  the  brain  was  made,  though  headache,  vertigo,  nausea  and 
optic  neuritis  were  absent.  At  the  operation  alarming  haemorrhage  took  place 
during  the  removal  of  the  bone  owing  to  the  immense  size  of  some  branches  of 
the  posterior  meningeal  vein.  This  was  checked  by  packing  while  the  opening  was 
enlarged.  The  dura  w'as  dark,  covered  with  large  vessels,  and  did  not  pulsate. 
It  was  adherent  to  a  growth  beneath,  which,  though  friable,  was  easily  lifted  from 
its  bed  between  the  dura  and  the  apparently  healthy  brain.  The  patient  died  on 
the  twelfth  day  with  p^Tcxia  and  delirium.  At  the  necropsy  a  portion  of  the 
growth  was  found  to  have  escaped  removal,  and  the  microscope  showed  that  the 
sm-face  of  the  brain  was  itself  invaded. 

It  ^^'i^  now  be  necessary  to  consider  growths  of  the  brain  itself. 
Almost  every  form  of  neoplasm  may  be  found  ^^^thin  the  cranial  cavity. 
The  most  common  forms  are  sarcoma,  glioma,  tuberculoiLS  tumour, 
syphihtic  tumour,  endothelioma,  and  cysts.  Less  common  are  fibroma 
and  osteoma,  while  rarer  forms  are  hydatid  cysts,  psammoma,  hpoma, 
large  aneurysms  of  the  arteries  at  the  base  of  the  brain,  and  tumours  of 
the  pituitary  body.  Some  help  as  to  the  varieties  of  growth  most  likely 
to  be  met  with,  and  the  relative  frequency  of  each,  will  be  gained  from 
the  following  table. ^  The  interval  since  the  publication  of  this  paper 
may  make  it  appear  out  of  date.  Owing  to  the  care  with  which  it  was 
drawn  up,  and  the  sound  pathological  basis  on  which  it  rests,  this  is  not  so. 
The  paper  remains  one  of  great  value  and  is  still  quoted  and  relied  upon 
by  different  authorities.  It  will  be  noticed  that  Dr.  W.  Hale  White's 
conclusion  that  10  per  cent,  of  the  cerebral  growths  collected  by  him  could 
certainly  have  been  operated  on  is  distinctly  higher  than  is  shown  to 
be  the  case  now  in  the  light  of  the  experience  of  twenty  years  later. 

Of  one  hundred  cases  of  cerebral  growth  the  proportions  were  as 
follows  : 


Tubercle  . 
Glioma 
Glio-sarcoma 
Sarcoma  . 
Carcinoma 
Lymphoma 
Myxoma  . 
Cyst 

Gumma     . 
Doubtful  . 


45 
24 
2 
10 
5 
1 
1 
4 
5 
3 

100 


Lancet,  August  11,  1888.  p.  304.  ^  Aimr.  Journ.  Med.  ScL,  February  1895. 

Dr.  W.  Hale  ^^^lite,  Guy's  Hospital  Reports,  1886. 


298  OPERATIONS  ON  THE  HEAD  AND  NECK 

Of  the  forty-five  cases  of  tubercle,  the  cerebrum  was  affected  in  twenty- 
two,  the  cerebellum  in  twenty  cases.  The  growth  was  multiple  in  nine- 
teen, and  single  in  twenty-four  cases.  In  all  the  forty-five  cases  one  or 
more  other  structures  than  the  brain  were  affected.  Dr.  W.  Hale  White 
concludes  that  not  more  than  three  tuberculous  cases  were  likely  to 
be  benefited  by  operation,  and  even  in  these  the  other  organs  were 
tuberculous. 

Ot  the  twenty-four  cases  of  glioma,  of  ten  only  could  it  be  said  that 
they  were  not  infiltrating.  The  cerebrum  was  the  seat  of  the  disease  in 
thirteen  cases,  the  cerebellum  in  four.  In  one  case  there  were  multiple 
gliomata  in  the  brain,  and  in  two  others  there  were  growths  in  other  parts 
of  the  body. 

Of  the  ten  cases  of  sarcomata  several  afiected  the  dura  mater  in  inac- 
cessible positions  ;  of  the  five  cases  which  attacked  the  brain  only,  one 
alone  could  have  been  removed  T\ith  any  prospect  of  success.  Of  the 
remaining  growths  none  of  the  carcinomata  or  glio-sarcomata  were  amen- 
able to  treatment.  Of  the  four  cases  of  cyst  one  could  certainly,  and 
another  possibly,  have  been  operated  upon  ;  the  myxoma  was,  and  the 
lymphoma  was  not,  amenable  to  operation  ;  and  of  the  three  doubtful 
cases,  two  could  have  been  operated  upon.  Dr.  W.  Hale  White's  summing 
up  is  as  follows  :  "  Thus  we  see  that  out  of  one  hundred  cases  of  tumour 
of  the  brain,  ten  might  certainly  have  been  operated  upon,  and  four 
additional  ones  might  possibly  have  been  ;  so  that  in  10  per  cent,  of  our 
cases  we  can  hold  out  some  hope  of  operative  relief  to  our  patients,  pro- 
vided that  a  correct  diagnosis  of  the  position  of  the  growth  be  made, 
even  so  late  as  shortly  before  their  death,  whilst,  of  course,  earher  in 
their  histories  many  others  might  have  been  operated  upon  ^"ith  a  good 
prospect  of  success." 

The  following  are  the  conclusions  of  another  physician  of  great 
clinical  and  pathological  experience — -Dr.  Byi'om  Bramwell,  well 
known  as  an  authority  on  this  subject,  the  conclusions  having  been 
given  at  a  debate  on  Intracranial  Surgery,  at  the  Medico-Chirurgical 
Society  of  Edinburgh.^  Dr.  Bramwell  considered  that  the  cases  in 
which  intracranial  tumours  can  be  successfully  removed  by  the  surgeon 
are  rare,  a  consideration  of  the  conditions  present  making  it  easy  to 
understand  why  this  must  necessarily  be  the  case.  (1)  In  a  certain 
but  very  small  number  of  cases  an  intracranial  tumour  is  not  charac- 
terised by  any  symptoms  during  fife  which  enable  a  positive  diagnosis 
to  be  arrived  at.  (2)  In  some  of  the  cases  of  intracranial  tumour  in 
which  the  symptoms — e.g.  headache,  vomiting,  giddiness,  and  double 
optic  neuritis — distinctly  show  the  presence  of  an  intracranial  tumour, 
there  are  no  locahsing  symptoms  which  enable  the  physician  to 
determine  in  what  part  of  the  cranial  cavity  the  tumour  is  situated.  These 
cases  constitute  a  not  inconsiderable  proportion  of  the  whole.  It  is  by 
no  means  uncommon  to  meet  with  large  tumours  in  the  temporo-sphenoidal 
and  frontal  ^  lobes,  the  "  silent  areas  "  of  the  brain,  which  are  unattended 

1  Trans.,  vol.  xiii,  1894,  p.  180. 

^  There  is  increasing  evidence  to  show  that  the  frontal  lobes  can  no  longer  be  regarded 
as  "  silent  areas  "as  has  hitherto  been  the  case.  Sir  D.  Ferrier  (Allbutt  and  Rolleston's 
System  of  Medicine,  vol.  viii,  p.  50)  comes  to  the  following  conclusions  vnih.  regard  to  the 
frontal  lobe  : 

(i)  Lesions  of  the  frontal  lobe  may  be  said  to  be  not  infrequently  latent. 

(ii)  On  the  other  hand,  in  some  cases,  especially  if  the  lesion  is  bilateral,  and  even  in 
the  case  of  lesions  which  are  not  calculated  to  cause  pressure  or  disturbance  of  the  brain 
in  general,  there  may  be  mental  symptoms  of  which  the  chief  characteristics  are  failure 


GROWTHS  OF  THE  BRAIN  299 

with  any  very  definite  and  characteristic  locahsing  symptoms.  The 
occipital  lobe  was  formerly  also  thought  to  be  a  silent  area,  but  it  is  now 
known  that  lesions  in  this  situation  produce  homonymous  hemianopsia, 
a  most  important  localising  symptom  (p.  292).  (3)  In  a  few  cases,  in 
which  there  are  localising  symptoms,  these  give  an  erroneous  impression 
as  to  the  position  of  the  tumour. 

In  support  of  this  statement  an  instructive  case  is  <^iven  in  wiiich,  in  a  syphilitic 
patient,  the  local  i)ain  and  tenderness  and  the  localised  character  of  the  s])asnis, 
wliicli  connnenced  in  the  left  big  toe,  clearly  indicated  that  the  tumour  would  in 
all  probability  be  found  in  the  cortex  in  the  region  of  the  foot-centre.  The  necropsy 
showed  a  glioma  involving  the  right  o])tic  thalanuis,  the  growth  iuiving  encroached 
upon  the  posterior  division  of  the  internal  cajisule  and  a])parently  implicated  the 
fibres  to  the  left  leg. 

(4)  In  many  of  the  cases  in  which  the  exact  position  of  the  tumour 
is  clearly  demonstrated,  successful  operative  procedure  is  impossible 
or  uncalled  for.  Thus,  {a)  in  addition  to  tumours  situated  at  the  base, 
the  basal  ganglia,  &c.,  Dr.  Bramwell  is  inclined  to  include  under  this 
head  a  large  proportion  of  tumours  situated  in  the  cerebellum,  and  for 
these  reasons  :  The  surgeon  can  hardly  hope  successfully  to  remove 
tumours  which  involve  the  middle  lobe  of  the  cerebellum.  Tumours 
which  are  situated  in  the  lateral  lobes  are  with  difficulty  reached,  and  the 
operation  required  for  their  removal  is  a  dangerous  one  ;  the  surgeon  has 
to  work  in  a  very  narrow^  space,  and  there  is  a  risk  of  w^ounding  the  large 
venous  sinuses,  the  medulla,  the  pons,  &c.  Further,  it  is  often  an 
extremely  difficult  or  impossible  thing  to  determine,  during  life,  in  which 
lobe  of  the  cerebellum  the  tumour  is  situated.  (6)  In  many  cases  the 
tumour  is  so  extensive  and  infiltrates  such  a  large  area  of  brain  tissue 
that  its  complete  removal  is  impossible,  (c)  In  others  the  tumour  is 
multiple.  (fZ)  In  others  it  is  malignant  and  of  a  secondary  nature,  (e)  In 
some  the  cerebral  tumour  is  complicated  by  associated  lesions  in  other 
organs  which  contra-indicate  any  operative  interference.  Thus,  in  not 
a  few  cases  of  tuberculous  growth  of  the  cerebellum  the  lungs  are  also 
affected,  and  in  some  syphiHtic  cases  the  vessels  either  of  the  brain  or  other 
parts  of  the  body  are  so  extensively  diseased  that  an  operation  is  very 
hazardous.  (/)  Speaking  of  syphilitic  tumours.  Dr.  Bramwell,  while 
admitting  the  good  results  obtained  by  very  active  drug  treatment, 
was  disposed  to  think  that  in  many  of  the  syphihtic  cases  in  which  the 
gumma  is  large  and  of  some  standing — cases  in  which  a  cicatrix  must 
necessarily  remain  on  the  surface  of  the  brain — operative  procedure 
is  advisable  after  the  acute  symptoms  have  subsided  under  the  vigorous 
use  of  specific  remedies,  as  the  termination  of  many  of  these  cases  (the 

of  memory,  hebetude,  apathetic  indifferent  or  tendency  to  sleep,  vague  restlessness,  and 
inability  to  concentrate  attention,  or  a  silly  jocularit}\ 

(iii)  The  regional  diagnosis  of  lesion  of  the  frontal  lobe  is  rendered  more  probable  if,  in 
addition  to  the  psychical  symptoms,  there  occur  convulsive  or  paralytic  symjjtoms,  mono- 
plegic  or  hemiplcgic,  on  the  opposite  side  of  the  body.  These  symptoms  are  indicative  of 
extension  of  the  lesion  backward  into  the  Rolandic  area. 

(iv)  The  diagnosis  of  lesions  of  the  frontal  lobe  may  be  made  with  still  greater  cer- 
tainty if,  in  addition  to  the  symptoms  enumerated  under  paragraphs  (ii)  and  (iii), 
there  are  signs  of  pressure  in  the  anterior  fossa  ;  consistmg  in  protrusion  or  displace- 
ment of  the  ej-eball,  with  perhaps  unilateral  loss  of  vision,  anosmia,  and  paralysis  of  one 
or  other  of  the  oculomotor  nerves. 

(v)  The  diagnosis  is  confirmed  if,  in  addition  to  some,  or  a  combination  of  several,  of 
the  above-mentioned  sj-mptoms,  there  is  pain  on  deep  pressure  on  the  frontal  bone.  This 
local  pain  may,  however,  be  entirely  absent  if  the  lesion  be  subcortical,  and  is  especially 
to  be  found  in  cases  of  tumour  causing  tension  or  irritation  of  the  dura  mater. 


300  OPERATIONS  ON  THE  HEAD  AND  NECK 

patients  ultimately  becoming  useless  members  of  society,  or  insane)  is  so 
deplorable.^ 

The  above  conclusions  of  Dr.  B}Tom  Bramwell  were  based  on  an 
analysis  of  eighty-two  cases  of  intracranial  tumour  which  he  had  seen 
dm'ing  life  and  which  he  had  examined  post-mortem.  In  seventy-seven 
out  of  the  eighty-two  operative  interference  for  removal  of  the  tumour 
was  contra-Lndicated.  Of  the  five  remaining  cases  he  considered  that 
in  two  the  success  of  an  operation  would  have  been  extremely  doubtful ; 
in  the  remaining  three  an  operation  might,  he  thought,  have  probably 
been  attended  with  success. 

But;  while  believing  that  there  are  comparatively  few  cases  in  which 
the  surgeon  can  hope  successfully  to  remove  ^  an  intracranial  growth,  Dr. 
Byrom  Bramwell  would  very  strongly  advocate  trephining  as  a  palhative 
measure  ^  in  many  of  these  cases.  "  Thus  in  not  a  few,  the  headache 
is  intense,  and  it  has  been  conclusively  shown  that  in  some  of  these  cases 
sudden  death  takes  place,  apparently  as  a  result  of  the  pain  and  resulting 
inhibition  of  the  heart,  a  point  to  which  Dr.  Hughlings  Jackson  has 
directed  attention.  Again,  in  other  cases  in  which  the  intracranial 
pressure  is -greatly  increased,  the  patient  dies  either  suddenly  in  an  epi- 
leptic fit,  or  gradually  as  a  result  of  failure  of  the  respiration.  Further, 
it  must  be  remembered  that  in  a  large  proportion  of  the  cases  of  intra- 
cranial tumour  the  optic  neuritis  is  intense,  and  that  in  not  a  few  of  them 
the  optic  neuritis,  if  allowed  to  contmue,  passes  on  to  optic  atrophy,  and 
produces  more  or  less,  and  it  may  be  complete,  blindness.  Now,  it  has 
been  conclusively  shown  that  in  some  cases'  in  which  the  operation  of 
trephining  has  been  performed  both  for  tumour  and  abscess,  the  optic 
neuritis  has  speedily  disappeared,  in  consequence,  I  beheve,  of  the  sudden 
rehef  of  the  increased  intracranial  pressure." 

It  will  thus  be  seen,  in  many  cases,  in  spite  of  the  aid  derived 
from  locahsation,  that  the  operation  must  be  exploratory.  The  surgeon 
will,  however,  so  plan  the  operation  that  in  the  event  of  the  impossibihty 
of  the  removal  of  the  growth,  he  can  proceed  to  the  paUiative  operation  of 
decompression  for  the  rehef  of  symptoms. 

These  are  the  opinions  of  two  well-known  physicians  in  this  country 
on  the  percentage  of  cerebral  growths  suitable  for  operation.     To  turn 

1  While  admitting  the  force  of  this  opinion  it  is  to  be  feared  that  if  surgeons  follow  Dr. 
BramweU's  advice  they  wUl  sometimes  find,  if  they  publish  the  results  of  their  eases  after 
carefuly  watching  them,  that  they  have  merely  substituted  one  cicatrix  for  another  (p.  273). 

2  Dr.  W.  J.  Taylor  has  published  an  account  (Ann.  of  Surg.,  1912,  vol.  Ivi.,  p.  55) 
on  the  end  results  of  63  cases  of  operative  treatment  of  cerebral  tumour  which  have 
been  under  his  personal  care  or  observation  extending  over  a  period  of  twenty-five  years. 
Of  the  63  cases  1  lived  for  twenty  years.  2  for  about  six  years,  while  all  the  others  died 
within  three  years  of  the  operation.  In  30  of  the  cases  the  tumour  was  localised  and 
was  found  at  "the  operation  :  in  14  of  these  the  tumour  was  completely  removed,  in  9  it 
was  partly  removed,  while  in  the  remaining  8  cysts  were  opened  and  drained.  Six  of 
the  cases  were  tumours  of  the  dura  mater  ;  of  these  3  died  withim  a  few  hours  of  haemor- 
rhage, one  was  alive  five  months  after  and  was  then  lost  sight  of,  another  died  with  a 
recurrence  after  108  days,  while  the  other  lived  for  twenty  years.  Eight  of  the  cases 
were  simple  cys-ts  of  which  6  recovered  from  the  operation  and  1  was  alive  five  and  a  half 
years  after.  The  operation  mortality  was  very  heavy,  6  of  the  patients  died  in  the  first 
five  days,  and  13  in  the  first  ten  days,  giving  an  operation  mortality  of  19  per  cent. 
Dr.  Taylor  describes  these  end  results"  as  "  very  bad  indeed."  In  many  of  the  33  cases 
in  which  the  tumour  was  not  found,  decompression  was  successful  in  relieving  the 
symptoms  for  a  variable  time.  A  paper  by  v.  Eiselsberg  (Wien.  Klin.  Woch.  1912,  p.  17), 
in  which  100  cases  are  analysed,  may  also' be  referred  to.  The  operation  ie  two  stages 
is  recommended. 

'  Palliative  measures  are  again  referred  to  at  p.  318. 


GROWTHS  OF  THE  BRAIN  301 

elsewhere,  Oppenheim  analysed  twenty-three  cases  observed  by  himself 
and  verified  by  necropsy.  Only  one  could  have  been  removed  by  opera- 
tion. Von  Bergmann  puts  the  percentage  of  suitable  cases  as  at  most 
6  to  7  per  cent.,  and,  with  very  few  exceptions,  would  limit  the  operation 
to  growths  of  the  motor  region  and  to  those  parts  of  the  brain  ad- 
joining it.  Having  spoken  in  general  terms  of  intracranial  growths, 
it  will  now  be  necessary  to  consider,  from  a  surgeon's  point  of  view,  the 
varieties  most  frequently  calUng  for  operation.  These  are  the  tuberculous, 
the  gliomata  and  sarcomata,  gummata,  and  cysts. 

Tuberculous  Tumours.  As  a  rule  these  should  only  be  attacked  when 
there  is  good  reason  to  believe  that  the  growths  are  primary  and  single. 
The  frequency  with  which  the_y  are  multiple  and  present  as  well  as 
elsewhere  is  alluded  to  above  (p.  298).  But  where  a  tuberculous  growth 
is  threatening  to  cause  blindness,  severe  headache,  constant  vomiting,  &c., 
it  should  be  explored,  and  removed  if  possible. 

Sir  V.  Horsley  ^  expressed  himself  as  strongly  in  favour  of  operation. 
Where  a  trial  of  medical  treatment  for  four  months,  fails,  such  tuberculous 
nodules  are  probably  densely  fibrous  with  caseous  centres.  Age,  no 
doubt,  has  an  important  effect  here.  Thus,  in  a  child,  owing  to  the 
yielding  skull,  the  presence  of  a  tuberculous  mass  may  be  long  un- 
suspected. 

Ransohoff,  of  Cincinnati,  whose  personal  experience  is  considerable, 
as  he  has  operated  on  eight  cases  of  cerebral  growths,  reports  his  two 
successes  with  very  instructive  comments.^  The  nature  of  the  growth 
in  the  first  case  is  not  stated.  The  second  case,  stated  to  have  been 
a  solitary  tuberculous  deposit,  was  operated  on  in  two  stages. 

At  the  first  operation  an  opening  three  and  a  half  inches  long  and  three  inches 
wide  was  made.  When  thi'ee  days  later  the  dui-a,  which  pulsated  feebly,  was 
opened  no  growth  was  found.  The  patient  was  now  placed  in  the  sitting  position — 
local  anaesthesia  being  now  employed — a  step  which  caused  the  brain  to  recede 
and  allow  of  palpation  far  beyond  the  limits  of  the  cranial  opening.  The  growth 
was  found  half  an  inch  below  the  surface  in  the  ascending  frontal  convolution,  and 
was  easily  removed.  Thi-ee  and  a  half  months  after  the  operation  the  patient  had 
had  no  convulsions,  but  a  decided  weakness  of  the  flexors  of  the  thumb,  index  and 
middle  fingers  remained.  In  tins  case  the  general  symptoms  of  brain  growths 
(headache,  choked  discs,  and  optic  neuritis)  were  absent,  the  symptoms  being 
altogether  focal.  This  is  explained  by  the  fact  that  when  the  growth  was  removed 
it  displaced  12  grammes  of  water,  a  pressure  to  which  the  brain  accommodates 
itself.  With  the  develoi)ment  of  symptoms  of  intracranial  pressure  the  value  of 
focal  symptoms  decreases.  This  explains  the  frequency  of  failure  to  find  a  growth 
when  seemingly  umnistakable  localiumg  symptoms  are  present. 

Ransohoff  points  out  that  in  two-stage  operations  the  second  one  can 
be  done  satisfactorily  mider  local  anaesthesia.  If  it  be  needful  to  cut 
away  more  bone,  chloroform  must  be  administered.  He  thinks  that 
adoption  of  the  two-stage  method  will  diminish  the  very  high  mortahty. 
This,  due  chiefly  to  shock  and  haemorrhage,  is  stated  by  Haas,  from  an 
examination  of  122  operations  for  removal  of  growths,  to  be  as  high  as 
61  per  cent.  Ransohoff  beheves  that  tuberculous  deposits  in  the  brain 
are  tw^ce  as  common  as  any  other  tumours. 

He  quotes  from  a  paper  by  Preyer,  who  ^  collected  the  cases  operated  on  up  to 
that  time,  sixteen  in  number  ;  Ransohoff's  case  and  one  of  Heidenhain  made  eighteen. 
Three  died  from  the  operation  ;  six  survived  several  months,  two  several  years  ; 
one  of  Czerny's  lived  four  years  and  two  months,  one  of  Sir  V.  Horsley's  seven  years 

1  Brit.  Med.  Journ.,  1893,  vol.  ii,  p.  1365. 

2  Journ.  Amer.  Med.  Assn.,  October  11,  1902. 
^  Rev.  Med.  de  la  Suisse,  May  and  June  1900. 


302  OPERATIONS  ON  THE  HEAD  AND  NECK 

and  eight  months,  dying  then  of  tuberculous  disease  of  the  spine ;  one  operated  on 
by  Kronlein  was  believed  to  be  alive,  six  years  after  operation. 

Von  Bergmannsome  years  ago  opposed  operations  on  tuberculous  deposits  in  the 
brain  on  the  grounds,  chiefly,  of  the  risk  of  setting  up  tuberculous  meningitis  and 
the  great  difficulties  of  enucleating  such  a  deposit  here,  compared  with  one  in 
the  skin  or  bones.  He  "  has  reported  twelve  cases  of  cerebral  tuberculosis  treated 
operatively.  In  seven  of  these  the  central  convolutions  were  affected  ;  in  four 
the  cerebellum.  In  one,  in  addition  to  disseminated  tuberculosis  of  the  pia,  there 
was  an  affection  of  the  parietal  lobe.  Of  the  seven  cases  with  affection  of  the 
motor  region  thi'ee  were  cured,  two  died  from  the  effects  of  the  operation,  and  two 
from  an  extension  of  the  tuberculosis.  The  five  cases  of  affection  of  the  cerebellum 
all  terminated  fatally,  three  immediately  after  the  operation.  In  eight  cases  the 
tubercles  were  not  completely  removed,  and  in  each  case  death  rapidly  ensued." 

Caseating  foci  in  the  cerebellum,  owing  to  their  comparative  frequency, 
need  especial  allusion.  The  very  high  mortahty  of  Von  Bergmann's 
results — himself  one  of  the  chief  pioneers  on  cerebral  surery — and 
the  cases  alluded  to  below  make  it  extremely  doubtful  if  it  is  justifiable 
to  continue  attacks  on  tuberculous  deposits  in  this  situation  (p.  322). 

Sir  V.  Horsley  ^  has  removed  a  tuberculous  growth  from  the  right  lobe 
of  the  cerebellum. 

Death  took  place  nineteen  hours  later,  the  patient  having  only  partially  recovered 
consciousness.  Generalised  chronic  tubercle  was  found  in  the  viscera.  The  opera- 
tion was  here  performed  as  a  last  resource. 

Mr.  Bennett  May  -  removed  a  similar  growth  from  the  right  lobe  of 
the  cerebellum  of  a  child. 

The  extreme  bulging  of  the  dura  mater  gave  evidence  of  great  intracranial 
pressvire.  The  cortex  appeared  quite  healthy,  but  at  one  spot  palpation  gave  an 
ill-defined  feeling  of  hardness.  This  spot  being  incised,  the  finger  detected  a  hard 
mass  nearly  an  inch  below  the  surface.  This  was  dug  out  with  the  handle  of  a 
small  teaspoon.  It  was  larger  than  a  pigeon's  egg,  hard  and  horny  outside  and 
caseating  in  the  centre.  The  haemorrhage  was  trifling,  but  the  patient  sank  from 
shock  a  few  hours  later.     No  necropsy  was  permitted. 

Mr.  Waterhouse  ^  mentions  with  helpful  candour  three  cases  in  which 
he  had  operated  upon  tuberculous  tumours  of  the  brain.  In  none  was  the 
tumour  single.  Two  cases  died  -^ithin  forty-eight  hom's  of  the  operation, 
while  in  the  third  partial  recovery  for  four  months  ensued,  followed  by 
death,  due  to  another  tuberculous  growth. 

Gliomata  and  Sarcomata.  As  several  cases  are  referred  to,  some  fully, 
in  these  pages,  and  as  the  important  questions  of  appearance  and  in- 
filtration are  dealt  with  in  the  section  on  "Operations  on  the  Brain" 
(p.  321),  I  shall  only  refer  to  one  more  instance  of  these  growths.  It  vnU  be 
found  reported  by  Dr.  C.  K.  Mills  ;  ^  the  following  epitome  is  given  in  the 
British  Medical  Journal,  Jan.  24,  1903,  p.  13.  It  contains  two  special 
points  of  interest  :  (1)  the  use,  successfully,  of  the  Rontgen  rays,  as  a 
means  of  diagnosis,  and  (2)  the  means  adapted  for  meeting  the  haemor- 
rhage. 

The  patient,  a  girl  aged  21,  had  had  symptoms  for  tlu-ee  years,  andpresented 
all  the  classical  phenomena — oj^tic  neiu-itis,  headache,  vomiting,  &c.,  together  with 
left  hemiparesis.  Skiagraphy  showed  an  abnormal  shadow  of  about  tlu'ee  inches 
in  diameter  and  irregular  in  outline,  hing  directly  upon  the  Rolandic  area.  Over 
its  anterior  portion  the  middle  meningeal  and  its  branches  ran,  and  the  inner  table 
of  the  skull  was  seen  to  be  disorganised  over  the  region  of  the  growth.  The  central 
fissm-e  ha\ing  been  localised,  the  cranium  was  opened  by  Stellwagen's  trephine 

1  Brit.  Med.  Journ.,  April  1887.  ^  Lancet,  April  16,  1887. 

'  Brit.  Jled.  Journ.,  October  1,  1898,  p.  968 
*  Phila.  Med.  Journ.,  September  27,  1902. 


GROWTHS  OF  THE  RRAIN  .303 

(Fig.  135),  but  tlio  lui'morrhage  was  so  sevens  that  tlu;  wound  had  to  be  packed, 
and  further  .stei)s  postponed.  The  jiatient  rallied  well,  and  at  the  second  o])eration 
owinj;  to  the  severe  lueniorrhage  before,  both  eoiniuon  carotids  were  clamped  by 
Crile\s  method.'  An  encapsuled  ovoid  growth,  three  inches  in  length,  wliich  proved 
to  be  a  s])indle-cell  sarcoma,  was  discovered  and  removed  with  hardly  any  bleeding. 
The  i)atient  tlied  in  a  few  hours  from  post-operative  shock. 

Gummata.  Some  have  expressed  the  opinion  that  here  surgical  inter- 
ference is  uncalled  for.  While  no  one  will  operate  on  a  gumma  of  the 
brain  till  a  sufficient  trial  has  been  given  to  mercury  and  potassium 
iodide,'  or  possibly  an  injection  of  salvarsan,  there  is  no  doubt  whatever 
that  a  syphilitic  lesion  may  reach  a  stage  here,  e.g.  from  its  density,  as 
elsewhere,  in  which  it  has  quite  got  beyond  the  reach  of  specific  remedies. 
Such  a  lesion,  if  localisuble  and  to  be  got  at,  should  be  attacked,  because, 
if  left  alone,  it  will  go  on  causing  trouble  indefinitely,  and  further  the 
compression  and  wasting  of  adjacent  nerve  tissue  which  it  will  set  up 
will  in  time  become  irreparable.  On  this  point  the  remarks  of  Dr. 
Byrom  Bramwell  (p.  299)  bear  strongly. 

Sir  V.  Horsley,  who  is  of  opinion  ^  that  cerebral  gunmiata  are  not 
really  cured  by  drugs,  would  certainly  limit  the  trial  of  drugs  to  two 
months.  He  holds  that  gummata  are  here  incurable,  because  there  is 
always  a  certain  degree  of  pachymeningitis  around  them,  and  that  this 
is  inevitably  progressive. 

One  of  the  most  interesting  instances  of  operation  in  these  cases  is  one 
of  Sir  W.  Macewen's.^ 

In  a  woman,  aged  25,  there  was  left-sided  motor  monoplegia  of  arm  and  leg, 
preceded  by  muscular  twitchings  and  tingling  sensations,  without  loss  of  sensation, 
due  to  syphilis,  which  resisted  prolonged  treatment.  A  cortical  lesion  of  the  right 
motor  area,  in  the  upper  half  of  the  ascending  frontal  and  parietal  convolutions, 
with  probable  involvement  of  the  paracentral  lobule,  was  diagnosed.  A  crown  of  bone 
over  an  inch  in  diameter,  with  its  anterior  border  reaching  to  a  point  about  half 
an  inch  behind  the  auriculo-bregmatic  line,  and  its  uj^per  margin  reacliing  to  within 
half  an  inch  from  the  centre  of  the  superior  longitudinal  sinus,  was  removed.  Its 
inner  sm-face  showed  osteophytes.  The  dura  mater  was  tliickened  and  rough. 
Crucial  flaps  of  this  being  reflected,  a  yellowish  opaque  effusion  covered  the  brain, 
obscuring  the  convolutions  and  bridging  the  fissure  of  Rolando.  This  was  very 
friable  and  came  away  in  minute  portions.  Towards  the  upper  part  of  the  opening 
the  brain  offered  resistance  on  palpation.  This  sensation  jjroceeded  from  the 
interior  of  the  brain,  in  the  direction  of  the  paracentral  lobule,  a  layer  of  brain 
tissue  intervening  between  this  more  resistant  structure  and  the  finger.  An  incision 
being  made  tlirough  the  upper  part  of  the  ascending  parietal  towards  this  firm 
structure,  about  two  drachms  of  grumous  fluid  escaped.  The  resistance  now  dis- 
appeared, and  cerebral  pulsation  was  for  the  first  time  feebly  perceptible.  The 
patient  made  a  good  recovery,  and  regained  sufficient  power  over  the  left  side  to 
enable  her  to  walk  two  miles,  and  to  do  her  household  work. 

Mr.  Waterhouse  ^  mentioned  an  interesting  case  of  intracranial 
gumma,  in  which,  in  spite  of  the  administration  of  potassium  iodide  and 
mercury  for  four  weeks,  and  then  potassium  iodide  in  doses  of  30  gr.  t.d. 
for  a  further  period  of  five  weeks,  the  symptoms  steadily  increased. 
The  patient  became  hemiplegic,  then  comatose.     A  large  gurmna  was 

^  This  is  described,  together  with  other  methods  of  temporary  closure  of  the  common 
carotids,  q.v. 

^  The  American  method  of  pushing  this  drug  in  large  doses  at  frequent  intervals,  in 
milk  [Arch,  of  Medicine,  New  York,  October  1884),  is  especially  applicable  here.  A 
warning  is  needed  now.  ^\'hether  this  drug  be  used  for  gummata  or  in  uncertain  cases, 
its  lowering  effects  must  always  be  remembered.  Some  daj's  should  always  be  allowed 
to  elapse  between  the  discontinuing  of  the  drug  and  the  operation,  otherwise  the  shock 
of  a  severe  operation  will  be  ncedlesslv  increased. 

*  Brit.  Med.  Journ.,  1893,  vol.  ii,  p.  1365. 

*  Lancet,  May  23,  1885.  ^  Loc.  supra,  cit. 


304  OPERATIONS  ON  THE  HEAD  AND  NECK 

removed  "  from  the  left  area  of  Rolando."     Recovery  was  rapid  and 
complete. 

A  case  of  gmnma  and  localised  meningitis  of  the  motor  region  success- 
fully operated  upon  will  be  found  reported  by  Dr.  C.  K.  Mills.^ 

The  patient,  aged  27,  had  been  twice  previou.sly  treated  with  success  by  large 
doses  of  pota.ssium  iodide.  On  his  third  admission  the  prominent  sjTnptoms  were 
extreme  pain  in  the  left  parietal  region,  frequent  spasmodic  seizures  of  right 
upper  and,  later,  of  right  lower  limb  and  right  side  of  face.  When  the  bone- 
flap  was  turned  back — vStellwagen's  trephine  was  used — the  dura  was  adherent 
to  the  skull  over  a  considerable  portion  of  the  bone-flap  which  had  to  be  pulled 
away  from  the  membrane.  The  latter  was,  in  places,  four  or  five  times  thicker 
than  normal.  The  dura,  pia  and  arachnoid  were  ahherent  to  each  other  and  to 
an  oblong  flat  mass,  which  corresponded  almost  exactly  in  its  dimensions  to  the 
shadow  furnished  by  the  Rontgen  rays.  As  it  was  impossible  to  dissect  the  mem- 
branes from  the  mass  beneath,  it  was  decided  to  remove  them  altogether.  This 
was  done  with  but  little  disturbance  of  the  brain  tissue.  To  replace  the  removed 
dura,  advantage  was  taken  of  a  suggestion  by  Prof.  Keen,  and  an  incision  made  in 
the  scalp  outside  of  the  line  of  the  main  opening.  The  scalp  was  turned  back, 
and  a  piece  of  the  pericranium  dissected  loose  and  inserted  into  the  opening  left 
by  removal  of  the  dura.  This  piece  of  pericranium  was  turned  upside  down,  so 
that  the  osteogenetic  surface  would  be  away  from  the  brain  and  not  next  to  it. 
The  last  note  of  this  case,  four  weeks  after  the  operation,  runs  as  follows  :  "  The 
patient  had  made  a  j)erfect  surgical  recovery ;  his  headache  and  epilepsy  have 
disappeared." 

Cysts.  There  are  three  separate  conditions  under  which  these 
tumours  especially  occur,  (i)  One  is  in  the  cerebellum,  particularly  in 
childhood,  and  affords  the  only  hopeful  outlook  for  operations  at  this  early 
age.  Sir  James  Goodhart  ^  says  that  cysts,  "  although  not  common, 
should  be  kept  in  mind.  I  must  have  seen  some  five  or  six  cases,  and  one 
can  never  see  a  fatal  ending  in  such  as  these  without  regretting  that 
surgery  was  not  allowed  to  attempt  a  cure."  (ii)  Cysts  may  also  occur 
after  injury  over  the  motor  area,  as  in  the  following  case  :  ^ 

A  man,  aged  22,  had  eijileptiform  convulsions,  each  lasting  from  two  to  three 
minutes,  with  an  average  of  over  one  hundred  in  twenty-four  hours.  The  con- 
vulsions were  limited  to  the  tongue,  right  facial  muscles,  and  platysma.  When 
they  subsided  the  parts  remained  paralysed.  Consciousness  was  retained.  Eight 
years  previously  he  received  an  injury  to  the  head,  after  which  his  right  arm 
became  weak,  though  he  was  able  to  work.  It  was  clear  that  an  irritating  focal 
lesion  existed,  confined  to  the  base  of  the  ascending  convolutions,  causing  a 
Jacksonian  epilepsy.  At  the  operation,  in  the  lower  part  of  the  ascending  frontal  a 
cyst  about  the  size  of  a  filbert  was  found,  situated  partly  in  the  cortical  and  partly 
in  the  white  substance  of  the  brain,  surrounded  by  a  narrow  zone  of  encephalitis. 
In  manipulating  the  medullary  substance  dm-ing  the  removal  of  the  cyst,  the  patient 
while  under  chloroform  had  a  convulsion  similar  to  those  prior  to  the  operation. 
The  convulsion  ceased  with  the  removal  of  the  cyst,  and  he  never  had  another. 
The  wound  healed  firmly  under  one  dressing,  the  paralysis  of  the  facial  muscles 
soon  disappeared,  and  the  patient  has  since  been  constantly  at  work.  The  power 
of  the  right  arm  has  also  increased.  Possibly  the  cyst  might  have  caiLsed,  indirectly, 
slight  pressure  on,  or  had  set  up  inhibitory  action  of,  the  middle  part  of  the. 
ascending  frontal. 

Allusion  has  already  been  made  (p.  275)  to  the  difficulty  which  is 
sometimes  met  with  in  securing  the  obhteration  of  these  cysts,  and  the 
need,  here,  of  frequently  prolonged  drainage,  (iii)  While  the  two  forms 
of  cvsts  mentioned  above  are  those  most  frequently  met  with,  the  surgeon 
mus't  be  prepared  to  meet  with  a  third  in  which  the  cyst  is  associated 
wdth  a  new  growth.     Such  a  case  has  been  reported  by  Mr.  Ballance.^ 

1  Philn.  2Ied.  Journ.,  November  29,  1902.  ^  Diseases  of  Children. 

3  Macewen,  Brit.  Med.  Journ.,  Augxist  11,  1890. 
*  Trans.  Med.  Chir.  Soc,  March  1896. 


GROWTHS  OF  THE  JUIAIN  ;3()5 

A  lioy,  aged  1 1,  liad,  six  moiitlis  bi-foro  adiiiissioii,  received  a  severe  Mow  on  tlio 
head.  Fits,  eoinmeiiein<^  witii  twitehiiig  of  the  riglit  angle  of  the  mouth,  were 
followed  by  paralysis  of  llie  right  side  of  the  faee,  and  right  extremities.  November 
1891).  The  lower  part  of  the  left  motor  area  having  been  exposed,  a  large  subcortical 
cyst,  lying  tmder  a])parentiy  normal  brain  tissue,  was  found  and  evacuated. 
February  ISid. — As  the  symj)toms  returned,  a  tube  was  passed  into  the  cyst,  in 
order  to  drain  it  continuously.  'I'he  symptoms  then  in  most  ])arl  disaj)|)eared,  and 
the  boy  remaineil  in  fairly  good  health  until  January  ]S9:{,  when  his  condition  rather 
suddenly  became  exceedingly  grave.  At  a  third  operation  a  growth  three  ounces 
in  weight  was  removed  from  between  the  dura  and  tlu;  left  motor  cortex.  The 
boy  left  the  hospital  quite  well  save  for  a  slight  right  liemi|)legia.  June  1893.  He 
was  readmitted  in  September  1893  in  an  almost  moribund  condition,  and  died  a 
few  hours  after  another  attem[)t  to  relieve  the  symptoms  of  pressure.  At  the 
necropsy  an  enormous  growth  was  found  in  the  left  cerel)ral  hemisphere. 

If  it  is  right  to  say  that  cerebral  surgery  has  not  done  as  much  as 
was  expected  of  it  fifteen  years  ago,  and  that  surgeons  no  longer  attack 
cerebral  growths  with  the  enthusiasm  and  frequency  of  that  time^ 
this  proves  that  the  enthusiasm  was  not  based  on  careful  and  reliable 
reasoning,  that  operations  for  cerebral  growths  were  performed  without 
sufficient  discrimination,  and  that  the  risks  inseparable  from  this  path 
in  surgery  were  under-estimated — surgeons  forgetting  that  while  aseptic 
surgery  had  removed  certain  risks,  others,  especially  shock  and  collapse, 
remained  inseparable  from  the  pectiliar  vitality  of  the  part  attacked.  Any 
candid  surgeon,  acquainted  with  the  history  and  progress  of  his  profession, 
will  allow  that  in  two  directions  the  progress  of  modern  surgery  has 
been  less  brilliant  than  might  have  been  expected  when  its  other  triumpha 
are  considered.  The  two  referred  to  are  :  removal  of  cerebral  growths 
compared  with  the  other  advances  of  cranial  surgery,  the  surgery  of  the 
intra-thoracic  viscera.  The  explanation  of  this  is  not  far  to  seek.  It 
lies  in  the  fact,  to  which  due  weight  has  not  been  attached,  that  all  the 
organs  here  concerned  are  peculiarly  vital  structures,  and  that,  however 
great  advances  may  be  made,  this  fact  will  remain  unchanged. 

Reference  to  the  discussion  on  the  "  Treatment  of  Intracranial 
Tumoiu's,"  introduced  by  Sir  D.  Ferrier  in  a  speech  of  great  ability,^  in 
which  he  put  the  question  of  operation  in  the  most  favourable  light  possible, 
will  support  the  above  conclusions.  Sir  D.  Ferrier  mentioned,  briefly,  two 
cases  in  which  the  patients  had  survived  the  operation  two  years  or  more. 
Two  surgeons  only  took  part  in  the  discussion,  and  two  more  successful 
cases  of  removal  of  cerebral  growths  were  mentioned,  but  so  briefly  as 
to  be  of  little  value. 

Dr.  Byrom  Bramwell,  the  president  of  the  section  before  which  the 
paper  was  read,  stated  that  his  "  experience  in  regard  to  the  success  of 
operative  procedure  differed  notably  from  that  of  Prof.  Ferrier,  for  in  none 
of  his  fourteen  cases  in  which  an  operation  had  been  performed  had  a 
tumour  been  successfully  removed  by  the  surgeon.  The  additional 
experience  of  the  past  few  years  had  entirely  confirmed  the  conclusions 
which  he  had  published  in  the  Edinburgh  MedicalJournal  four  years  ago." 
Speaking  of  the  proportion  of  operable  cerebral  tumours,  Sir  D.  Ferrier 
•considered  it  a  fair  estimate  to  say  that  only  7  per  cent,  of  cerebral  tumours 
are  capable  of  being  surgically  dealt  with.  As  to  the  recent  statistics 
of  the  results  of  operation,  he  considered  that  when  cases  were  collected 
from*  all  sources,  and  therefore  containing  many  factors  not  strictly 
-comparable  with  each  other — of  which  one,  the  personal  equation  of  the 
.operator,  is  exceedingly  variable — such  a  collection  of  cases  gave  13  per 

1  Brit.  Med.  Journ.,  October  1,  1898. 
SURGERY  I  20 


306  OPERATIONS  ON  THE  HEAD  AND  NECK 

cent,  of  complete  recoveries,  i.e.  the  patients  were  alive  at  least  a  vear, 
and  in  some  cases  several  years,  after  the  operation.  Turning  to  the 
cases  at  the  National  Hospital  for  the  Paralysed  and  Epileptic,  where  the 
operations  were  performed  by  Sir  Victor  Horsley  and  Mr.  Ballance,  men 
of  special  skill  in  this  branch  of  surgery.  Sir  D.  Ferrier  pointed  out  that 
the  cases  operated  on  gave  a  percentage  of  16-6  of  complete  recovery. 

Two  well-known  authorities  on  growths  of  the  brain,  Dr.  Beevor  and 
Mr.  Ballance,  thus  reply  to  the  question,  "  What  do  patients  suffering 
from  tumours  of  the  brain  gain  from  surgery  ?  "  ^  "  It  appears  to  us  that 
in  the  several  following  ways  enormous  benefit  may  be  given  by  operation  : 

"  (I)  The  complete  removal  of  a  tumour,  as  in  Sir  V.  Horsley's  case,  of 
a  small  tuberculous  mass  occupying  the  cortex  in  the  region  corresponding 
to  movements  of  the  thumb. 

"  This  patient,  a  man  aged  20,  suffered  from  frequent  local  fits,  be- 
ginning in  the  thumb  and  forefinger,  and  from  headache.  From  theye 
symptoms  he  was  completely  relieved  by  removal  of  the  tumour  and  part 
of  the  cortex. 2 

"  (2)  Partial  removal  of  the  tumour,  as  was  probably  done  in  the 
case  on  which  the  paper  was  founded. 

"  The  02:)eration  on  this  patient  relieved  her  of  headache,  vomiting,  double  o])tic 
neuritis,  and  from  the  greater  part  of  her  paralysis.  The  mental  condition,  which 
was  very  much  deteriorated,  was  restored,  the  patient  regaining  her  former  cheerful 
condition. 

"  (3)  The  drainage  of  a  cavity  in  a  cerebral  glioma  or  sarcoma  which 
cannot  be  removed.  This  is  well  illustrated  by  a  case  under  the  care  of 
Sir  W.  Gowers  and  Mr.  Ballance. 

"The  patient,  aged  11,  suffered  from  headache,  vomiting,  double  optic  neuritis, 
fits  beginning  in  the  thumb  and  followed  by  hemiplegia,  and  was  practically  relieved 
of  all  his  symptoms,  including  moral  deterioration  (stealing),  by  this  procedure. 
He  lived  for  three  years. 

"  (4)  The  removal  of  bone  and  incision  of  the  dura  mater.  The  benefit 
resulting  from  this  operation  is  well  shown  by  a  case  which  was  under 
the  care  of  Dr.  Buzzard  and  Mr.  Ballance. 

"A  woman,  aged  41,  was  admitted  with  symptoms  pointing  to  tumour  of  the 
internal  capsule,  viz.  hemiana?sthesia.  nearly  complete  hemiplegia,  double  optic 
neuritis  with  failing  sight,  and  severe  headache  with  agonising  paroxysms.  In  (me 
of  these  paroxysms  she  became  comatose,  and  was  evidently  dying,  it  was  thought, 
from  haemorrhage  into  the  tumour.  The  above  operation  was  at  once  performed, 
and  the  relief  of  the  urgent  symptoms  was  immediale  ;  and  in  a  month's  time  the 
report  states  that  there  was  no  headache,  vomiting,  or  optic  nem-itis,  and  some 
return  of  jjower  and  sensation  had  already  occurred,  with  improvement  of  sight  and 
restored  mental  condition. 

"  (5)  Removal  of  a  considerable  area  of  bone  without  opening  the  dura 
mater  is,  we  believe,  considered  by  some  to  be  adequate  to  relieve  the 
classical  symptoms  of  tumour.  It  is  true  that  the  dura,  bulging  through 
the  opening  in  the  skull,  indicates  that  there  is  a  relief  of  pressure,  but 
what  we  have  to  deal  with  is  tension  within  a  practically  inelastic  mem- 
brane, and  the  intra-dural  space  can  hardly  be  materially  increased  while 
the  dura  is  intact,  and  the  opening  in  the  skull  is  comparatively  small. 
The  sac  of  the  dura  cannot  be  distended  to  its  full  extent  while  the  cranium 
is  intact,  and  so  when  bone  is  removed  its  foldings  are  flattened  out.  A 
considerable  fall  in  pressure  can  only  be  obtained  by  taking  away  a  large 
area  of  bone,  and  in  tumour  cases  when  this  is  done  the  dura  still  bulges 

1  Brit.  Med.  Journ.,  1835,  vol.  i,  p.  8.  ^  ^rit.  Med.  Journ.,  1887. 


GROWTHS  OF  THE  BRAIN  807 

uiuler  much  increased  pressure.  As  we  have  known  of  no  case  in  which 
the  removal  of  bone  alone  has  relieved  the  pressure  symptoms,  we  should 
advise  that  the  dura  should  always  be  opened  ;  another  reason  of  great 
import  being  that  the  cortex  might  be  involved  without  any  of  the  typical 
signs  being  present.  .  .  . 

"  (0)  We  would  conclude  this  paper  with  the  question,  '  How  soon 
should  one  of  the  preceding  operations  be  performed  ?  '  When  the  type 
symptoms  are  present,  it  is  quite  certain  that  no  delay  is  desirable  after  a 
fair  trial  has  been  given  to  antisyphilitic  remedies,  and  we  should  limit 
this  time  to  six  weeks  or  two  months.^  The  main  difficulty  arises  when 
the  symptoms  are  not  typical  ;  and  it  is  to  be  borne  in  mind  that  large 
slowlv-growing  tumours  may  be  present  without  any  symptoms  which  are 
unequivocal.  As  an  instance  of  this  a  case  may  be  referred  to  which  was 
under  the  case  of  Sir  V.  Horsley  and  Dr.  Beevor.  The  patient  had 
occasional  fits,  beginning  in  the  corner  of  the  mouth,  with  unconsciousness, 
six  years  before  other  symptoms  arose  which  justified  operation,  and  then 
the  tumour  was  found  to  be  so  situated  that  it  could  not  be  removed 
without  producing  aphasia.  It  would  be  easy  to  mention  other  cases 
illustrating  the  same  point.  In  any  case  where  the  typical  signs  of 
tumour  are  absent,  and  where  the  fits  always  begin  with  the  same  localised 
warning,  and  are  attended  with  loss  of  consciousness,  the  question  is, 
'  Are  these  fits  due  to  idiopathic  epilepsy,  or  are  they  due  to  a  tumour  ?  ' 
And  we  should  say  that  no  operation  is  advisable,  other  signs  of  tumour- 
being  absent,  unless  the  paralysis  which  follows  the  fits  is  permanent — 
that  is,  not  recovered  from  in  the  course  of  a  few  days — or  unless  the  fits 
occur  very  frequently.  While  it  is  impossible  to  lay  down  absolute  rules 
for  the  treatment  of  these  cases,  it  would  appear  that  occasional  fits,  be- 
ginning locally,  followed  by  loss  of  consciousness,  and  attended  only  by 
headache,  would  not  justify  an  operation  ;  but  that  any  other  combina- 
tion of  the  type  symptoms — headache,  purposeless  vomiting,  optic 
neuritis,  especially  with  failing  sight,  localised  fits,  and  permanent 
paralysis — would  render  surgical  operation  advisable." 

We  come  now  to  the  last  of  the  questions  which  arise  before  an  oj)era- 
tion  on  a  growth  of  the  brain  :  (F)  The  conditions  which  justify  operative 
interference,  and  the  probable  results  of  this  step.  These  may  be 
summed  up  as  follows  : 

(1)  That  as  the  most  benign  growths  have  proved  ultimately  fatal, 
operations  are  justifiable  under  certain  conditions.  But  (2)  for  the  re- 
moval of  the  growth  the  site  of  the  growth  must  be  known.  At  present, 
if  locahsation  be  impossible,  only  a  palliative  operation  should  be  at- 
tempted. The  cases  collected  for  Von  Bergmann  show  this  clearly.  In 
one  group,  116  cases,  an  accurate  diagnosis  was  possible  ;  in  all  the 
growth  was  removed,  and  in  only  7  per  cent,  was  the  operation  fatal. 
In  the  second  group,  257  cases,  the  diagnosis  was  imperfect,  and  50  per 
cent,  died  as  a  direct  result  of  the  operation.  At  present  growths  of  the 
motor  area  are  the  ones  which  most  clearly  justify  attacks.  Operations 
for  the  removal  of  growths  of  the  cerebellum,  except  in  the  case  of  cysts, 
are  rarely  hkely  to  be  successful  (pp.  275,  304). 

(3)  The  growths  which  are  most  favourable  for  operation  are  fibromata, 
encapsuled  sarcomata,  and  gummata.  (4)  The  operation  should  be  under- 
taken at  an  earUer  stage  than  has  hitherto  been  the  case,  before  the 
patient  is  weakened  by  headache,  vomiting,  a  long  course  of  potassium 
1  Sir  V.  Horsley,  Brit.  Med.  Journ.,  1893. 


308  OPERATIONS  ON  THE  HEAD  AND  NECK 

iodide,  &c.  (5)  As  a  large  opening  in  the  skull  is  absolutely  necessary, 
the  operation  should  usually  be  performed  in  two  stages. ^  (6)  PalUative 
trephinings  have  been  shown  to  be  thoroughly  justified  (pp.  300, 
306).  This  step,  if  not  deferred  till  too  late,  may  be  trusted  to  remove 
for  a  time  the  headache  and  vomiting,  to  arrest  the  optic  neuritis  which 
will  go  on  to  bhndness,  and  to  diminish,  but  probably  not  to  arrest 
entirely,  the  epileptiform  con\^lsions.  The  following  case  recorded  by 
Sir  A.  Pearce  Gould,  shows  that  where  a  growth  has  been  localised,  but 
has  not  been  found,  and  where  its  complete  removal  has  not  been 
possible,  the  symptoms  have  been  materially  relieved  by  the  relief  given 
to  the  pressure. 

The  patient,  aged  41,  had,  six  weeks  before,  suffered  from  severe  headache  without 
vomiting,  followed  by  aphasia,  right  facial  paralysis,  and  stu]K)r  deepening  into 
coma  (February  7,  1897).  A  two-inch  trephine  was  used  over  the  left  face  centre. 
When  the  dura  mater,  wliich  bulged  into  the  wound  without  pulsating,  was  divided 
the  brain  bulged  still  more.  Puncture  of  this  with  a  director  in  two  or  three 
directions  proved  negative.  Four  days  after  the  operation  the  brain  had  receded 
below  the  trephine  opening,  over  which  the  scalj)  had  been  replaced  ;  three  days 
later  the  patient  was  quite  conscious  and  had  lost  his  headache,  paratysis,  twitchings 
and  aphasia.  He  was  able  to  resume  work  in  four  months,  but  it  was  noted  that 
six  epileptiform  fits  had  occurred  :  otherwise  the  health  was  good.  The  patient 
was  able  to  earn  his  living  as  a  market  gardener,  though  still  liable  to  epileptic 
tits,  during  one  of  which  he  was  drowned  in  1903.  There  was  no  necroj^sy.  It  will 
be  noted  that,  in  this  ca.se,  in  addition  to  the  trepliining,  the  dura  m^ter  was  opened. 

Sir  D.  Ferrier  ad\^sed,  if  no  guide  to  the  site  of  the  trephining  be 
present,  that  the  palhative  opening  be  made  freely  over  the  occipital 
or  frontal  region.  A  free  opening  may  lead  to  the  appearance  of  a  hernia 
cerebri ;  this  must  be  treated  by  careful  pressure  and  the  strictest  asepsis  : 
of  the  other  palhative  measures,  drainage  of  the  lateral  ventricles  and 
lumbar  punpture.  it  must  suffice  to  say  that  our  knowledge  is,  at  present, 
scanty.  As  to  the  actual  results,  even  in  the  cases  where  the  growth  has 
been  successfully  removed,  complete  recovery  is  the  exception.  The  hfe 
of  the  patient  is  prolonged,  and  the  pressure  symptoms,  headache,  &c., 
are  cured,  but  the  epileptiform  seizures  are  only  diminished,  though  often 
markedly  so.  Much  the  same  may  be  said  of  the  paralysis  in  many 
cases. 

OPERATIVE   PROCEDURES    ON    THE   BRAIN.    CHIEFLY   FOR   THE 
REMOVAL  OR  THE  PALLIATIVE  TREATMENT  OF  GROWTHS 

Preparation  of  the  patient.  The  day  before  the  operation  the  patient's 
head  is  shaved  and  thoroughly  cleansed  according  to  one  of  the  methods 
described  on  p.  16.  The  patient  has  the  usual  purgative  administered 
the  evening  before,  followed  by  an  enema  on  the  morning  of  the  operation. 
Anv  course  of  iodides  or  bromides  should  be  suspended  for  at  least  a  week 
before  the  operation. 

Marking  out  the  position  of  the  lesion  and  the  flap.  Great  attention 
must  be  paid  to  the  exact  localisation,  and  this  step  should  not  be  left 
imtil  just  before  the  operation.  Dr.  C.  K.  Mills,  a  well-known  American 
neurologist,  whose  papers  are  always  practical  and  lucid,  emphasises  the 
following  from  an  experience  of  twenty-two  cases  in  which  operations  were 
performed  for  new  growths.  "  A  mistake  of  less  than  one  inch  in  locating 
the  fissure  of  Rolando  or  the  height  of  the  horizontal  branch  of  the  Sylvian 
1  Dr.  Howard  Lilienthal  has  ixiblished  a  paper  {Ann.  Surg.,  1910.  vol.  li,  p.  30)  on 
"Operations  in  two  .stages"  in  which  the  advantages  of  this  procedure  in  a  number  of 
other  conditions,  in  addition  to  intracranial  disease,  are  insisted  upon. 


OPERATIONS  ON  THE  BRAIN  309 

fissure,  may  add  considerably  to  tlie  uncertainties  and  difficulties  in  an 
attempt  at  removal  by  makinfi;  the  opening  so  as  to  only  partially  include 
the  neoplasm.  Not  only  the  limits  but  as  nearly  as  possible  the  direction 
of  the  osteoplastic  flap  should  be  marked  out,  as  well  as  the  extent  and 
direction  of  its  base  line,  so  that  no  loss  of  five  or  ten  minutes  takes  place 
in  attempts  to  localise  it  with  chances  that  not  even  then  is  it  in  the  best 
position  or  direction." 

The  procedure  advised  by  Dr.  Mills,  when  it  is  intended  to  remove  a 
growth  limited  to  the  motor  area,  is  first  of  all  to  mark  out  the  Sylvian 
point  together  with  the  stem  and  posterior  horizontal  branch  of  that 
fissure.  The  area  supposed  to  include  the  underlying  tumour  is  then 
exactly  mapped  out,  and,  finally,  the  base  line  of  the  flap  which  the 
surgeon  is  to  make  should  also  be  indicated.  The  spot  for  the  insertion 
of  the  Stellwagen  trephine,  the  instrument  employed  by  Dr.  Mills  {see 
p.  318),  is  next  determined.  As  the  arm  of  this  trephine  can  be  extended 
so  as  to  give  a  radius  of  nearly  two  inches,  the  point  selected  for  the  pin 
should  be  about  half  an  inch  in  front  of  the  Rolandic  fissure,  at  about  its 
middle  or  a  very  little  below  this  point.  It  is  now  known  that  the  motor 
area  is  in  front  of  the  fissure  of  Rolando,  and  the  circle  outlined  by  the 
arm  of  the  trephine,  when  the  pin  is  placed  in  the  position  just  stated, 
would  be  such  as  to  include  a  little  more  than  the  motor  region  forwards 
and  backwards,  while  it  would  nearly  uncover  it  towards  the  median  line 
and  also  in  the  direction  of  the  Sylvian  fissure.  When  the  position  for 
the  pin  and  the  extremities  of  the  base  line  have  been  determined  by 
careful  measurement,  they  are  marked  on  the  scalp  by  small  incisions.^ 

At  the  time  of  operation  it  is  then  only  necessary  for  the  pin  to  be 
inserted  in  the  proper  position  in  the  scalp,  and  for  the  knife  to  be  inserted 
at  one  end  of  the  base  line  and  swept  around  the  circle  until  it  reaches 
the  other  end.  No  time  is  then  lost  in  determining  the  direction  and 
length  of  this  line. 

Anaesthetic.  If  not  contra-indicated,  a  hypodermic  injection  of  a 
quarter  of  a  grain  of  morpliia-  is  given  and  then  chloroform  is  administered. 
The  object  of  giving  the  morphia  is  twofold  :  in  the  first  place,  it  allows 
of  the  performance  of  a  prolonged  operation  without  the  necessity  of 
giving  a  large  amount  of  chloroform,  the  amount  actually  used  in  an 
operation  lasting  two  hours  being  very  small. 

The  second  reason  is  perhaps  the  more  important  :  that  this  drug 
causes  well-marked  contraction  of  the  arterioles  of  the  central  nervous 
system,  and  that  consequently  an  incision  into  the  brain  is  accompanied 
by  very  little  oozing  if  the  patient  be  under  its  influence. 

Removal  of  bone  and  exposure  of  the  brain.  It  will  be  taken  for 
granted  that  for  the  present,  at  all  events,  operations  for  removal  of 

^  Or  by  nitrate  of  silver.  A  solution  of  silver  nitrate  (30  gr.  to  the  ounce)  is  painted 
along  the  lines  and  allowed  to  dry.  It  is  then  brashed  over  lightly  with  a  solution  of 
pj^'ogaUic  acid  (5  gr.  to  the  ounce).  The  stain  thus  produced  is  not  washed  away 
when  the  scalp  is  subsequently  sterihsed. 

-  In  one  case,  a  child  of  4,  one-twentieth  of  a  grain  was  found  amply  sufficient.  The 
advisability  of  a  preliminary  injection  of  morphia  has  been  a  good  deal  disputed.  Sir 
F.  W.  Hewitt  in  his  most  careful  work  on  anaesthetics,  p.  422,  says  :  "  The  ase  of  mor- 
phine before  chloroform  has  been  found  to  be  advantageous  in  cerebral  surgery,  there 
being  less  vascularity  of  the  brain  and  its  membranes  with  this  mixed  narcosis  than 
with  chloroform  alone.  But  as  many  of  the  patients  requiring  these  operations  may 
be  at  the  time  of  the  administration  in  a  state  of  torpor  or  semi-coma,  or  may  during  the 
operation  display  symptoms  of  shock  or  respiratory  depression,  considerable  discretion 
must  be  exercised  in  applying  the  method.  Many  surgeons,  indeed,  who  at  one  time  used 
this  mixture  narcosis,  have  now  abandoned  it  in  these  operations." 


310  OPERATIONS  ON  THE  HEAD  AND  NECK 

growths  of  the  brain  will  generally  be  performed  in  two  stages  : 
(a)  Removal  of  the  bone,  (6)  incision  of  the  membranes  and  the  brain 
with  removal  of  the  growth,  an  interval  of  a  few  days  intervening  between 
the  two  operations. 

Sir  V.  Horsley,.  to  whom  as  a  pioneer  at  once  most  skilful  and  scientific 
we  owe  so  much,  having  turned  down  the  flap  which  bears  his  name  and 
which  obviated  the  risk  of  a  hernia  cerebri  inseparable  from  the  old 
crucial  incision,  removed  the  necessary  amount  of  bone  with  a  large 
trephine  followed  by  the  use  of  powerful  bone  forceps  or  saw.  The 
objections  to  this  procedure  are  :  (a)  For  removal  of  a  growth,  and  still 
more  for  the  palliative  operation  of  "  decompression  "  a  large  amount  of 
bone  requires  removal  :  {h)  If  a  large  amount  of  bone  is  taken  away, 
the  resulting  gap  in  the  cranial  wall  may  itself  be  the  cause  of  considerable 
trouble.  To  ob\'iate  these  objections  the  osteoplastic  method  of  resection 
of  the  skull  may  be  employed.  This  method,  introduced  by  Wagner  as 
long  ago  as  1889,  has  increasingly  gained  ground  in  recent  years.  Prof. 
Kronlein  thus  strongly  advocates  its  use.^ 

The  old  opinion  still  holds  that  the  power  of  regeneration  in  the  convex  bones 
of  the  skull  following  loss  of  substance  is  small,  and  that  consequently  defects  of 
any  extent  are  only  filled  with  connective  tissue  and  not  with  bone.  In  certain 
cases  such  defects  have  recently  been  observed  to  close  through  regeneration  of 
bone.  These  are,  however,  conspicuous  exceptions,  and  as  such  they  only  confirm 
the  rule.  Experience  shows  that  the  connective  tissue  scar,  which  usually  clo.ses 
small  defects  of  the  cranial  bones,  maj'  be  so  firm  and  dense  as  to  lead  one  to  believe 
that  a  production  of  new  bone  has  taken  place.  The  conditions  are  entireU' 
different  in  the  case  of  more  extensive  defects  of  the  skull  which  are  only  covered 
by  skin  and  scar  tissue.  Such  patients  are  not  only  extraordinarily  vulnerable  as 
regards  any  violence  affecting  the  skull,  but  their  infirmity  frequently  manifests 
itself  in  an  entirely  different  manner.  This  is  very  clearly  shown  by  an  observation 
recently  communicated  by  Konig.  Konig's  patient  had  an  exteiLsive  traumatic 
defect  in  the  left  parietal  region.  He  manifested  a  degree  of  weak-mindedness 
bordering  on  idiocy,  and  suffered  from  epileptiform  attacks.  All  the.se  severe 
disturbances,  which  Konig  very  correctly,  no  doubt,  referred  to  the  displacement 
and  distortion  at  the  surface  of  the  brain  in  the  region  of  the  defect,  disappeared 
as  soon  as  ho  successfidly  brought  alx)ut  bony  closure  of  the  defect.  Based  upon 
such  experiences,  it  is  altogether  jastifiable  to  demand  that  extensive  and  permanent 
defects  of  bones  should  be  avoided  from  the  beginning  in  cases  of  operations  upon 
the  brain. 

We  must  not,  however,  attach  too  much  importance  to  a  single  case, 
and  it  is  by  no  means  certain  that  where  a  large  amount  of  bone  has  been 
removed  and  the  healing  of  the  wound  has  run  an  aseptic  and  rapid  course 
that  the  defect  left  and  the  resulting  scar  are  of  the  weak  and  perilous 
nature  imphed  by  Prof.  Kronlein.  Anyone  of  large  ho.spital  experience 
is  familiar  with  cases  where,  after  a  comminuted  compound  fracture  of 
the  skull,  the  patient  comes  from  time  to  time  with  a  thinly  covered 
pulsating  scar,  for  the  renewal  of  some  artificial  covering.  But  owing 
to  the  widely  different  conditions  under  which  the  two  scars  have  formed 
there  is  no  comparison  between  the  state  of  such  a  scar  and  that  resulting 
from  a  wide  removal  of  bone  with  strict  attention  to  the  rules  of  modern 
surgery.  This  is  certainly  true  of  the  removal  of  bone  in  the  temporal 
fossa.  Mr.  J.  Hutchinson,  jun.,  whose  experience  and  success  in  the 
removal  of  the  gasserian  ganghon  by  the  temporal  route  is  well  known, 
writes  -  that  the  large  aperture  left  by  trephining  and  bone  forceps 

^  Von  Bergmann's  Sysi.  of  Pract.  Surgery,  Aincr.  Trans.,  vol.  i,  p.  .330. 
2  The  Surgical  Treatment  of  Facial  Neuralgia,  1905,  p.  91  ;  Sir  F.  Treves's  Manual  of 
Operative  Surgery,  vol.  i,  p.  22.5. 


()l>i:i{ATI()NS  ON  THE  BRAIN  311 

"  becoiucs  so  completely  lilled  up  with  bone  in  a  year  or  two  that  it  can 
no  longer  be  detected."  Till  recently  the  objections  to  the  osteoplastic 
method  were  valid  ones  (1)  that  unless  performed  by  complicated 
instruments  not  always  at  hand  and  involving  special  experience  in 
technique  the  method  was  a  prolonged  one,  especially  in  thick  and  com- 
pact skulls,  save  in  specially  experienced  hands,  and  (2)  if  performed 
by  the  very  simple  mallet  and  chisel  it  entailed  what  has  appeared  to  many 
to  be  an  unnecessary  violence  and,  perhaps,  for  there  can  scarcely  be  any 
proof  here  one  w'ay  or  the  other,  a  harmful  degree  of  concussion  of  the 
brain. 

Now,  however,  Wagner's  method  has  been  so  simplified,  as  will  be 
seen  below,  that  the  above  objections  arc  no  longer  valid.  The  course 
to  be  taken  is,  however,  an  open  one.  On  the  one  hand  if  the  surgeon  pre- 
fers it,  especially  in  his  earlier  cases,  he  is  entirely  justified  in  using  the 
simpler  method.  Time  and  further  experience  alone  ^vili  show  whether 
the  advocates  of  the  osteoplastic  flap  and  this  only  have  been  premature 
in  their  claim  that  this  method  is  essential  for  sound  surgery.  Before 
dealing  in  some  detail  with  the  different  ways  of  removal  of  the  skull 
a  few  words  must  be  said  about  the  haemorrhage.  This  in  large  incisions 
of  the  scalp  must  always  be  free  ;  in  some  cases  it  has  been  so  profuse 
as  to  add  gravely  to  the  perils  of  the  patient.  The  simplest  methods  of 
meeting  are  described  at  p.  255.  Makka's  clamps  (Fig.  118),  if  available, 
may  be  used,  or  a  fairly  large  drainage-tube  sterilized  and  split  longi- 
tudinally may  be  carried  once  round  the  forehead  above  the  root  of 
the  nose  and  the  ears  and  below  the  occipital  protuberance  and  secured 
over  a  pad  of  gauze.  There  is  no  need  to  clamp  the  tubing  very 
tightly,  a  step  which  is  further  objectionable  from  the  risk  which  it 
entails  of  causing  sloughing  of  soft  parts  in  a  prolonged  operation. 
It  must  be  remembered  that  the  above  step  cannot  always  be  relied  upon 
to  arrest  the  haemorrhage  from  the  scalp. ^  If  it  fail,  the  surgeon  must, 
if  not  intending  to  employ  the  osteoplastic  method,  raise  the  flap  rapidly, 
including  the  periosteum,  and  seize  each  bleeding  vessel,  including  the 
whole  thickness  of  the  scalp,  with  Spencer- Wells  forceps.  As  soon  as  the 
flap  is  partly  raised  an  assistant  can  compress  its  edge  between  his  fingers, 
relaxing  his  pressure  over  different  parts  of  this  in  turn,  as  the  operator 
takes  up  the  vessels. 

We  will  now  suppose  that  the  surgeon  W'ho  is  not  employing  the  osteo- 
plastic method  has  turned  down  his  flap,  wrapped  this  in  sterile  gauze, 
arrested  the  bleeding,  and  removed  the  tubing.  In  order  to  remove  the 
bone  freely — and  a  cramped  opening  is  certain  to  defeat  the  object  of  the 
operation — the  following  courses  are  open  to  him  : 

( 1 )  He  may  make  a  large  opening  with  a  one  or  two-inch  trephine  in 
the  centre  of  the  area  to  be  removed,  and  then  complete  the  removal  with 
bone  forceps  such  as  those  of  Hofimann  (Fig.  126).     This  is,  however, 

^  Thus  in  a  case  of  removal  of  a  small  spindle  cell,  encapsuled  sarcoma  of  the  brain 
and  dura  mater,  in  which  the  skull  wall  was  hypertrophied  and  the  diploe  obliterated, 
reported  by  Dr.  J.  E.  Owens,  of  Chicago  (Ann.  of  Surg.,  May  1905,  p.  695),  "  in  spite  of 
the  fact  that  the  head  was  encircled  by  an  elastic  band  haemorrhage  persisted  even  after  a 
number  of  artery  forceps  had  been  employed.  These,  as  well  as  digital  compression  here 
and  there,  were  not  sufficient  to  completely  arrest  the  bleeding."  After  partial  forma- 
tion of  an  osteoplastic  flap  the  completion  of  the  operation  had  to  be  deferred  owing  to 
the  alarming  prostration  of  the  patient,  chiefly  from  loss  of  blood.  The  operation  was 
completed  about  a  week  later,  and  then  the  htemorrhage  from  the  scalp  was  so  free  as  to 
be  only  arrested  by  loosening  the  flap  at  the  pedicle  for  the  purpose  of  enclosing  the 
latter  in  an  elastic  ligature.     The  patient  recovered. 


312  OPERATIONS  ON  THE  HEAD  AND  NECK 

always  a  very  slow  process,  increasing  greatly  the  amount  of  anaesthetic 
necessary  ;  in  thick  or  sclerosed  skulls  Hoffmann's  forceps  may  prove  in- 


C. 

FiG    l^O      Three  useful  skull-cutting  forceps.     A,  Hoffmann's.     B.  Lane's. 
^  "  '  C,  De  Vilbiss. 

adequate  and  it  is  well  to  be  provided  with  a  pair  of  powerful  forceps 
sS  as  those  figured  above  or  Lane's  fulcrum  cutting  forceps  (Fig.  126) 
To )  A  quicktr  method  is  to  make  four  small  trephine  openings  at  the 


OPERATIONS  ON  THE  BRAIN  813 

angles  of  the  area  to  be  removed,  and  then  to  join  these  by  the  forceps 
shown  in  Fig.  12(5,  or  by  the  forceps  of  De  Vilbiss  (Fig.  12G),  or  by  a  Gigh's 
saw  as  described  below. ^  If  the  ha3morrhage  on  division  of  the  bone,  now 
or  with  an  osteoplastic  flap,  is  severe — and  this  lias  been  perilously  the 
case  on  several  occasions — the  following  ways  of  controlling  the  hoenior- 
rhage  suggest  themselves,  e.g.,  pressure  with  sterile  gauze  wrung  out  of 
hot  sterile  saline  solution,  or  out  of  sterile  adrenalin  solution  (1  in  JOOO) ; 
the  application  of  Horsley's  wax  ;  crushing  the  cut  edge  of  the  bone  with 
strong  forceps — too  much  force  must  not  be  used  or  fresh  channels  are 
opened  ;  the  use  of  sterile  wooden  pegs  ;  these  faihng,  temporary  com- 
pression of  one  or  both  carotids  may  be  tried. 

The  bone  being  removed,  the  surgeon  decides  by  the  pulse  and  con- 
dition of  his  patient,  the  urgency  of  the  case,  and  the  report  of  the 
anaesthetist,  whether  he  shall  complete  the  operation  or  defer  this  to  a 
later  stage.  In  all  doubtful  cases  this  will  be  the  wiser  course.  It 
was  advocated  some  years  ago  by  Sir  W.  Macewen  and  Sir  V.  Horsley,  and 
their  advice  is  now  largely  followed.  It  is  no  exaggeration  to  say  that  if 
it  had  been  taken  oftener  the  mortality  of  this  operation  would  not  have 
been  so  high.  The  step,  as  pointed  out  by  Sir  W.  Macewen,  not  only 
diminishes  shock,  but  also,  if  the  dm'a  be  opened,  by  soldering  the 
membranes  at  the  margin  of  the  exposed  brain,  shuts  off  the  subdural  space 
and  so  prevents  the  escape  of  blood  into  it.  The  objections  must  not 
be  forgotten,  viz.,  the  double  anaesthetic,  the  two  operations,  and  the 
difficulty  of  keeping  the  wound  aseptic.  If  the  above  course  is  taken, 
all  haemorrhage  is  finally  arrested,  the  flap  is  replaced,  a  few  sutures 
inserted,  and  the  usual  dressings  applied. 

The  osteoplastic  flap.  The  first  point  to  consider  is  the  position  of 
the  flap.  If  localising  symptoms  are  present,  and  the  removal  of  the 
tumour  is  considered  feasible,  the  flap  will  naturally  be  cut  so  as  to 
expose  freely  the  site  of  the  tumour.  In  those  cases  where  the  tumour 
cannot  be  localised,  or  where,  though  its  situation  is  known,  its  removal  is 
considered  to  be  impossible  and  the  operation  is  undertaken  solely  with 
the  object  of  relieving  symptoms,  its  situation  must  be  carefully  planned 
so  as  to  minimise  the  chance  of  any  untoward  results,  such  as  paralysis, 
following  the  operation.  Many  surgeons  prefer  to  make  a  flap  the  centre 
of  which  is  just  above  the  ear.  Others  prefer  one  of  the  "  silent  "  areas 
such  as  the  frontal.  Dr.  Hudson  [vide  infra)  advises  the  occipital  region 
in  these  cases  as  less  likely  to  cause  damage,  as  he  maintains  that  the 
brain  can  project  in  a  backward  direction  without  interfering  with  these 
centres. 

The  following  are  among  the  many  methods  which  may  be  actually 
employed. 

(1)  The  mallet  and  chisel  and  their  disadvantages  have  been  already 
mentioned  (p.  311). 

Doyen's  guarded  chisel  or  guarded  saw  may  be  used  (Fig.  127). 

A  large  horse-shoe  shaped  incision  must  first  of  all  be  made  through 
the  soft  parts  down  to  the  bone.  This  flap  is  not  dissected  free  and 
turned  down,  but  by  means  of  an  elevator  the  soft  parts  are  turned  to 
one  side  so  as  to  expose  the  bone  throughout  the  line  of  the  incision.  The 
bone  is  then  divided  by  one  of  the  following  methods  : 

^  Trephines  and  other  instruments  worked  by  an  electric  motor  or  surgical  engine 
require  much  skill  and  care  in  avoiding  injury  to  the  dura  mater.  Their  use  is  described 
on  p.  316. 


314 


OPERATIONS  OX  THE  HEAD  AND  NECK 


iSc 


Fig.  127.     A,  Doyen's  guarded  chisel. 
B,  Doyen's  guarded  saw. 


(2)  Four  small  perforations  may  be  made  by  means  of  a  small  trephine 
at  the  angles  of  the  flap.     These  holes  are  then  joined  (Fig.  134)  by  the 

De  Vilbiss  forceps,  by 
Hey's  saw,  or  by  means  of 
a  Gigli's  saw  {vide  infra). 

(3)  The  openings  in  the 
bone  may  be  made  with 
Doven's  perforator  and 
burrs  (Figs.  130,  131). 
These  small  openings  are 
then  joined  by  one  of  the 
methods  mentioned  above. 
Marion,  of  Paris.  ha\ang 
tried  nearl^'all  the  different 
methods  of.  craniectomy,  has  come  to  the  conclusion  that  much  the  most 
rapid  is  that  by  means  of  Gigli's  saw.^  M.  Marion  employs  Doyen's  instru- 
ments for  perforating  the  skull  and  uses  a  modification  of  the  introducing 
director  usually  sold  %\ith  Gigli's  saw.  A  small  trephine  may  be  used 
instead  of  Doyen's  perforator.  As  to  the  introducer,  the  whalebone  guide 
usually  sold  will  not  stand  boihng  and  tends  to  fray  and  perish.  A 
flexible  strip  of  copper  and  a  loop  of  silver 
wire  will  supply  all  the  needs  of  an  intro- 
ducer. 

The  flap  of  soft  parts  having  been  out- 
lined by  incision  and  the  periosteum  sepa- 
rated for  about  a  quarter  of  an  inch 
(Fig.  130),  four  or  moreoriflces,  according 
to  the  size  of  the  bony  flap  to  be  raised, 
are  made  with  M.  Doyen's  instruments. 
"  The  perforator  is  first  fitted  on,  and  the 
bone  is  perforated  down  to  the  inner 
table  very  rapidly.  Owing  to  the  tri- 
angular shape  of  the  perforator,  with  an 
almost  blunt  extremity,  one  can  scarcely 
injure  the  dura  mater  if  care  is  taken  when 
the  inner  table  is  reached.  As  the  deeper 
layers  are  arrived  at  the  centre  of  the 
perforation  becomes  depressible.  A  cha- 
racteristic sensation  indicates  that  the 
skull  is  actually  perforated.  A  burr 
(Fig.  131)  being  next  substituted  for  the 
perforator — the  burr  should  be  sufficiently 
large,  from  12  to  15  mm.  in  diameter — 
each  orifice  is  enlarged  until  its  dimen- 
sions, superficial  and  deep,  are  almost  the 
same.  The  orifices  are  now  joined  by  the 
saw.      This  is  introduced  by  passing  the 

director  (Fig.  133)  from  one  orifice  to  the  next  (Fig.  132),  a  step  rendered 
easy  by  the  elasticity  of  the  director,  and  by  giving  a  slight 
curve  to  its  extremity.  The  saw  is  then  passed  along  the  groove,  and 
if  there  be  any  difficulty  in  doing  this  a  thread  or  a  piece  of  fine 
silver  wire  is  first  attached  to  the  saw  and  drawn  through."  The 
1  Arch.  Gen.  de  Med.,  26,  1904,  p.  1025. 


Fig.  12'8.     Gigli's  thread-saw. 


OPERATIONS  ON  THE  BRAIN 


31 5 


Fi(i.  12!).  Steel  director  and  ■vvhalel)oncc;ui(l(>  foruse  witli(!if,di'.s 
saw.  Hole.s  are  first  made  witli  a  small  trepliiiie,  tlien  the 
director  makes  a  way  for  the  whalebone  guide,  threaded  with 
silk.  The  guide  is  withdrawn,  leaving  the  silk  in  situ  ;  the  silk 
afterwards  assists  in  the  passage  of  the  Gigli's  saw. 


director  is  hold  in  position  by  an  assistant  to  protect  the  dura  mater. 
The  first  two  holes  are  then  joined  by  the  saw.     "  The  sawing  is  effected 
easily  and  rapidly  (Fig.  134)  if  care  is  taken   that  the   two 
ends  of  the  saw  are  not  held  at  too  acute  an  angle,  and  the 

two  hands 
and  the 
angles  of  the 
saw  kept  in 
the  same 
place.  Fur- 
ther, the  sec- 
tion of  the 
bone  should 
not  be  made 
perpendicular  to  its  surface  but  a  little  obliquely  from  without  inwards. 
When  all  the  circumference  of  the  flap  has  been  thus  treated,  the  saw 
is  slipped  down  to  the 
base  of  the  flap,  and  this 
is  partly  sawn  through, 
a  step  which  greatly 
facilitates  i  ts  fracture . ' ' 
The  following  ad- 
vantages are  claimed 
by  M.  Marion  for  this 
method.  (1)  Only  one 
special  instrument, 
Gigli's  saw,  is  re- 
quired. Unless  a  small 
trephine  is  used 
Doyen's  instruments 
will  also  have  to  be 
added.  (2)  It  is  rapid 
and  gentle.  M.Marion 
claims  that  as  large  a 
flap  as  can  be  desired 
can  be  raised  in 
less  than  five 
minutes.  The  vibra- 
tions of  any  elec- 
trical apparatus  are 
avoided  and  the  need 
of  any  installation  dis- 
pensed with.  (3)  The 
surface  of  the  section 
is  very  clean  and  per- 
mits of  the  most  exact 
readjustment  of  the 
flap.  (-4)  There  is  no 
danger    of    womiding 

the     dura     mater.  Fig.   130.      The   outline    of    the    osteoplastic    flap 

(5)   By    this    means  it  having  been  marked  out  by  incising  the  soft  parts 

is  easv  to  saw  through  ^"^^  slightly  separating  the  periosteum,  five  open- 

,11"  J.  ^ ,        „        9  ings  in  the  cranium  are  being  completed  with  M. 

the  base  of  the   flap  m  Doyen's  burr.     (Marion.) 


31 G 


OPERATIONS  ON  THE  HEAD  AND  NECK 


part,^  a  step  which,  if   not  indispensable,    greatly  facilitates  the  regu- 
larity of  the  line  of  fracture,  a  point  which  is  not  without  importance 

in  the  readjustment  of  the  flap. 
The  only  objection  to  the 
method  is  a  small  one.  A  saw 
may  break,  especially  when 
used  at  too  acute  an  angle  or 
when  the  hands  are  worked 
in  different  planes.  Several 
should  always  be  at  hand. 

(4)  The  bone  may  be  divided 
by  means  of  electrically  driven 
burrs  or  saws.  This  method 
is  both  powerful  and  rapid.  A 
large  bone  flap  can  be  cut  in  a 
few  minutes.  There  is  usually 
less  trouble  from  bleeding  from 
the  bone.  The  chief  disadvantage  is  that  the  dura  mater  is  imperfectly 
protected. 

(5)  Stellwagen's  Trephine  (Fig.  135).  This  instrument,  which  com- 
bines the  knife  and  trephine,  is  intended,  while  worked  by  hand,  to  supply, 
in  great  measure,  the  speed  of  craniectomy  by  the  help  of  the  electro- 


FiG.  131. 


M.  Doyen's  porforator  and  burr. 
(Marion.) 


Fig.   132.     The  cranium  having  been  cut  through  up  to  the  third  opening, 

Gigli's  saw  is  being  passed  from  the  third  to  the  fourth  opening  with  the  aid  of 

M.  Marion's  guide.     (Marion.) 

motor.  As  in  the  case  of  all  new  inventions  it  has  been  promptly  and 
largely  tested  by  American  surgeons,  some  of  whom,  but  not  all,  speak 
very  highly  of  it. 

1  This  method  may  be  adopted,  whatever  method  may  have  been  employed  to  cut 
the  flap.  The  base  of  the  flap  may  also  be  partly  divided  by  De  Vilbiss  forceps  or  by  the 
cliisel :  Gigli's  saw  is,  however,  simplest  and  most  satisfactory.  If  the  flap  is  forced 
back  without  partial  division  pf  its  base  serious  fracture  of  the  skull  may  result. 


OPERATIONS  ON  THE  BRAIN 


317 


Advantages  of  S(('llwagen\s  trephine.  A  largo  openiiij]f  is  rapidly  made. 
P^roin  accoiiiits  of  Anioricaii  cases  the  time  varied  according  to  experience 
with  the  instrument,  from  thirty  to  eight  minutes.  It  does  away  with  the 
risky  jarring  inseparable  from  the  use  of  mallet  and  chisel. ^  It  makes 
the  osteoplastic  fiap  so  accurately  that  the  reunion  is  ({uick  and  certain. 

One  possible  difticulty  is  that,  when  the  flap  is  large,  that  it  may  be 
difficult  to  catch  all  the  vessels  that  are  divided  as  quickly  as  is  desirable. 


FiLJ.  133.     M.  Marion's  guide  for  digli's  .saw.     (Marion.) 

This  may  be  avoided  by  carrying  the  kuife  to  a  certain  distance,  the  vessels 
are  then  secured,  and  the  knife  is  next  carried  round  another  portion  of 
the  circle  and  so  on. 

(0)  Dr.  Hudson  2  has  described  a  new  operation  for  decompression. 

A  large  osteo])liistic  flap  is  made  on  tha-posterior  aspect  of  the  skull  over  the 
occipital  lobes  of  the  cerebrum  so  as  to  allow  of  the  expansion  of  the  brain  in  a 


Fig.  134.     Division  of  the  cranium  by  Gigli's  saw.     (Marion. 


backward  direction.  By  means  of  special  forceps  designed  by  Dr.  Hxidson,  the  bone 
is  cut  with  a  bevelled  edge  so  as  to  allow  of  exact  reposition.  The  Hap  is  replaced 
and  kept  in  position  by  loosely  twisted  silver  wires.  As  the  tumour  grows  and 
the  intra-cranial  pressure  increases,  the  wire  loops  untwist  and  the  bone  is  displaced 
backwards.  Should  this  not  occur,  a  little  cucaine  may  be  injected  and  the  bone  is 
given  a  lift  by  a  sharp-pointed  stylet. 

^  It  is  interesting  to  note  that  Prof.  Keen  has  opened  the  skull  with  a  chisel  and 
mallet  in  150  cases,  and  that  he  has  yet  to  see  the  first  instance  of  mischief  from  this 
method. 

2  Ann.  of  Surg.,  1912,  vol.  Iv,  p.  744. 


318 


OPERATIONS  ON  THE  HEAD  AND  NECK 


Cushing's  Operation  for  Decompression  (Fig.  136).  Gushing  insists  on 
the  importance  of  preserving  the  temporal  muscle  in  the  formation  of  an 
artificial  hernia  cerebri.  He  turns  down  a  large  flap  on  the  lateral  aspect 
of  the  skull,  consisting  of  the  soft  parts  down  to  the  temporal  fascia. 
When  this  flap  has  been  turned  down,  the  temporal  muscle  is  divided 
parallel  to  its  fibres,  and  the  periosteum  is  exposed  by  retracting  the 
edges.  The  periosteum  is  then  separated  and  divided  and  the  requisite 
amount  of  bone  removed,  preferably  by  a  trephine  and  skull-cutting 
forceps.  The  divided  temporal  muscle  is  then,  when  the  compression 
has  been  relieved,  brought  together  by  a  few  sutures.  Gushing  finds 
that  in  this  way  an  enormous  hernia  cerebri  may  develop  without  sub- 
sequent ill  effects.     When  the  tumour  cannot  be  localised,  or  if  it  should 

be  of  such  a  character  as  to  render  removal 
impossible,  this  operation  is  often  remark- 
ably successful  in  relieving  the  distressing 
symptoms. 

Second  Stage  of  the  Operation.  This  is 
undertaken  after  an  interval  of  five  to  seven 
days  or  more.  If  no  more  bone  requires  re- 
moval, and  this  should  have  been  rendered 
unnecessary  by  the  careful  preliminary  local- 
isation advised  on  p.  309,  local  ansesthesia, 
as  recommended  by  Dr.  Ransohoff,  may  be 
tried  if  a  second  general  anaesthetic  is  thought 
undesirable.  The  sutures  are  removed  and 
the  flap  turned  down  and  wrapped  in  sterilised 
gauze.  The  next  step  is  the  opening  of  the 
dura  mater.  This  stage  is  absolutely 
necessary  for  the  relief  of  symptoms.  If 
decompression  alone  is  aimed  at  the  dura 
should  first  be  incised  in  the  line  of  the 
vessels,  a  second  incision  being  subsequently  made  at  right  angles 
to  the  first.  The  four  pointed  flaps  thus  formed  are  dissected  up  close 
to  the  margin  of  the  bone  and  are  then  cut  away.  If  it  is  thought 
that  the  removal  of  the  tumour  is  possible,  the  dura  is  not  cut  away  but 
a  flap  is  turned  down  so  as  to  expose  the  surface  of  the  brain.  Prof. 
Kocher  advises  that,  when  the  convex  border  of  the  bony  flap  is  situated 
near  the  middle  line  of  the  head,  that  the  dural  flap  may  be  inverted,  i.e., 
the  base  being  placed  upwards  and  the  convexity  downwards.  He  further 
points  out  that  it  is  desirable  that  the  line  of  incision  in  the  dura  should 
not  coincide  with  the  edge  of  the  divided  bone.  The  dura  mater  is  best 
opened  first  by  incision  with  a  scalpel  and  then  by  bhmt-pointed  curved 
scissors,  great  care  being  taken  not  to  wound  the  parts  beneath.  The 
main  branches  of  the  middle  meningeal  are  best  secured  by  underrunning 
them  with  fine  catgut  by  means  of  a  small  fully-curved  needle  before 
they  are  divided.  The  dura  mater  should  be  raised  with  much  gentle- 
ness, as  if  any  adhesions  are  torn,  very  free  venous  hgemorrhage  may 
result.^ 


Fig.  135.  Stellwagen's  tre- 
phinC;  with  saw  and  knife 
blades.  The  latter  arc  used 
to  incise  the  scalp.  The  arm 
can  be  adjusted  to  describe 
a  circle  of  from  2^  to  4^ 
inches  in  diameter. 


^  Any  of  the  dura  mater  which  is  adherent  to  the  growth  is  usually  much  altered. 
In  a  recent  case,  the  membrane  will  simply  be  highly  vascular.  In  advanced  cases  it 
may  be  yellowish,  and  in  some  instances,  on  separating  it  from  the  growth  beneath  it 
is  found  to  be  of  a  dirty  reddish  colour.  In  all  cases  where  it  is  adherent  the  dura  mater 
must  be  freely  excised,  if  possible. 


OPERATIONS  ON  THE  BRAIN 


319 


Treatment  of  the  Brain.  If  this,  after  incision  of  the  dura  mater, 
bulges  very  proiniuently  into  the  wound,  it  indicates  pathological  intra- 
cranial tci^sion,  and  probably  a  growth. 

C.  H.  Frazier,^  calling  attention  to  the  fact  that  this  bulging  of  the 
brain  may  be  one  of  the  most  embarrassing  features  of  cerebral  operations, 
distinguishes  between  "  initial  "  bulging,  that  which  follows  immediately 
on  reflecting  the  dura  and  is  due  to  the  increased  tension  caused  by  a 
growth,  and  "  consecutive  "  bulging  caused  by  the  osdema  set  up  in 
normal  brain  tissue  by  the  exploratory  manipulations.     This  far  exceeds 


Fig.  136.     Cushing's  operation  ot  sub-temporal  decompression. 


the  "  initial  "  form,  and,  as  it  is  most  embarrassing,  exploration  should  be 
as  expeditious  as  possible.^  Alterations  in  the  density  of  the  brain  must 
next  be  observed,  but  it  must  be  remembered  that  the  softer  cerebral 
growths  situated  beneath  the  cortex  are  scarcely  to  be  detected,  save 
by  exploratory  incision  ;  with  tuberculous  nodules  it  is  different.  A 
needle  is  of  very  little  value  in  exploring  for  a  growth.  A  tumour  too 
soft  to  be  detected  by  the  finger  will  not  be  recognised  by  a  needle  : 
serious  haemorrhage  may  follow  its  use.  Careful  search  with  one  of  the 
instruments  shown  in  Fig.  137,  or  digital  palpation  and  the  insertion  of 

^  Amer.  Journ.  Med.  Set.,  Feb.  1904. 

2  In  some  cases  where  there  is  abundant  evidence  of  increased  intracranial  tension 
a  growth  may  be  present,  but  out  of  range  of  the  operation.  This  is  especially  likely 
to  be  the  case  where  "  false  "  localising  symptoms  are  present.  Thus,  in  a  case  in  which 
Dr.  \Yeir  (Arm.  of  Surg.,  June  1887)  trephined  over  the  upper  part  of  the  right  fissure  of 
Rolando  for  spasms  in  the  left  limbs  and  loss  of  power  in  the  left  leg,  no  growth  was 
found.  Death  took  place  ten  weeks  later,  and  a  spindle-celled  sarcoma,  apparently 
originating  in  the  pia  mater,  was  found  springing  from  the  lower  surface  of  the  left  cere- 
bellar lobe,  displacing  the  medulla  forwards  to  the  right,  and  invading  the  fourth  ventricle. 
In  such  a  case  the  best  course  to  pursue  would  be  to  complete  the  operation  for  decom- 
pression. 


320 


OPERATIONS  ON  THE  HEAD  AND  NECK 


the  finger-tip  under  the  margin  of  the  bony  opening  are  preferable. 
The  removal  of  a  growth  is  best  effected  by  one  of  Sir  Victor  Horsley's 
combined  spatiilse  and  directors  shown  in  Fig.  137.  If  a  sarcoma 
be  encapsuled  it  may  be  shelled  out  by  one  of  these  aided  by  the 
finger. 

Hsemorrhage.     In  removing  a  portion  of  the  brain,  or  a  growth,  the 
bleeding  which  has  been  so  much  dreaded  will  usually  cease  if  the  wound 

be  packed  for  a  few  minutes  with  strips 
of  sterilised  gauze.  The  value  of  a  pre- 
liminary injection  of  morphine  has 
already  been  alluded  to.  Other  methods 
for  arresting  hsemorrhage  are  irrigation 
with  sterile  saline  solution  at  a  tempera- 
ture of  110°  to  120°,  fine  catgut  ligatures 
tied  without  jerking  and  not  too  tightly  ; 
or  if  these  fail  the  use  of  adrenalin  solu- 
tion (1  in  1000).  Should  the  bleeding  be 
otherwise  uncontrollable  it  may  be 
necessary  to  leave  the  gauze  packing  in 
situ,  the  end  of  the  strip  being  brought 
out  at  one  end  of  the  lower  angles  of  the 
womid.  Sir  V.  Horsley  has  invented  a 
combination  of  fine  dissector  and  small 
aneurysm  needle  well  adapted  to  facili- 
tate underrunning  and  ligature  of  the 
vessels  of  the  pia  mater.  If  any  bleeding 
vessel  is  not  well  within  reach,  the  open- 
ing must  be  enlarged  to  get  at  it.  When 
other  methods  fail — and  careful  plugging 
and  firm  pressure  with  firm  bandages 
over  the  dressings  has  failed  more  than 
once — small  Spencer- Wells  forceps  may 
be  left  on  for  thirty-six  or  forty-eight 
hours  ;  but  the  patient  must  be  carefully 
watched,  lest  his  restlessness  cause  the 
friable  tissues  to  give  way,  or  inflict 
damage  on  the  brain.  The  treatment  of 
haemorrhage  from  the  meningeal  or 
diploic  vessels,  or  from  any  of  the  large 
venous  sinuses,  has  been  given  at  p.  266. 
Incision  of  the  Brain.  The  cuts  in 
the  cortex  must  be  made  exactly  vertical 
to  the  surface.  If  possible,  portions  of 
each  centre  should  always  be  left,  so  that 
the  cortical  representation  of  the  par- 
ticular group  of  movements  may  never  be  totally  destroyed.  A  portion 
of  brain  removed  does  not  leave,  as  might  have  been  supposed,  a  per- 
manent gap  mth  vertical  sides,  for,  in  a  very  short  time,  the  corona 
radiata  forming  the  floor  of  the  pit  bulges  almost  to  a  level  with  the 
surroimding  cortex. 

Difficulty  in  detecting  the  growth.^     This  may  arise  from  several 
causes  (1)  The  want  of  distinctness  in  the  growth — in  other  words,  its 

^  These  remarks  refer  to  gliomata. 


Fig.  137.  Combined  blunt  dis- 
sectors and  si:)atul{e  used  by  Sir 
V.  Horsley.  I'hey  are  equally 
adapted  for  the  protection  of  the 
dura  mater  under  the  saw,  or  for 
the  separation  of  a  growth  from 
the  surrounding  brain.  They  also 
act  as  flat  probes  in  testing  the 
depth  of  trephine-holes. 


OI'KKATIONS  ON  THE  BRAIN  321 

close  rosemblaiiLe  to  iiornuil  brain  substance.^  A  glioma  may  have 
the  appearance  of  hypertrophied  convolutions.  (2)  The  growth  may  be 
overlaid  by  normal  brain  tissue.  (3)  By  change  in  the  growth — viz., 
ha)morrhage  from  its  thin-walled  vessels,  and  later  on,  secondary  changes 
in  the  clot.     These  conditions  may  be  very  ])uz;zling. 

Difficulty  in  isolating  the  growth.  (1 )  This  may  be  due  to  the  absence 
of  a  capsule,  aiul  thus  to  the  infiltiation  of  surrounding  parts.  This  is  of 
especial  importance  in  the  case  of  gliomata.  A  capsule  would  occasionally 
appear  to  have  been  present.  Thus  in  Dr.  Bennett  and  Sir  R.  J.  Godlee's 
case  the  glioma  was  found  to  be  "  thinly  encapsuled,  but  quite  isolated 
from  the  surrounding  brain  substance."  Not  so,  however,  is  it  in  many 
other  cases.  Indeed,  the  chief  pathologists  speak  decisively  on  this 
point.  Dr.  Fagge  thus  wrote  :  "  The  substance  of  a  glioma  is  always 
continuous  with  that  of  the  surrounding  cerebral  tissue,  for  there  is  never 
a  capsule  as  with  some  sarcomata.^  Indeed,  it  often  assumes  the  form 
of  the  pai't  in  which  it  grows,  so  that  one  might  imagine  the  corpus  striatum 
or  the  thalanms  or  some  particular  convolution,  to  have  become  swollen 
to  three  or  four  times  its  usual  size."  Sir  J.  Bland  Sutton  ^  writes  : 
"  Virchow  pointed  out  that  when  a  glioma  is  situated  near  the  surface 
of  the  cerebral  cortex  it  appears  like  a  colossal  convolution." 

Sir  D.  Ferrier  ^  says  on  this  point  :  "  It  is  unfortunately  the  case  that  a 
large  proportion  of  the  tumours  which  invade  the  brain  are  of  an  infiltra- 
ting character,  and  apt  to  recur  in  spite  of  apparently  the  most  complete 
extirpation.  One  can  scarcely  hope  for  a  cure,  therefore,  under  such 
conditions  ;  but,  nevertheless,  there  are  many  cases  in  which  extirpation 
of  such  tumours  has,  for  a  time  at  least,  rescued  the  patient  from  im- 
pending coma  and  death,  and  restored  him  for  a  time  to  clearness  of  intel- 
lect and  a  fair  degree  of  comfort."  A  little  later  on  we  are  advised  that, 
"  It  is,  on  the  whole,  better  not  to  attempt  to  remove  a  tumour  which 
proves  to  be  a  soft  infiltrating  one  without  distinct  demarcation  from  the 
healthy  brain  substance." 

The  benefits  to  be  obtained  from  partial  removal  of  a  cerebral  tumour 
are  at  present  doubtful.  Sir  V.  Horsley  ^  mentions  several  cases  where 
partial  removal  was  followed  by  considerable  improvement;  while  Dr. 
Byrom  Bramwell  regards  this  as  a  very  doubtful  step.  On  the  one 
hand  partial  removal  may  cause  very  serious  haemorrhage  when 
the  patient  is  ill  fitted  to  stand  this.  On  the  other  hand  the  tension 
may  be  so  great — the  initial  and  consecutive  bulging  already  spoken  of — 
that  unless  some  of  the  growth  be  removed  it  maybe  impossible  to  draw 
the  edges  of  the  dura  mater  together.  Further,  Mr.  Ballance's  case 
mentioned  at  p.  306  shows  how  long  life  may  be  prolonged  after  incomplete 
removal. 

(2)  Another  source  of  doubt  in  telling  when  a  glioma  not  encapsuled 
has  been  isolated,  arises  from  the  fact  that,  as  pointed  out  by  Dr.  Fagge, 
these  growths,  in  common  with  all  the  less  circumscribed  forms  of  cerebral 
tumours,  are  apt  to  set  up  morbid  changes  in  their  immediate  vicinity, 
usually  of  the  nature  of  softening,  partly  inflammatory,  partly  oedematous. 

^  A  glioma  may  be  of  a  pinkish  red  colour,  or  it  may  look  so  exactly  like  the  normal 
brain  substance  that  a  microscope  is  required  to  demonstrate  its  presence.  (Fagge's 
Medicine,  vol.  i,  p.  523.) 

2  The  glioma  is  distinguished  by  having  no  capsule,  but  merging  indefinitely  into  the 
tissue  around.     (Wilks  and  Moxon,  Path.  Anat.,  p.  239.) 

^  Tumours  Innocent  and  Malignant,  p.  174. 

*  Brit.  Med.  Journ.,  1898,  vol.  ii,  p.  9G6.  ^  Ibid.  1906,  vol.  ii,  p.  411. 

SURGERY  I  21 


322  OPERATIONS  ON  THE  HEAD  AND  NECK 

If  a  cyst  be  found  it  should  be  completely  removed,  if  possible.  If  this 
be  not  feasible,  all  the  more  superficial  part  should  be  cut  away,  and  the 
cavity  packed  with  sterilised  fjauze. 

Operation  for  Tumours  of  the  Cerebellum.  Unusual  difficulties  always 
attend  these  operations  owing  to  the  limited  space,  the  numerous  sinuses, 
and  the  proximity  of  the  medulla  and  its  centres.  It  must  also  be  remem- 
bered that  though  it  is  often  easy  to  diagnose  a  tumour  in  the  cerebellum, 
it  is  often  impossible  to  exactly  localise  it.  Indeed,  not  infrequently 
it  is  not  possible  to  be  sure  in  which  side  of  the  cerebellum  it  is  situated. 
Bone  must  therefore  be  freely  removed  so  as  to  allow  of  a  thorough 
exploration. 

An  incision  ^  should  be  made  commencing  just  behind  one  mastoid 
process,  and  then  curving  a  short  distance  above  the  superior  curved  line 
to  terminate  in  the  corresponding  position  behind  the  opposite  mastoid 
process.  There  wdll  be  free  bleeding  which  must  be  checked  in  one  of  the 
ways  already  described.  The  periosteum  is  then  incised  and  together 
with  the  muscles  attached  to  the  occipitah  is  detached  with  the  help  of 
an  elevator  and  the  flap  thus  formed  is  turned  down.  The  bone  is  best 
removed  by  making  an  opening  with  a  large  trephine  and  then  to  enlarge 
this  by  means  of  some  convenient  form  of  bone-cutting  forceps.  The  cere- 
bellum may  also  be  exposed  by  making  two  trephine  openings  as  near  the 
mid-line  as  possible  and  then  cutting  away  the  intervening  bone.  The 
external  occipital  protuberance  should  always  be  preserved  on  account  of 
the  torcula  herophili  which  lies  beneath  it.  The  lateral  sinus  should, 
however,  be  exposed  on  each  side  of  this.  Bone  may  be  removed  down- 
wards to  within  one  inch  of  the  foramen  magnum.  An  osteoplastic  flap 
is  unnecessary  here  owing  to  the  thickness  of  the  flap  of  soft  parts.  If, 
at  this  stage,  the  patient's  condition  continue  good,  the  operation  should 
be  completed  ;  otherwise  it  is  w^ell  to  defer  this  for  some  days.  When 
sufficient  bone  has  been  removed  the  cerebellum  is  freely  exposed  by 
turning  down  a  flap  of  dura  mater.  The  occipital  sinus  is  secured  and 
ligatured  above  and  below. 

If  a  growth  is  present  the  cerebellum  will  now  bulge  prominently  into 
the  wound.  If  the  growth  is  in  a  lateral  lobe  it  should  be  sought  for 
and  removed  as  recommended  in  the  case  of  the  cerebrum. 

If  on  the  other  hand  there  is  reason  to  suspect  the  presence  of  growth 
at  the  cerebello-pontine  angle,  a  favourite  site,  the  subsequent  steps  are 
far  more  difficult.  The  shortest  route  to  the  cerebell-o-pontine  angle  is 
along  a  line  parallel  to  the  petrous  part  of  the  temporal  bone.  Provided 
the  opening  in  the  bone  is  extended  as  far  outwards  as  possible,  one  may 
after  retracting  the  cerebellum  inwards  obtain  a  view  not  only  of  the 
seventh  and  eighth  nerves  as  they  enter  the  internal  auditory  meatus, 
but  also  of  the  sensory  root  of  the  fifth  nerve  at  the  apex  of  the  petrous. 
It  is,  however,  extremely  doubtful  if  a  growth  in  this  situation  can  be 
safely  removed  considering  its  surroundings. 

The  need  of  the  greatest  care  in  all  manipulations  of  the  cerebellum, 
especially  near  its  centre,  is  inculcated,  owing  to  the  risk  of  bruising  the 
medulla  and  pons. 

Owing  to  the  increased  tension  it  will  probably  be  impossible  to 
displace  the  cerebellum  sufficiently  with  a  retractor  to  expose  the  growth. 
Either  the  ventricle  must  be  punctured  or  part  of  one  cerebellar  hemisphere 
removed.     Dr.  Fraz'er  considers  puncture  of  the  ventricles  so  often  fatal 

^  Harvey  Gushing  suggests  a  T-.shaped  incision  for  exposing  the  cerebellum. 


OPERATIONS  ON  THE  BRAIN  323 

as  to  be  unjustifiable.^  On  the  other  liaud,  removal  of  a  hiige  part  of  ojie 
cerebeHar  lieniisphere  has  given  marked  rehef  in  several  cases,  though 
no  growth  was  found.  Thus  blindness,  headache,  vertigo  have  all  been 
greatly  relieved.  The  following  case,  mentioned  by  Dr.  R.  W.  Murray 
in  the  Medical  Chronicle,  June  1905,  is  a  good  instance  of  the  way  in 
which  the  situation  of  a  growth,  though  producing  well-marked  symptoms, 
may  cause  insuperable  difficulties  in  its  removal. 

A  woman  had  suffered  from  occi])ital  headache,  vomiting,  failing  sight,  and 
tendency  to  fall  to  the  left  side.  On  the  removal  of  the  brain  at  the  necropsy,  the 
left  half  of  the  cerebellum  appeared  normal.  It  was  only  after  making  sections 
and  a  careful  examination  that  a  small  growth  was  found  in  the  left  amygdala. 
It  was  a  mixed  cell  sarcoma  of  the  jjia  mater  of  the  cerebellum  and  the  choroidal 
plexus  of  the  fourth  ventricle. 

Closure  of  the  Wound.  All  bleeding  having  been  stopped,  the  cut 
dura  mater  is  sutured  witli  fine  catgut.  If  the  brain  bulges  much  while 
the  dura  is  being  sutured,  it  should  be  depressed  wuth  a  spatula,  while  the 
edges  are,  if  possible,  quickly  brought  together  by  a  continuous  suture. 
If  necessary  a  flap  of  pericranium  may  be  employed.  Room  must  be 
left  for  drainage,  and  the  flap  adjusted  with  salmon-gut  sutures.  Sir  V. 
Horsley  removes  the  drainage  tube  which  is  to  be  inserted  at  the  most 
dependent  part  of  the  incision  (as  the  patient  hes  in  bed),  at  the  end  of 
twenty-four  hours,  and  makes  firm  but  gentle  pressure  over  the  centre  of 
the  flap.  The  tube  serves  to  drain  the  steady  oozing  of  blood  and  serum 
from  the  cut  surfaces,  which  takes  place  during  the  first  day,  and  its 
removal  at  the  end  of  this  time  is  advised,  in  order  to  allow  of  a  certain 
amount  of  tension  from  wound  exudation  to  occur  within  the  cavity  ;  this 
tension  not  interfering  with  primary  union  if  kept  within  proper  bomids, 
while  it  secures  pressure  on  the  bram  which  tends  to  extrude, 
and  serves,  when  the  wound  is  finally  healed,  to  separate  the  skin  flap 
from  the  brain  beneath  by  a  cushion  of  soft  connective  tissue.  If,  after 
the  removal  of  the  tube,  there  is  much  pain  and  throbbing  in  the  wound, 
and  the  union  threatens  to  break  down,  the  edges  must  be  sufficiently 
separated  with  a  probe,  gently  used,  in  the  track  of  the  drainage  tube  and 
another  drain  inserted. 

Nothing  has  been  said  about  the  replacement  of  the  bone  in  those 
cases  where  the  osteoplastic  method  has  not  been  employed,  as  the  opera- 
tion wiU  often  be  done  in  two  stages,  and,  thus,  the  bone  will  not  have 
survived  the  interval.  As  has  been  said  before,  exact  evidence  is  required 
as  to  how  far  large  gaps  eventually  become  closed  and  to  what  extent 
artificial  protection  is  needed. 

Needless  to  say  every  precaution  for  meeting  and  treating  shock, 
both  during  and  after  the  operation,  must  be  taken  (see  p.  29).  In  these 
cases  it  is  a  mistake  to  wait  for  shock  and  to  treat  it  :  shock  should  be 
expected  as  a  matter  of  course,  not  waited  for. 

Excision  of  Cortex  Centres  for  Epilepsy.  This  matter  has  been  referred 
to  at  p.  279.  Though  cases  have  been  pubhshed  in  which  some  rehef 
has  followed  this  operation, ^  it  is  now  recognised  that  the  relief  is 
only  of  a  temporary  nature.  It  is  now  generally  regarded,  that  with  the 
exception  of  suitable  cases  of  traumatic  epilepsy  [q.v.),  epilepsy  is  mihkely 
to  be  benefited  by  operative  treatment.  The  follo\\dng  words  of  Sir  W. 
Macewen,  though  spoken  many  years  ago,  have  still  an  important  bearing 

^  An  authoritative  account  of  the  surgical  aspects  of  growths  of  the  cerebellum  has 
been  given  by  Dr.  C.  H.  Frazier  {New  York  Med.  Jount.,  February  11,  1905. 
^  See  Prof.  Keen,  Amer.  Journ.  Med.  Set.,  October  and  November  1888. 


324  OPERATIONS  ON  THE  HEAD  AND  NECK 

on  this  subject.  "  Can  the  motor  area  be  removed  in  large  pieces  with 
immunity  from  serious  consequences  ?  If  this  region  be  of  such  psychical 
importance  to  movement,  and  destructive  cortical  lesions  in  it  are  followed 
by  secondary  degeneration  of  the  motor  tracts,  then  excision  of  these 
areas  will  necessarily  induce  permanent  paralysis,  late  rigidity,  and  ulti- 
mate structural  contracture.  The  removal  of  large  wedges  from  the 
brain,  especially  in  the  motor  area,  will  produce  serious  effects  upon  the 
brain  as  a  whole,  causing  during  cicatrisation  a  dragging  and  displace- 
ment of  the  neighbouring  parts,  with  final  anchoring  of  the  cerebrum  to 
the  cicatrix."  ^ 

Causes  of  difficulty  in  cerebral  operations  and  of  their  not  doing  well. 
Most  of  these  have  been  fully  alluded  to. 

(1)  The  ancesthetic  may  not  be  well  taken  (pp.  248,  309).  The  possi- 
bility of  employing  local  anaesthesia  in  the  second  stage  of  the  operation 
has  been  pointed  out  at  p.  318. 

(2)  Hwmorrhage  (p.  320).  This  has  already  been  discussed.  Dr. 
Ransohoff '^  records  a  case  in  which  che  haemorrhage  met  with  during 
the  removal  of  the  bone  proved  actually  fatal. 

"  An  osteoi^lastic  resection  had  been  commenced  and  about  one  inch  of  the  bone 
cut  through  when  profuse  bleeding  occurred,  which  was  not  arrested  by  phigging 
with  Horsley's  wax.  The  bone  was  rapidly  removed  with  a  trephine  and  bone 
forceps  in  order  to  get  at  the  source  of  the  haemorrhage,  but  death  took  place 
just  as  the  dura  was  reached.  A  glio-sarcoma,  the  size  of  a  small  peach,  not 
adherent  to  the  dura  was  found  just  under  the  trephine  opening.  The  diploic 
veins  in  the  neighbourhood  of  the  opening  were  much  enlarged.  There  had  been 
no  unusual  bleeding  from  the  scalji.  Raising  the  patient  into  the  ujiright  position 
was  of  no  avail,  and  there  was  no  time  for  ligature  of  the  carotid." 

In  two  cases  the  haemorrhage  has  occurred  some  little  time  after  the 
operation,  and  has  then  been  due  to  the  vomiting  after  the  anaesthetic. 

(3,  4  and  5)  Difficulties  in  sufficiently  exposing  the  area  occupied  by 
the  growth,  in  detecting,  and  in  isolating  it. 

(6)  Shock.  Many  of  the  causes  of  this  are  sufficiently  obvious.  One 
may  be  mentioned  which  has  not  been  already  discussed,  i.e.  the  inter- 
ference with  subjacent  parts  of  the  brain,  or  the  opening  of  a  lateral 
ventricle  in  the  removal  of  a  deep-lying  growth. 

(7)  (Edema  of  the  lungs.  This  is  especially  likely  after  prolonged 
operations,  where  it  has  been  necessary  to  give  ether,  and  in  cases  where, 
for  some  time  before  the  operation,  the  patient  has  been  practically  bed- 
ridden, and  the  functions  at  a  very  low  ebb. 

(8)  Hernia  Cerebri.  This  may  occur  in  two  ways :  {a)  Immediately, 
during  the  operation,  in  a  case  where  there  is  much  evidence  of  intra- 
cranial pressiu-e,  and  where  it  has  not  been  possible  to  remove  the  cause. 
Thus,  in  a  case  of  Dr.  Pilcher's,  the  projecting  cerebral  mass  was  so 
great  in  volume  and  so  tense  that  there  was  no  possibility  of  returning 

^  "  Anchoring  of  the  brain  and  some  of  its  consequences. ^ — When  injury  has  been  in- 
flicted on  the  surface  of  the  cerebrum,  followed  by  plastic  effusion  and  cicatricial  forma- 
tion, the  superficial  substance  is  apt  to  become  soldered  to  the  membranes  when  these 
remain  intact,  which  may  in  turn  be  fixed  to  the  skull,  or,  in  the  event  of  their  detach- 
ment, the  brain  may  become  directly  adherent  to  the  bone.  Thus  the  surface  of  the 
brain  becomes  anchored  to  the  rigid  cranial  wall.  It  has  no  longer  the  free  play  within 
its  water  bed  fco  expand  and  contract  according  to  the  varying  state  of  the  circulation. 
Each  variation  produces  a  dragging  of  the  brain  at  the  spot,  and  through  it  the  whole 
hemisphere  is  affected.  Any  sudden  physical  effort  jiulls  on  the  brain,  producing  a  slight 
shock,  just  as  if  the  cerebrum  had  received  a  blow.  Vertigo  results.  Following  upon 
this,  the  grey  matter  of  the  cortex,  immediately  surrounding  the  cicatrix,  by  the  incessant 
movement  is  apt  to  become  unstable  and  produce  fits.  Some  cases  of  traumatic  epilepsy 
are  thus  caused."  ^  Trans.  Amer.  Surg.  Assoc,  1903. 


CRANIECTOMY  FOR  MICROCKPHALUS,  IDIOCY,  ETC.  325 

it  within  the  cranial  cavity.  It  was,  accordingly,  sliced  down  to  the 
level  of  the  bone.^  (6)  Later  on  it  may  point  to  unrelieved  tension, 
(c)  In  other  and  more  immerous  cases  a  later  hernia  cerebri  indicates 
infective  changes,  or  may  be  the  result  of  softening  of  the  brain. 

(9)  Impossibility  of  complete  removal. 

(10)  The  liability  of  patients,  with  increased  intracranial  pressure  due 
to  the  presence  of  a  growth,  to  sudden  and  unexpected  death,  has  already 
been  mentioned. 

Sir  D.  Ferrier  -  gives  two  instances  in  which  sudden  death  occurred. 
In  one,  a  growth  the  size  of  a  hen's  egg  was  found  at  the  necropsy,  under 
the  cortex  in  the  area  of  Rolando  ;  while  in  the  other  the  symptoms 
pointed  to  a  growth  in  the  upper  part  of  the  same  area. 

(11)  Septicaemia  and  allied  conditions. 

(12)  Reappearance  of  the  growth. 

CRANIECTOMY  FOR  MICROCEPHALUS.   IDIOCY.   ETC. 

Lannelongue's  suggestion  of  invoking  the  aid  of  surgery  in  the  treat- 
ment of  imbecility  ^  aroused  much  interest,  and  in  the  immediately 
succeeding  years  a  large  number  of  cases  were  submitted  to  craniectomy, 
with  a  view  of  either  removing  some  morbid  condition  or  relieving  pressure 
on  the  brain,  or  in  some  way  stimulating  its  development.  Like  some 
other  advances  of  modern  surgery,  it  has  not  been  based  on  the  sound 
foundation  of  pathology  or  common  sense.  The  disease  is  probably 
primarily  due  to  defective  cerebral  development,  the  early  ossification  of 
the  sutures  being  secondary  to  this.  These  hopeless  pathological  con- 
ditions, the  poor  vitality  of  the  patients,  and  their  mifitness  for  severe 
surgical  operations,  render  the  results,  as  might  have  been  expected, 
very  unsatisfactory. 

It  is  first  necessary  to  consider  what  'pathological  conditions  are  likely  to  he  met 
ivith  and  how  far  theij  are  remediable.  These  appear  to  be:  (i)  Microcephalus, 
whether  due  to  premature  closure  of  the  cranial  sutures  (Virchow),  or  secondary 
to  maldevelopment  of  the  brain  (Broca).  In  the  following  conditions  the  brain  is 
at  fault,  with  or  without  marked  microcephalus,  and  sclerosis  and  atrophy  are  met 
with  in  a  varying  degree  in  nearly  all.  (ii)  Porencephalits.  By  this  is  meant  a 
localised  atrophy,  leaving  a  cavity  in  either  cerebral  hemisphere,  which  may  be 
deep  enough  to  open  into  a  lateral  ventricle,  (iii)  Maldevelopment  and  atrophy 
of  the  minute  structure  of  the  cortex  of  the  hemispheres,  without  any  gross  defecte. 
(iv)  Meningo-encephalitis,  leading  to  thickening  of  the  meninges  and  atrophy  of  the 
cortex,  (v)  Cysts,  perhaps  containing  blood  (q.v.).  (vi)  Hiemorrhages  into  or  on 
the  surface  of  the  brain,  (vii)  Hydrocephalus.  This  last  will  be  sei:)arately  con- 
sidered. It  is  obvious,  first,  that  many  of  the  above  are  only  to  be  recognised  by 
exploration,  and  that  most  of  them,  if  found,  are  hopeless  of  improvement.  Thus 
it  is  clear  that  where  sclerosis  and  atrophy  are  present  to  a  marked  degree,  in  cases 
of  porencephalus.  where  one  entire  hemisphere  is  converted  into  a  cystic  cavity 
surrounded  by  slu-unken  brain  tissue  and  thickened  arachnoid,  interference  will 
be  futile.  In  the  latter  it  may  be  fatal  by  the  shock  that  will  follow  on  the  with- 
drawal of  a  relatively  large  amount  of  cerebro-spinal  fluid. 

Dr.  J.  Griffiths,  of  Cambridge,^  showed  that  the  skulls  of  microcephalic 
idiots  may  be  classified  in  the  following  groups  :  (a)  The  skull  is  of  normal 
shape  and  outline,  but  small,  ill-developed,  and  ill-filled.  There  is  no 
premature  synostosis  of  the  sutures.  (6)  The  skull  is  not  only  small,  but 
deformed  from  imequal  growth.  Whether  this  deformity  is  due  to 
primary  disease  of  the  bones  or  to  premature  synostosis  of  several  of  the 

1  Ann.  of  Surg.,  March  1889.  ^  Brit.  died.  Joum..  October  1,  189S,  p.  965. 

*  Btdl.  de  VAcad.  des  Sciences,  1890,  and  Union  Medicate,  t.  i,  1890,  p.  42.    ' 

*  Proc.  Med.  Chir.  Sac,  March  8,  1898. 


326  OPERATIONS  ON  THE  HEAD  AND  NECK 

sutures,  or  whether  it  is  due  to  disease  as  well  as  defective  growth  of  the 
brain,  is  still  an  open  question.  As  in  one  form  of  microcephaly  the  brain 
itself  is  generally  defective  in  the  power  of  growth,  its  development 
having  been  arrested  at  an  early  period  of  embryonic  life,  and  as  in  the 
other  there  is,  in  addition  to  arrested  development,  disease  of  the  brain 
substance,  and  as  the  existence  of  cases  of  microcephaly  in  which  prema- 
ture synostosis  has  been  able  to  impede  or  dwarf  the  growth  of  a  normal 
brain  is,  as  yet,  quite  hypothetical,  craniectomy  can  be  productive  of  no 
permanent  good,  the  original  fault  being  in  the  cerebrum  and  not  in  the 
skull. 

In  recommending  operative  steps  the  wise  surgeon  will  be  careful 
not  to  be  too  sanguine,  remembering  the  nature  of  many  of  the  conditions 
which  he  may  meet  with,  and  the  impossibility  of  improving  some  of  them. 
Furthermore  it  must  be  remembered  that  here,  as  in  trephining  for  epilepsy, 
cases  have  been  reported  much  too  soon  to  be  looked  upon  as  successes. 

The  second  point  is,  that  we  are  here  dealing  with  very  vital  parts 
in  patients  of  poor  vitality,  and  that,  unless  the  surgeon  is  careful  not  to 
attempt  too  much,  death  from  shock  will  be  a  very  present  danger. 
Thirdly,  many  fatal  cases  have  not  been  published,  and  we  do  not  know 
what  the  mortality  of  this  operation  really  is. 

Before  leaving  the  question  of  the  advisability  of  operative  interference 
in  microcephaly  the  conclusions  of  Prof.  Keen,  of  Philadelphia,  may  be 
quoted — conclusions  which  are  most  valuable  on  account  of  his  long 
experience  in  operative  surgery,  and  especially  from  his  well-known  skill 
in  operations  on  the  head  and  brain.  Prof.  Keen  performed  craniectomy 
in  eighteen  cases  of  microcephaly,  the  youngest  patient  being  eighteen 
months  and  the  eldest  seven  and  a  half  years  old.  In  five  cases  the  opera- 
tion was  fatal  ;  in  six  cases  slight  improvement  followed  ;  in  seven  none 
at  all.  Prof.  Keen's  conclusions  are  as  follows  :  No  good  can  be  expected 
from  the  operation  in  cases  with  average-sized  heads,  nor  in  those  cases 
with  extreme  microcephaly,  nor  when  the  patient  is  over  seven  years  old. 
In  one  case  a  restless,  mischievous  idiot  was  transformed  into  a  "  quiet, 
sleepful  child  "  ;  but  the  improvement,  when  there  is  any,  is  usually 
slight.  Much  depends  upon  special  education  after  the  operation.  In 
some  cases  of  moderate  microcephaly  the  operation  is  justifiable,  and  in  a 
small  number  a  slight  improvement  will  follow  ;  but  in  the  majority  there 
will  be  no  result,  good  or  bad  ;  while  in  a  definite  proportion  (15  per  cent.) 
"  the  operation  will  happily  be  followed  by  death."  ^ 

Dr.  J.  Chalmers  Da  Costa  adds  the  weight  of  his  opinion  to  the  above. 

"  Microcephalus  is  not  the  result  of  premature  sutural  ossification.  A  micro- 
cephalic brain  is  not  a  more  or  less  normal  brain  of  very  small  size,  the  idiocy 
resulting  from  the  smallness  of  the  parts  j^resent,  but  is  always  an  abnormal  and 
undeveloped  and,  in  many  cases,  a  diseased  brain.  If  a  strip  of  bone  is  removed 
from  the  skull,  new  normal  brain  cells  will  not  be  produced.  Parts  that  are  entirely 
absent  cannot  be  created,  and  powers  that  do  not  exist  cannot  be  called  into  being. 
The  reported  improvement,  if  continuous,  is  not  due  to  the  operation,  but  to 
proper  instruction  and  care.  The  proper  treatment  for  microcephalus  is  educa- 
tional, hygienic  and  disciplinary."  ^ 

This  writer  puts  the  mortality  as  "nearer  15  than  2  per  cent,  as  alleged." 

Operation.     We  will  consider  first  a  case  in  which  there  is  marked 

microcephalus,  in  which,  perhaps,  premature  ossification  is  the  cause  of 

the  trouble.     The  operation  should  always  be  of  the  nature  of  a  linear 

1  Journal  of  Nervous  and  Mental  Diseases,  February  1898. 

2  Ibid.  June  1904. 


TREPHININC;  IN  (iENKUAL  PARALYSIS  327 

craniectomy,  completed  as  speedily  as  possible.  Every  precaution 
should  be  taken  against  shock,  and  if  the  ha3morrhage  has  been  severe  it 
may  be  necessary  to  resort  to  infusion  of  saline  fluid.  Lannelongue  ^ 
operated  in  his  first  case  as  follows  :  Having  made  an  incision  through 
the  scalp  and  pericranium  just  to  the  left  of  the  sagittal  suture,  a  small 
circle  of  bone  was  removed  with  a  trephine,  a  finger's  breadth'  from  the' 
suture  ;  from  this  as  a  starting-point,  a  narrow  strip  of  bone  was  cut  out 
parallel  with  and  to  the  left  of  the  sagittal  suture,  extending  from  the 
coronal  to  the  lambdoid  suture.  The  periosteum  was  not  replaced.  Sir 
V.  Horsley  removes  the  periosteum  over  the  bone  to  be  excised.  This  last 
step  he  effects  by  making  parallel  saw-cuts  backwards  and  forwards 
from  the  trepliine  opening,  and  then  removing  the  bone  between  the  saw- 
cuts  with  bone  forceps  such  as  those  of  De  Vilbiss.  In  some  cases  in 
addition  to  the  removal  of  bqne  parallel  to  the  sagittal  suture,  a  second 
narrow  strip  has  been  removed  over  the  corresponding  fissure  of  Rolando. 
The  dura  mater  is  not  incised  and  the  greatest  care  must  be  taken  to  avoid 
injury  to  it  during  the  operation.  Dr.  Griffiths  ^  and  others  have  estab- 
lished artificial  lambdoid  sutures,  operating  at  intervals,  first  on  one 
side  of  the  skull  and  then  on  the  other.  Numerous  other  incisions  have 
been  employed  for  the  craniectomy,  among  which  may  be  mentioned  an 
elhptical  or  H -shaped  craniectomy  of  the  vertex,  and  a  large  horse-shoe- 
shaped  division  of  the  bone  on  the  lateral  aspect  of  the  skull. 

Dangers  of  the  Operation.  These  are  chiefly  :  (1)  Shock.  (2)  Haemor- 
rhage. Haemorrhage  from  the  scalp  may  be  met  by  drainage  tubing 
passed  round  the  head  or  by  Makka's  clamps,  but  other  bleeding  may  be 
encountered.  (3)  Injury  to  the  dura  mater,  especially  adherent  in 
children.  (4)  Infective  changes  in  the  wound  ;  these  patients,  restless 
and  ill-regulated  in  their  behaviour,  may  make  the  maintenance  of  asepsis 
very  difficult,  especially  in  older  and  thus  less  easily  managed  cases,  by 
tearing  off  their  bandages.     (5)  Hyperpyrexia  of  obscure  origin. 

TREPHINING  IN  GENERAL  PARALYSIS  OF  THE  INSANE,  AND  IN 
OTHER  FORMS  OF  INSANITY 

This  operation  has  been  recommended  on  the  authority  of  Dr.  Claye 
Shaw  ^  and  Dr.  J.  Batty  Tuke,^  but  the  results  have  been  such  that  it  does 
not  deserve  encouragement  even  as  a  palliative  step.  It  must  not  be 
forgotten  that  here  is  no  morbid  condition  that  can  be  cured  ;  that  the 
excess  of  fluid^ — the  removal  of  which,  and  so  the  relief  of  tension,  is  the 
object  of  trephining — is  variable  ;  and  while  it  is  clear  that  in  those  cases 
which  have  improved  after  the  operation  the  benefit  has  been  only 
temporary,  it  must  be  remembered  that  temporary  periods  of  spontaneous 
marked  improvement  are  not  uncommon. 

As  the  question  of  trephining  occasionally  arises  in  traumatic  insanity, 
Dr.  Da  Costa's  incisive  remarks  as  to  the  principles  which,  should  guide 
us  may  be  quoted.^ 

Having  condemned  operation  in  cases  of  non-traumatic  insanity,  hypochon- 
driacal delusions  and  hallucinations,  Da  Costa  divided  cases  of  travsmatic  insanity 
into  two  classes.  To  the  first  belong  those  cases  in  which  the  injury  has  caused 
no  gross  lesion  and  in  which,  on  account  of  trivial  shock,  mental  or  physical,  the 

^  UUnion  Medicnle,  July  8,  1890.  ^  Loc.  supra  cit. 

^  Brit.  Med.  Joiirn.,  vol.  ii,  1889,  p.  1090  ;   vol.  ii,  1891,  p.  581. 

*  Ihid.,  vol.  i,  1890,  p.  8. 

*  Journal  of  Nervous  and  Mental  Diseases,  June  1904. 


328         OPERATIONS  ON  THE  HEAD  AND  NECK 

patient  has  developed  a  distinct  neurosis,  on  the  basis  of  which  a  psychosis  has 
supervened.  In  this  group  operation  is  not  to  be  thought  of.  In  the  second  group 
are  found  cases  in  which  the  injury  is  the  direct  and  sufficient  exciting  cause  of  the 
condition.  Here  the  insanity  may  develop  at  once  or  some  time  after  the  injury. 
Whether  the  insanity  follows  sooner  or  later,  the  chief  indications  are  depression 
of  bone,  local  tenderness,  fixed  headache,  or  some  localising  .symptom.  When 
there  are  positive  signs  of  increased  pressm-e,  trephining  as  a  palliative  measure 
may  be  considered  proper.  "  One  should  not  operate  upon  a  case  simply  because 
there  is  a  dubious  record  of  an  antecedent  fall  or  blow,  which  merely  suggests  the 
possibility  of  a  traumatic  origin  for  the  insanity."  Da  Costa  believes  that  injury 
is  the  direct  cause  of  insanity  in  only  2  per  cent,  of  the  cases. 

OPERATIVE   TREATMENT   OF   HYDROCEPHALUS.     DRAINAGE   OP 

THE  VENTRICLES 

In  hydrocephalus  there  is  distension  of  the  ventricles  with  cerebro-spinal 
fluid.  The  condition  may  be  congenital  'or  it  may  commence  during 
the  first  few  years  of  life.  As  medical  treatment  is  ineffective,  surgical 
treatment  may  be  called  for.  Unfortunately,  in  the  majority  of  the  cases, 
the  distension  of  the  ventricles  is  secondary  to  some  disease  in  the  cere- 
bellum, corpora  quadrigemina,  or  crura  cerebri  obstructing  the  veins  of 
Galen,  or,  as  Mr.  Hilton  showed  long  ago,^  to  occlusion  of  the  cerebro  spinal 
opening  in  the  fourth  ventricle — all  equally  hopeless  forms  of  disease. 
In  other  cases  the  collection  of  fluid  is  due  to  meningitis,  tuberculous, 
syphilitic,  or  cerebro-spinal.  By  others  hydrocephalus  is  regarded  as 
dependent  upon  an  arrest  of  development  of  the  brain. 

Simple  tapping  of  the  ventricle  through  a  lateral  angle  of  the  anterior 
fontanelle  has  been  often  carried  out,  w^ith  the  result  of  often  giving 
marked  relief,  obviously,  from  the  nature  of  the  cause,  only  temporary, 
convulsions  and  coma  carrying  off  the  patient  after  a  varying  interval. 
Withdrawal  of  the  fluid  slowly  by  a  Southey's  tube  has  been  equally 
unsuccessful. 

Drainage  of  the  Lateral  Ventricles.  Prof.  Keen,  of  Philadelphia,  was 
the  first  to  formulate  this  operation,  as  distinguished  from  the  ordinary 
puncture. 

The  ventricle,  in  a  boy  aged  4  years,  was  exposed  by  trephining  one  inch  and  a 
quarter  above  and  behind  the  external  auditory  meatus,  and  by  puncturing  the 
brain  with  a  needle  at  this  spot.  At  a  depth  of  about  an  inch  and  three-cpiarters 
the  ventricle  was  reached  and  cerebro-spinal  fiuid  escajjed.  Three  double  horsehair 
sutm-es  were  then  introduced  and  the  needle  withdrawn.  Drainage  thus  estab- 
lished was  kept  up  for  fourteen  days,  when  the  horsehair  was  replaced  by  a  drainage 
tube.  On  the  twenty-eighth  day  after  tlie  operation,  the  symptoms  returning,  a 
corresponding  operation  was  performed  on  the  right  side.  The  cliild  died  on  the 
fort  J'- fifth  day. 

Intracranial  Drainage  o£  the  Ventricles  by  making  a  communication 
between  the  ventricles  and  the  subdural  space.  This  method  was  brought 
before  the  Clinical  Society  by  Dr.  Sutherland  and  Sir  W.  Watson  Cheyne.^ 
The  operation  is  based  upon  the  experiments  of  Dr.  Leonard  Hill.^ 

The  child,  aged  G  months,  was  markedly  hydrocephalic,  emaciated,  anaemic,  with 
intelligence  undeveloiDcd,  and  quite  blind.  The  condition  was  attributed  to  con- 
genital syphilis.  The  dura  was  exposed  at  the  left  lower  angle  of  the  anterior 
fontanelle.  To  form  a  drain  a  bundle  of  the  iinest  catgut,  containing  some  sixteen 
strands  and  about  two  inches  long,  had  been  prepared,  one  end  of  the  strands  being 
tied. together,  and  the  other  end  free.     The  dm-a  mater  was  incised  and  the  tied  end 

^  Rest  and  Pain,  Lectures  ii  and  iii.     Mr.  Hilton  first  noted  this  fact  in  1844. 

*  Trans.,  vol.  xxxi,  p.  166. 

^  Physiology  and  Pathology  of  the  Circulation,  1896. 


DRAINAGE  OF  THE  VENTRICLES  329 

of  tlie  huiuUe  was  ])ushed  downwards  and  backwards  between  the  brain  and  (lie  dura, 
i.e.  in  the  subihual  space  ;  the  other  end  was  jnished  through  the  thinned  cerebral 
substance  into  the  lateral  ventricle.  The  incision  in  the  dura  was  closed.  On  the 
Hfth  day.  when  the  wound  was  healed,  it  was  noticed  that  the  head  was  distinctly 
smaller  in  all  dimensions.  This  diminution  in  size  continued,  but  without  any  im- 
provement as  regards  the  child's  intelligence  or  vision.  Symptoms  of  basal  men- 
ingitis began  to  a])})ear  nine  weeks  after  the  operation,  and  death  followed  three 
weeks  later.  At  the  necropsy,  though  the  ventricles  were  not  distended,  a  consider- 
able quantit3f  of  iluid  remained  in  the  subdural  space. 

The  best  material  for  gradual  drainage  would  appear  to  be  strands  of 
sterilised  silk  as  used  by  Mr.  W.  S.  Haudley  in  the  operation  of  lymph- 
angioplasty.  Mr.  Pendlebury  thus  describes  an  operation  in  which  this 
material  is  used.^ 

"A  sharp  pedicle  needle  with  a  good  curve  is  threaded  with  No.  12  plaited  silk, 
both  having  been  carefully  sterilised.  The  thread  when  doubled  is  at  least  thirty 
inches  long.  The  head  is  shaved  and  made  thoroughly  aseptic.  A  spot  about 
one  inch  to  one  side  of  the  middle  line  is  chosen  as  near  the  posterior  part  of  the 
anterior  fontanelle  as  ])ossible.  With  a  tenotome  make  a  tiny  incision  through  the 
skin  in  this  position.  Push  the  threaded  needle  into  the  lateral  ventricle,  curve  it 
through  the  falx  cerebri  into  the  opposite  ventricle,  and  bring  it  through  the  skin 
in  a  corresponding  position  on  the  other  side  of  the  mid-line.  Withdraw  the  pedicle 
needle,  leaving  the  silk  in  situ.  Thread  the  double  silk  of  one  side  on  to  a  long 
probe  and  push  the  probe  beneath  the  skin  backwards  into  the  nape  of  the  neck. 
Do  the  same  with  the  silk  on  the  other  side.  Cut  off  the  superfluous  silk  and  put 
a  stitch  into  each  of  the  small  wounds  that  have  been  made  in  order  to  introduce 
the  probe  and  the  silk  it  carries  beneath  the  skin.  The  doubled  silk  now  connects 
both  ventricles  with  each  other  and  with  the  connective  tissue  of  the  neck." 

Drainage  of  the  Fourth  Ventricle.  This  was  performed  by  Mr.  Stiles 
in  a  case  of  acquired  hydrocephalus  due  to  basal  meningitis.^ 

The  patient,  aged  13,  with  well-marked  evidence  of  congenital  syphilis,  presented 
symptoms  of  chronic  basal  meningitis,  viz.  irregular  pjTcxia,  persistent  head 
retraction,  nystagmus,  gradually  increasing  blindness,  great  weakness  and  emacia- 
tion. This  condition  becoming  critical,  with  marked  cyanosis  and  rigors,  it  was 
decided  to  open  the  fourth  ventricle  and  drain  the  ventricular  system.  IVIr.  Stiles 
trephined  in  the  middle  line  over  the  lower  part  of  the  occipital  bone,  including 
the  margin  of  the  foramen  magnum,  and  enlarged  the  opening  by  forceps.  The 
dura  mater  was  opened  after  the  occipital  sinus  had  been  secured  between  two 
ligatures.  Separation  of  the  two  tonsils  of  the  cerebellum  allowed  of  the  escape 
of  nuich  cerebro-spinal  fluid.  Immediate  improvement  followed  the  operation 
and  lasted  for  a  week,  when  there  was  again  a  rise  of  temperature.  Death  occiu-red 
wath  hyperpjTCxia  nineteen  daj's  after  the  operation,  much  cerebro-spinal  fluid 
having  drained  aw^ay  in  the  interval. 

^  St/stem  of  Treatment,  Latham  and  English,  vol.  ii,  p.  1193. 

*  Bruce  and  StUe.s,  Trans.  Edin.  Med.-Chir.  Soc,  1898,  vol.  xvii,  p.  73. 


CHAPTER  XVI 
OPERATIONS  ON  THE  EAR 

A.  OPERATIONS  ON  THE  EXTERNAL  EAR 

These  will  require  but  a  brief  description.  Growths,  especially  papillo- 
mata  and  epitheliomata,  are  occasionally  met  with.  The  latter  require 
free  removal.  Rodent  ulcers  are  not  infrequently  found  invading  the 
external  ear  :  they  should  be  treated  on  the  hues  recommended  at  p.  394. 

Boils  or  Furuncles  in  the  external  auditory  meatus  are  often 
exceedingly  troublesome.  They  are  the  source  of  much  severe  pain,  and 
often,  as  one  abscess  subsides,  others  make  their  appearance. 

Treatment.  Owing  to  the  extreme  tenderness  a  general  anaesthetic 
is  necessarv  :  a  free  incision  is  then  made  into  the  centre  of  the  swelling 
which  usually  contains  a  small  amount  of  thick  pus.  The  ca\aty  is  then 
lightly  plugged  with  sterilised  gauze  and  a  hot  boracic  fomentation  is 
applied.  The  plug  should  be  changed  daily,  and  the  meatus  syringed 
with  carbohc  lotion  (1  in  -iO).  A  bacteriological  examination  of  the  pus 
should  always  be  made,  for,  in  recurring  cases,  a  vaccine  is  often  of  the 
greatest  service. 

Exostoses  are  occasionally  found  in  the  external  auditory  meatus. 
They  may  be  sessile  and  composed  of  cancellous  bone,  or  exceedingly  hard 
(ivory  exostosis).  Should  the  growth  be  pedunculated  it  may  be 
removed  through  the  external  auditory  meatus.  If  sessile  or  diffuse  the 
treatment  will  depend  upon  the  symptoms  present.  Should  there  be 
suppuration  in  the  middle  ear  they  should  always  be  removed,  as  the 
retention  of  discharge  which  is  certain  to  occur  is  liable  to  favour  an 
extension  of  the  septic  process  to  the  mastoid  or  to  the  cranial  cavity. 
In  other  cases  operation  will  be  indicated  if  there  is  a  tendency  to  occlude 
the  meatus,  or  if  they  are  causing  deafness.  If  the  growth  is  situated  near 
the  external  orifice  of  the  canal  it  may  be  removed  by  a  dental  drill, 
or  burr,  through  the  external  auditory  meatus.  If  its  attachment  is 
more  deeply  situated  it  is  best  to  make  a  curved  incision  immediately 
behind  the  auricle,  to  detach  the  cartilaginous  meatus  from  the  bone,  and 
then  to  remove  the  tumour  by  one  of  the  above  means  or  by  a  chisel.  The 
greatest  care  must  be  taken  to  avoid  damage  to  the  tympanic  membrane 
and  other  important  structures.  When  the  operation  is  completed  the 
wound  is  closed  and  the  meatus  hghtly  packed  with  sterilised  gauze. 
This  must  be  changed  daily  and  all  blood  and  discharge  washed  away  by 
gentle  syringing  with  dilute  carbolic  lotion. 

Foreign  Bodies  in  the  Ear.  These  may  usually  be  removed  by  syringing, 
or  by  the  use  of  aural  forceps,  or  a  small  ear  hook.  In  rare  cases  where 
the  foreign  body  is  firmly  impacted  it  will  be  necessary  to  make  a  curved 
incision  behind  the  ear,  detach  the  cartilaginous  meatus,  and,  after  incising 
this  in  the  longitudinal  direction,  displace  the  foreign  body  by  passing 
a  small  elevator  beyond  it  and  so  levering  it  out  through  the  wound. 

330 


OPERATIONS  ON  THE  EAR  331 

Removal  of  Aural  Polypi.  It  is  first  necessary  to  point  out  that  aural 
polypi  are  really  niassesof  granulation  tissue,^  of  inflammatory  origin,  and 
that  their  presence  denotes  the  existence  of  suppuration.  Treatment  of  the 
polypi  nuist  therefore  be  only  a  part  of  the  treatment  of  the  suppuration 
of  which  they  are  a  complication.  If  of  sufficient  size  to  cause  any  obstruc- 
tion they  should  always  be  removed  :  indeed,  not  infrequently,  the 
removal  of  a  polypus,  by  allowing  of  free  drainage,  may  lead  to  a 
termination  of  the  suppuration. 

Before  the  operation  the  meatus  should  be  cleansed  as  thoroughly 
as  possible  by  careful  syringing,  e.g.  by  Lot.  Hydrarg.  Perchlor.,  1  in 
3000.  It  must  be  remembered  that  the  discharge  which  is  always 
present  is  very  infective  and  that  removal  of  a  polypus  may,  by  opening 
up  some  fresh  channel  for  infection,  be  followed  by  some  acute  trouble 
in  the  mastoid  or  the  middle  ear.  The  operation  may  be  carried  out 
under  local  anaesthesia,  induced  by  the  application  of  a  20  per  cent, 
solution  of  cocaine  and  a  solution  of  adrenalin  hydrochloride  (1  in 
1000)  :  in  children  or  in  nervous  patients  a  general  anaesthetic  is 
desirable.  The  polypus  is  best  removed  by  a  small  wire  snare  (Wilde's 
or  Gruber's).  The  attachment  of  the  polypus  may  be  verified  by  a  fine 
probe,  after  which  the  wire  loop  is  pushed  deeply  into  the  meatus  and 
pushed  over  the  polypus  till  it  encircles  the  latter.  The  snare  is  then 
tightened,  and,  as  soon  as  the  pedicle  is  gripped,  a  gentle  pull  brings  the 
polypus  away.  If  the  polypus  is  presenting  at  the  meatus  no  speculum 
will  be  required.  The  haemorrhage,  which  is  sometimes  severe,  may 
be  controlled  by  syringing  with  hot  sahne  solution.  The  meatus  is 
then  lightly  packed  with  a  little  ribbon  gauze  and  a  pad  of  gauze  is 
applied  over  the  external  ear.  The  gauze  packing  is  removed  at  the 
end  of  twenty-four  hours,  and  the  meatus  is  syringed,  daily.  It  may  be 
necessary  lightly  to  touch  the  point  of  attachment  of  the  polypus  with 
the  galvano-cautery.  Drops  of  rectified  spirit  are  often  of  service  in 
the  after-treatment. 

Incision  of  the  Tympanic  Membrane.  This  operation  is  indicated  under 
the  following  circumstances,  (a)  In  acute  suppurative  otitis  media, 
when  spontaneous  perforation  of  the  drum  has  not  taken  place,  and^when 
there  is  severe  pain  accompanied  by  pyrexia.  (6)  In  acute  otitis  media 
where,  though  perforation  has  occurred,  pain  still  continues,  owing  to  the 
opening  being  too  small  to  allow  of  free  escape  of  the  pus.  Occasionally 
the  pain  and  discharge  cease  after  the  escape  of  pus,  only  to  be  followed  by 
a  further  abscess  owing  to  the  perforation  being  of  insufficient  size  to  secure 
free  drainage.  This  process  may  be  repeated  a  number  of  times,  (c)  In 
some  cases  of  chronic  catarrh  where  there  is  excessive  secretion  and  the 
drum  is  bulged  outwards. 

Operation.  Owing  to  the  extreme  tenderness  of  the  inflamed 
structures,  and  the  necessity  for  deliberation  on  the  part  of  the  operator, 
a  general  anaesthetic  such  as  nitrous  oxide  gas  and  oxygen,  is  desirable. 
The  external  meatus  must  be  irrigated  wdth  some  dilute  antiseptic  lotion 
to  remove  all  cerumen  or  epitheHal  debris,  and  is  then  dried  with  pledgets 
of  cotton  wool.  The  incision  is  made  with  a  small,  sharp  triangular 
myringotome  (Fig.  138  B).  A  large  speculum  is  introduced  and  a  strong 
light  thrown  on  the  membrane  either  from  a  forehead  mirror  or  a  head 
lamp.     Generally  speaking,  the  cut  should  be  made  below  and  behind 

^  Hence  after  the  removal  of  the  polypus  the  treatment  must  be  directed  to  the 
suppuration  and  its  cause. 


332  OPERATIONS  ON  THE  HEAD  AND  NECK 

the  handle  of  the  malleus.  The  knife  is  pushed  through  the  drum  close 
to  its  inferior  border,  and  then  cuts  in  an  upward  and  backward  direction, 
passing  midway  between  the  malleus  and  the  margin  of  the  membrane. 
If  cut  in  this  direction  the  edges  of  the  wound  will  retract  and  so  ensure 
free  drainage.  Owing  to  the  obhque  position  of  the  membrane,  the 
knife,  if  it  be  made  to  cut  downwards  and  forwards,  must  also  be  directed 
inwards  ;  otherwise  a  mere  puncture  instead  of  a  free  incision  will  be 
made.  If  there  is  already  a  perforation  or  if  there  is  a  locahsed  bulging 
the  incision  must  commence  at  this  point.  The  inner  wall  of  the  tym- 
panum must  be  avoided.  At  the  conclusion  of  the  operation  the  meatus 
is  again  gently  irrigated  and  then  hghtly  plugged  with  sterilised  gauze. 


SMIZ/^P/^ELIS      M£MBK/^f^E. 


PROCESS  l/J    BR£y*S 


M^^DLC    O^    f^z-ilU^SuS 


Carf£     Of'    L/OMT 


B. 

Fig.  138.     A,  The  tympanic  membrane,  showing  the  line  of  incision  in 
mj'^ringotomy.     B,  Politzcr's  mj'ringotomc. 

B.  OPERATIONS  FOR  THE  COMPLICATIONS  OF  SUPPURATIVE 
OTITIS  MEDIA.  POINTS  OF  PRACTICAL  IMPORTANCE  TO  THE 
SURGEON  IN  THE  ANATOMY  OF  THE  PARTS  CONCERNED.  ^ 

I.  Tympanum,  (a)  Roof  always  thin,  not  more  than  a  line  and  a  half 
in  thickness,  often  thinner  ;  indeed,  the  bony  roof  may  be  more  or  less 
deficient,  when  a  thin  membrane  alone  intervenes  between  the  middle  ear 
and  the  cranial  cavity.  Through  this,  inflammation  in  otitis  media  readily 
reaches  the  brain,  causing  meningitis,  subdural  or  cerebral  abscess. 
(6)  Parts  of  the  brain  and  cerebellum  which  are  in  relation  ^^ath  the  middle 
ear.  These  are  the  middle  and  back  part  of  the  temporo-sphenoidal  lobe, 
and  the  outer  and  front  part  of  the  lateral  lobe  of  the  cerebellum,  (c)  The 
mucous  membrane  and  the  endosteum  lining  the  tympanum  are  in  most 
intimate  contact ;  hence,  in  otitis  media  caries  and  necrosis  readily 
occur,  especially  if  the  blood-supply  to  the  tympanum  from  the  dura 
mater  is  cut  off.  {d)  The  skin  of  the  external  auditory  meatus  is  con- 
tinuous with  the  membrane  tympani,  and  thus  otitis  media  may  be  set 
up  from  without,  as  well  as  by  mischief  reaching  the  tympanum  through 
(e)  the  Eustachian  tube,  which  enters  in  front,  and  makes  the  mucous 
membrane  of  the  throat  continuous  with  that  of  the  tympanum.  (/)  The 
outlet  of  the  mastoid  cells  and  antrum  is  inadequate  for  drainage  through 
the  cavity  of  the  tympanum,  partly  because  the  greater  part  of  the  cavity 

^  These  should  be  studied  together  with  a  skull  and  one  or  two  sections  of  a  temporal 
bone. 


THE  MASTOID  ANTRUM  AND  MASTOID  CELLS      333 

of  the  antrum  is  situated  below  the  level  of  the  aditus,  and  partly  because 
the  attic  of  the  tympanic  cavity  into  which  the  channel  opens  contains  the 
head  of  the  malleus  and  the  body  and  short  process  of  the  incus,  which 
will  hinder  the  free  escape  of  pus.  The  floor  of  the  tympanum  is,  in  part, 
below  the  orifice  of  the  Eustachian  tube,  which  thus  only  imperfectly 
drains  the  cavity  of  the  middle  ear. 

TI.  Mastoid  Antrum  and  Mastoid  Cells,     (-^z)  Their  development  varies 


Fig    139.     A,  Maccwcn's  triangle.     B,  Posterior  margin  of  the  external  audi- 
tory meatus.     C,  External  auditory  meatus.     D,  Posterior  root  of  zygoma. 
E,  Zygoma  cut  across. 

with  age.  In  adults,  if  well  marked,  they  may  measure  an  inch  and  a  half 
horizontally,  two  inches  vertically,  and  reach  quite  up  to,  and  even 
around,  the  lateral  sinus.  (6)  Two  groups  of  cells  are  present,  and  their 
relations  are  of  the  utmost  importance — A.  The  upper,  or  antrum,  present 
both  in  early  and  later  life,  horizontal  in  direction  and  closely  adjacent  to 
and  communicating  with  the  tympanum.  B.  The  lower,  or  vertical. 
These  cells  are  not  present  in  early  life,  and  vary  much  as  regards  their 
contents.  In  only  about  20  per  cent,  do  they  contain  air.  The  mastoid 
antrum  is  of  far  greater  importance.  This  is  a  small  chamber  lying 
behind  the  tympanum,  into  the  upper  and  back  part  of  which  (the 
tympanic  attic)  it  opens.  Its  size  varies,  especially  with  age.  Present 
at  birth,  it  reaches  its  largest  size,  that  of  a  pea,  about  the  third  or 
fourth  year.  After  this  it  usually  diminishes  somewhat  oA\'ing  to  the 
encroachments  of  the  developing  bone  around  it.  Its  roof,  the  tegmen 
antri,  is  merely  the  backward  continuation  of  the  tegmen  tympani. 
The  level  of  this  is  indicated  by  the  horizontal  root  of  the  zygoma. 
"  The  level  of  the  floor  of  the  adult  skull  at  the  tegmen  antri  is,  on 
an  average,  less  than  one-fourth  of  an  inch  above  the  roof  of  the 


334  OPERATIONS  ON  THE  HEAD  AND  NECK 

external  osseous  meatus ;  in  children  and  adolescents,  from  one- 
sixteenth  to  one-eighth  of  an  inch  "  (Macewen).  The  outer  wall  of  the 
antrum  is  formed  by  a  plate  of  bone,  descending  from  the  squamous  to 
join  with  the  mastoid  part  of  the  temporal.  This  is  very  thin  in  early 
life ;  but  as  it  develops  by  deposit  from  the  periosteum,  the  depth  of  the 
antrum  from  the  surface  increases.  Macewen  gives  the  average  for 
this  depth  as  varying  from  one-eighth  to  three-quarters  of  an  inch.     At 


Fig.  140.  Oblique  section  through  the  right  temporal  bone  passing  through  the 
carotid  canal,  the  tympanic  cavity,  and  the  antrum.  The  two  portions  of 
the  bone  are  oi>ened  out  so  that  on  the  left  the  outer  boundaries  of  these 
structures  are  seen  from  within,  while  on  the  right  the  inner  aspect  is  shown. 
J,  the  tegmen  tympani.  B,  the  attic.  C,  the  carotid  canal.  D,  the  handle 
of  the  malleus.  E,  the  tympanic  membrane.  F,  the  incus.  G,  the  mastoid 
process.  H,  the  mastoid  cells.  /,  the  stylo-mastoid  foramen.  K,  inner 
wall  of  tympanic  cavity.  L,  carotid  canal.  M,  promontory.  N,  aque- 
ductus  fallopii.     O,  antrum.     P,  additus. 

the  junction  of  the  two  parts  of  the  outer  wall  of  the  mastoid  antrum 

is  the  squamo-mastoid  suture,  often  still  present  at  puberty.     Through 

the  floor,  formed  by  the  petro-mastoid,  the  antrum  communicates  with 

the  lower  or  vertical  cells  of  the  mastoid.     This  floor  is  on  a  lower  level 

than  the  opening  into  the  tympanum,  and  thus  drainage  of  an  infected 

antrum  is  difl&cult,  fluid  finding  its  way  more  readily  into  the  lower 

cells.     Behind  the  mastoid  antrum  is  the  bend  of  the  sigmoid  part  of 

the  lateral  sinus,  with  its  short  descending  portion. ^     The  sinus  lies  more 

superficially  than  the  antrum,  being  usually  one  fourth  of  an  inch,  occa- 

1  Korner,  of  Frankfort,  has  shown  (Arch,  of  OtoL,  vol.  xviii,  1889,  p.  311)  that  fatal 
intracranial  diseases  (meningitis,  sinus-phlebitis,  and  abscess)  more  frequently  occur  with 
disease  of  the  right  petrous  than  the  left.  This  is  due  to  the  fact  that  the  right  lateral 
sinus,  and  its  sigmoid  flexure,  come  more  forward  into  the  mastoid  and  base  of  the 
petrous  than  does  the  left,  and  therefore,  with  its  dura  mater,  lies  nearer  to  the  primary 
disease. 


THE  MASTOID  ANTRUM  AND  MASTOID   (  KIJ.S     335 

sionally  half  an  inch,  I'loiii  the  surface.  The  iimer  wall  is  formed  partly 
by  tlio  petrous  and  i)artly  by  tlie  mastoid  ])ortions  of  the  temporal  bone. 
The  exact  position  of  the  antrum,  a  little  above  and  behind  the  bony 
external  auditory  meatus,  is  represented  by  Macewen's  "  suprameatal 
triangle."  This  is  a  triangle  bounded  by  the  posterior  root  of  the  zygoma 
ajbove,  the  ujiper  and  posterior  segment  of  the  bony  external  meatus 
below,  and  an  imaginary  line  joining  the  above  boundaries.  "  Roughly 
speaking,  if  the  orifice  of  the  external  meatus  be  bisected  horizontally, 


Fig.  141.  The  outer  wall  of  the  mastoid  bone,  the  antrum,  attic,  and  tym- 
panum, together  with  the  posterior  wall  of  the  oseous  meatus,  have  been  re- 
moved here  in  order  to  show  the  field  of  operation  in  a  case  of  chronic 
extensive  disease.  It  will  be  noticed  that  the  mastoid  cells,  both  horizontal 
and  vertical,  are  widely  developed.  (1)  Posterior  root  of  the  zygoma,  forming 
the  upper  boundary  of  Macewen's  triangle.  (2)  Antrum  and,  in  front  of  it, 
the  attic.  (3)  Vertical  cells  of  the  mastoid.  Where  these  are  well  developed 
and  become  infected,  Bezold's  mastoiditis  (p.  338)  will  occur.  (4)  Ridge  on 
the  inner  wall  of  the  tympanum  indicating  the  Fallopian  ac[ueduct. 
(5)  Fenestrae  in  the  inner  wall  of  the  tympanum,  indicated  in  shadow.  (6)  A 
natural  deficiency  in  tegmen  enlarged  with  a  small  osteotribe  to  remind  my 
readers  how  thin  is  the  roof  of  the  antrum  and  tympanum.  (7)  Cells  present  in 
this  case,  even  in  the  zygoma  at  its  junction  with  the  middle  root.  This  will 
show  how  difficult  it  is  in  some  cases  to  bring  about  complete  asepsis. 


the  upper  half  would  be  on  a  level  with  the  mastoid  antrum.  If 
this  segment  be  again  bisected  vertically,  its  posterior  half  would 
correspond  to  the  junction  of  the  antrum  and  middle  ear,  and  immediately 
behind  this  lies  the  suprameatal  fossa  "  (Macewen).  When  opening 
the  antrum  through  this  triangle  the  operator  should  work  forwards  and 
inwards,  so  as  to  avoid  the  sigmoid  sinus,  while  to  keep  clear  of  the  facial 
nerve  (Figs.  140  and  141)  he  should  hug  the  root  of  the  zygoma  and  the 
upper  part  of  the  bony  meatus  as  closely  as  possible,  and  not  continue  his 
perforation  more  forwards  than  is  absolutely  needful.  The  level  of  the  base 
of  the  brain  will  be  a  few  lines  above  the  posterior  root  of  the  zygoma 
(Fig.  141)  and  about  one-quarter  of  an  inch  above  the  root  of  the  bony 
meatus. 


336  OPERATIONS  ON  THE  HEAD  AND  NECK 

In  the  first  few  years  of  life  certain  points  of  difference  exist  in  the 
anatomy  of  the  antrum,  which  are  of  practical  importance.  Speaking 
generally,  the  thinness  of  the  outer  wall  and  the  presence  of  the  squamo- 
mastoid  suture  favour  the  escape  of  infected  material  to  the  outside  of  the 
skull,  while  the  small  degree  of  development  of  the  mastoid  cells  also  helps 
to  render  less  frequent  intracranial  complications  at  this  age,  especially 
thrombosis  of  the  sigmoid  sinus.  Mr.  H.  Stiles  ^  points  out  two  more 
anatomical  details  which  should  be  remembered.  During  early  life  the 
undeveloped  condition  of  the  mastoid  process  leaves  the  stylo-mastoid 
foramen  exposed  upon  the  lateral,  not  the  under,  surface  of  the  base  of  the 
skull.  In  making  the  first  incision,  therefore,  by  which  the  soft  parts 
are  reflected  from  the  bone,  the  surgeon  should  take  care,  below  a  point 
on  a  level  with  the  middle  of  the  meatus,  to  make  his  incision  a  superficial 
one  only,  to  avoid  injuring  the  facial  nerve.  Secondly,  the  posterior  root 
of  the  zygoma,  which  in  the  adult  forms  a  surface-guide  to  the  level  of  the 
roof  of  the  antrum,  does  not  now  exist. 

B.  The  lower,  or  vertical.  These  cells  are  not  developed  in  early  life, 
and  vary  much  in  their  contents.  The  mastoid  process  begins  to  develop 
in  the  second  year.  As  it  increases  in  size,  the  mastoid  air-cells  make 
their  appearance,  but  they  do  not  reach  their  full  development  until 
puberty.  They  are  developed  as  diverticula  from  the  antrum  and  present 
a  very  varied  arrangement.  They  may  extend  throughout  the  whole 
process,  in  which  case  they  are  only  separated  by  very  thin  bony  lamellae 
from  one  another  and  from  the  lateral  sinus.  In  some  cases  they  are  small 
and  numerous,  while  at  other  times  the  mastoid  process  may  be  solid. 
The  air-cells  may  extend  beyond  the  limit  of  the  mastoid,  over  the  roof 
of  the  meatus  towards  the  zygoma  and  in  other  cases  towards  the  jugular 
process  of  the  occipital.  Their  mucous  lining  is  continuous  with  the 
mucous  membrane  of  the  tympanum  and  the  antrum. 

The  following  are  the  different  ways  by  which  infection  may  reach 
the  interior  of  the  skull  from  the  ear  :  (1)  Through  the  roof  of  the  antrum, 
especially  if  the  bone  be  naturally  deficient  here,  into  the  middle  fossa  ; 
(2)  Through  the  posterior  wall  of  the  antrum  to  the  lateral  sinus,  the 
sigmoid  groove  and  the  posterior  fossa  ;  (3)  By  the  labyrinth  and  internal 
auditory  meatus  into  the  posterior  fossa  ;  (4)  By  the  different  sutures 
with  their  contained  processes  of  dura  mater  ;  2  (5)  By  the  veins  which 
drain  the  tympanum  and  the  mastoid  cells.  These  fall  into  three  chief 
groups  :  (a)  Those  opening  into  the  lateral  sinus  ;  (b)  Those  passing 
through  the  mastoid  foramen  into  the  occipital  vein  and  soft  parts  outside 
the  skull ;  (c)  Those  rmming  through  the  petro-squamosal  suture  to  the 
dura  mater.  All  these  veins  carry  sheaths  of  connective  tissue,  and 
thus  inflammatory  products  may  reach  (a)  the  lateral  sinus,  causing 
septic  phlebitis  ;  (6)  the  soft  parts  outside,  causing  periostitis,  cellulitis, 
&c.  ;    (c)  the  dura  mater  and  brain,  causing  meningitis  and  abscess. 

Five  Results  of  Otitis  Media  which  may  come  under  the  notice  of  the 
Surgeon.  (1)  Acute  inflammation  of  mastoid  cells  :  mastoid  abscess  ; 
(2)  Chronic  mastoid  suppuration  ;  (3)  Abscess  in  the  brain  or  cerebellum  ; 

1  Brit.  Med.  Journ.,  vol.  ii,  1891,  p.  1142. 

^  The  sutures  may  be  of  fatal  significance.  Thus  in  cases  where  there  is  infective 
niii-cliief  outside  the  bone,  the  infection  having  made  its  way  there  by  an  opening  in  the 
mastoid,  or.  where  tliis  is  sclerosed,  bj'  dissectmg  its  way  along  the  external  auditory 
meatus,  if  it  reach  a  suture  and  its  contained  process  of  dura  mater,  infection  of  the 
inner  surface  and  meningitis  may  easily  follow. 


MASTOID  DISEASE  AND  OTITIS  MEDIA  337 

(4)  Infective  thrombosis  of  the  sinuses  and  pyaemia  ;  (5)  Meningitis  ;' 
one  or  more  of  these  often  coexist,  and  thus  the  symptoms  may  be  much 
bUMKhnl  t(),t(eth(M-  and  confusing. 

Acute  Mastoiditis  and  Acute  Mastoid  Abscess.  This  trouble  usually 
arises  in  the  course  of  chronic  middle  ear  suppuration.  It  is  a  rare 
complication  of  acute  otitis  media,  except  when  scarlet  fever  or  influenza 
is  the  cause  of  the  latter.  The  chief  symptoms  are  pain,  tenderness, 
redness  and  oedema  over  the  mastoid  process,  with  pyrexia  and  possibly 
rigors  occurring  in  a  patient  suffering  from  middle  ear    suppuration. 


Fig.  142.  A  left  temporal  bone  showing  the  antrum  and  the  mastoid  cells 
which  have  been  opened  up  for  an  acute  mastoid  abscess.  A,  Posterior  root  of 
the  zygoma.  B,  The  antrum.  C,  The  external  auditory  meatus.  D,  The 
mastoid  cells  which  have  been  opened  and  which  extend  to  the  apex  of  the 

mastoid  process. 

The  auricle  is  commonly  displaced  forwards  and  outwards  in  adidts,  and 
in  a  downward  direction  in  children.  This  is  due  to  pus  having  made 
its  way  through  the  thin  sheath  of  compact  tissue  of  the  mastoid,  thus 
giving  rise  to  a  subperiosteal  abscess. 

Indications  for  Operation.  In  adults  the  presence  of  a  subperiosteal 
abscess  is  always  an  indication  for  at  once  opening  up  the  mastoid 
antrum  and  cells  ;  but  in  young  children,  if  the  swelling  is  but  slight  and 
if  constitutional  symptoms  are  absent,  treatment  by  fomentations  may 
lead  to  a  spontaneous  escape  of  the  pus  through  the  external  ear. 

Occasionally  the  mastoid  abscess  bursts  into  the  external  auditory 

^  According  to  Poulsen  (^rc/i.  of  OtoL,  July  1892,  p.  346)  the  relative  frequency  of  the 
three  latter  complications  is  about  the  same.  Thus,  out  of  thirty-six  cases  of  complica- 
tions of  otitis  media,  there  were  thirteen  cases  of  abscess,  twelve  of  sinus  thrombosis,  and 
eleven  of  meningitis. 

^  It  must  be  remembered  that  in  these  cases  the  appearance  of  the  mastoid  abscess 
may  coincide  with  a  diminution,  or  even  entire  cessation,  of  the  discharge  from  the  ear. 
SURGERY  I  22 


338 


OPERATIONS  ON  THE  HEAD  AND  NECK 


meatus,  when  there  will  be  an  opening  on  the  posterior  wall  through  which 
a  probe  can  be  passed  into  the  mastoid  cells.  In  some  cases,  where  there 
are  large  air-cells  extending  to  the  apex  of  the  mastoid  process,  the  pus 
may  make  its  way  through  the  bone  in  this  situation  into  the  digastric 
fossa  whence  it  will  extend  deeply  among  the  muscles  at  the  side  of  the 
neck  :  this  variety  of  the  disease  is  known  as  Bezold*s  mastoiditis. 

In  other  rare  cases,  where  the  cells  extend  forward  to  the  root  of  the 
zygoma,  the  pus  may  make  its  way  in  this  direction  and  even  extend  into 
the  squamous  part  of  the  temporal  bone.     There  will  be  pain  and  swelling 

in  the  root  of  the  zygoma  and  the  temporal 
fossa,  and  probably  oedema  of  the  eyelids. 

In  all  these  cases  opening  the  antrum  and 
mastoid  cells  is  urgently  called  for. 

Antrectomy.  Operations  based  on  those  of 
Schwartze  and  Stacke.  The  name  of  Schwartze, 
of  Halle,  is  associated  with  the  first  attempt  to 
put  operations  on  the  antrum  on  a  satisfactory 
footing,  he  having  published,  in  1873,  a  series 
of  cases  in  the  Arch.  f.  Ohrenheilkunde,  Bd. 
vii,  u.  ix.  Replacing  such  very  hmited  opera- 
tions as  that  of  Wilde's  ^  incision  and  drilhng 
the  bone,  Schwartze  opened  up  the  mastoid 
cells  and  antrum,  establishing  drainage  between 
these  and  the  tympanum,  and  keeping  the  com- 
munication open  by  plugging  or  by  a  leaden 
nail.  This  pioneer  operation,  though  excellent 
and  based  on  correct  principles,  admitted  of 
improvement.  It  was  used  extensively  for 
many  years,  with  the  result  that  it  was  found 
admirably  adapted  for  acute,  but  insufficient 
for  some  chronic  cases  where  the  mischief  was 
143.  Automatic  mastoid  extensive.  Stacke,  in'1892,  published  ^  his  oper- 
retractor.  ation  which  modified  that  of  Schwartze  in  the 

following  important  details — viz.  the  detach- 
ment of  the  auricle,  the  removal  not  only  of  the  outer  wall  of  the 
antrum  but  the  upper  and  outer  part  of  the  bony  meatus,  the  taking 
away  of  the  ossicles  and  membrana  tympani,  and  the  replacing  of  the 
auricle,  drainage  being  effected  through  the  external  auditory  meatus. 

Generally  speaking,  in  acute  cases,  an  operation  based  on  Schwartze's 
is  called  for,  while  in  chronic  cases,  Stacke's  operation,  or  some  modifi- 
cation of  this,  is  indicated. 

The  Operation  for  Acute  Mastoid  Abscess.  The  hair  must  be  shaved 
and  the  skin  carefully  cleansed  for  a  distance  of  about  three  inches  behind 
and  above  the  ear.  In  the  case  of  a  woman  the  hair  may  be  kept  out  of 
the  way  by  a  bandage  round  the  head  or  by  a  rubber  cap.  Owing  to  the 
extreme  tenderness  the  cleansing  process  will  usually  have  to  be  carried 
out  after  the  patient  is  anaesthetised. 

The  position  of  the  patient  at  the  operation  is  of  considerable  import- 
ance :    the  head  and  shoulders  should  be  slightly  raised,  and  the  head 

^  In  Wilde's  operation  an  incision  is  made  down  to  the  bone  about  three-quarters 
behind  the  auricle.  Drainage  of  a  subperiosteal  abscess  is  thus  effected,  but  the  antrum 
is  not  opened. 

^  Arch,  of  Ohrenheilkunde,  Bd.  xxxi. 


YlG 


MASTOID  DISEASE  AND  OTITIS  MEDIA 


3'M 


tunu'cl  well  over  to  the  sound  side  so  that  the  diseased  ear  is  uppermost. 
A  loosely-filled  sand-bag  beneath  the  head  is  often  of  great  service  in  the 
maintenance  of  this  position  during  the  operation.  The  sterilizied  towels 
should  be  arranged  as  follows  :  one  towel  is  placed  beneath  the  patient's 
head  and  shoulders,  whih^  a  second,  folded  diagonally,  is  fastened  tightly 
rounil  the  head  so  as  completely  to  cover  the  hair.  The  patient's  body  is 
then  covered  by  one  or  more  large  towels,  and  finally,  a  small  towel  witti  a 
central  slit  is  arranged  so  as  to  cover  the  patient's  face  and  the  anaesthetist's 
hands  and  apparatus  and  to  leave  the  ear  and  seat  of  operation  alone 
exposed.     A  good  light  is  absolutely  essential,  as  the  field  of  operation 


Fig.  144. 


A,  Macewen's  gouge.     B,  Osteotribes  or  burrs  made  for  use  with  a 
trephine  handle. 


is  at  the  bottom  of  a  deep  wound,  easily  obscured  by  haemorrhage,  and 
in  close  proximity  to  structures  of  the  utmost  importance.  The  most 
satisfactory  illumination  is  obtained  from  an  electric  head-lamp,  which 
is  comfortable  to  wear  and  which  throws  a  bright  light  into  the  depths  of 
the  wound  without  in  any  way  obstructing  the  field  of  vision. 

A  curved  incision  must  be  made  parallel  to,  and  from  half  to  three- 
quarters  of  an  inch  behind,  the  attachment  of  the  auricle  ;  it  should 
commence  above  at  the  level  of  the  top  of  the  pinna  and  extend  downwards 
to  the  apex  of  the  mastoid  process.^  It  should  at  once  be  carried  down 
to  the  bone.  If  a  subperiosteal  abscess  is  present  it  is  in  this  way  opened 
and  an  area  of  bone,  bare  and  devoid  of  periosteum,  of  variable  extent, 
will  be  felt.  Free  haemorrhage  may  follow,  but  this  can  be  checked  by 
picking  up  the  cutaneous  vessels  with  Spencer- Wells  forceps. 

^  In  children  the  superficial  position  of  the  facial  nerve  must  be  remembered. 


340  OPERATIONS  ON  THE  HEAD  AND  NECK 

Whether  a  subperiosteal  abscess  is  present  or  no  the  periosteum  must 
be  stripped  with  a  raspatory  from  the  mastoid  process  in  a  forward 
direction  until  the  posterior  wall  of  the  external  auditory  meatus,  the 
suprameatal  spine,  and  Macewen's  triangle  are  exposed.  Care  must  be 
taken  to  avoid  injury  to  the  cartilaginous  meatus  and  its  cutaneous  lining. 

In  order  to  obtain  a  free  view  of  the  area  involved  the  margins  of  the 
incision  must  be  widely  retracted.  This  is  best  effected  by  the  retractor 
shown  in  Fig.  143.  By  tightening  the  screw  it  is  automatically  retained 
in  the  desired  position,  and  also  to  a  great  extent  checks  the  oozing  from 
the  cutaneous  vessels.  The  surface  of  the  bone  is  now  dried  and  carefully 
inspected  for  a  sinus  or  depression  from  which  pus  is  oozing  or  for  a 
discoloured  patch  of  bone.  Such  an  opening  may,  or  may  not,  be  present, 
and  the  next  stage  of  the  operation  will  depend  to  a  certain  extent  upon 
the  existence  or  non-existence  of  such  a  sinus. 

A.  If  a  sinus  is  found  this  should  be  opened  up  and  explored,  for 
here  the  pus  has  made  its  way  through  the  bone  and  consequently  this 
sinus  affords  a  direct  track  to  the  abscess  cavity. 

The  bone  must  be  removed  by  some  form  of  gouge  or  chisel.  Most 
surgeons  prefer  gouges  with  curved  cutting  edges  ;  others,  however,  use 
flat  chisels  with  slightly  rounded  corners  to  the  cutting  edge.  In  either 
case  several  sizes  should  be  ready  to  hand.  The  gouge  or  chisel  must  in  all 
cases  be  used  so  as  to  remove  thin  shavings  of  bone  from  the  exposed 
surface.  This  is  ensured  by  holding  the  gouge  so  that  it  makes  an  acute 
angle  with  the  surface  of  the  bone,  and  then  giving  it  a  few  light  taps  vnih 
the  mallet  until  a  grip  is  obtained  :  the  handle  is  then  depressed  and  a 
few  more  blows  will  cut  away  a  shaving  of  considerable  extent.  On 
no  account  is  the  gouge  to  be  driven  vertically  into  the  bone  so  that 
it  becomes  locked  ;  this  may  lead  to  a  fracture  of  the  skull  or  to  some 
serious  injury  to  the  brain  or  lateral  sinus.  The  gouge  or  chisel  must 
always  be  held  so  that  it  cuts  from  behind  forwards  and  from  above  down- 
wards. In  this  way  it  is  cutting  from  the  lateral  sinus  and  the  fossae  of 
the  skull,  and  hence,  even  if  these  structures  are  exposed  inadvertently, 
they  will  probably  escape  injury.  If  cutting  in  the  reverse  direction, 
however,  the  edge  of  the  instrument  may  be  driven  into  the  lateral 
sinus  or  brain  and  inflict  serious  injury  on  these  structures.  The 
gouge  should  be  lightly  but  firmly  grasped  by  the  thumb  and  the 
four  fingers,  while  the  WTist  rests  against  the  patient's  head  :  in  this  way 
it  may  be  kept  under  perfect  control,  and,  even  if  it  unexpectedly  should 
penetrate  any  thin  portion,  can  be  prevented  from  damaging  the  under- 
lying structures.  The  best  form  of  mallet  is  a  small  well-balanced 
metal  hammer  which  can  be  easily  sterilised.  In  many  patients,  especially 
children,  the  bone  is  so  soft  that  the  gouge  can  be  quite  easily  used  by  the 
hand  alone  without  the  assistance  of  the  mallet  except  perhaps  for  the 
first  few  cuts. 

The  condition  revealed  when  the  sinus  has  been  opened  up  in  the  way 
described  above  will  vary  a  good  deal  in  different  cases.  A  large  abscess 
cavity,  the  size  of  a  hazel-nut,  may  be  fomid,  or,  instead  of  a  single  abscess 
cavity,  a  number  of  cells  containing  pus  and  septic  granulation  tissue 
may  be  present.  In  either  case  the  extent  of  the  cavity  should  be  investi- 
gated by  a  small  blunt-ended  probe.  The  compact  tissue  of  the  mastoid 
must  now  be  gouged  away  so  as  to  thoroughly  expose  the  whole  of  the 
infected  area.  When  there  is  a  single  large  cavity  bone  nmst  be  removed 
so  as  to  avoid  any  overhanging  edge  beneath  which  suppuration  might 


MA.STOID  DISEASE  AND  OTITIS  MEDIA  341 

still  go  on.  When  many  septic  cells  are  present  each  must  be  opened  by 
gouging  away  the  bony  septa,  and  the  various  extensions  of  the  cells 
mentioned  on  ]).  'A'M')  must  be  remembered,  those  at  the  apex  receiving 
special  attention.  The  wound  must  be  carefully  inspected  after  each 
application  of  the  chisel  to  make  sure  that  the  lateral  sinus  and  the  dura 
mater  are  not  exposed.  The  former  is  especially  likely  to  be  injured  as 
bone  is  removed  to  expose  the  posterior  part  of  the  cavity.  Indeed, 
sometimes  the  bone  has  been  destroyed  by  the  backward  extension  of 
the  suppuration  to  such  a  degree  that  the  lateral  sinus  and  dura  of  the 
posterior  fossa  form  part  of  the  boundary  of  the  abscess  cavity.     The 


Fig.  14.5.     Maccwon's  combined  small  curette  and  seeker.     1'he  latter  will  serve 

as  an  ossicle-hook. 

middle  fossa,  which  very  rarely  extends  below  the  level  of  the  posterior  root 
of  the  zygoma,  is  unlikely  to  be  exposed  at  this  stage  of  the  operation. 
Directly  the  gouge  opens  up  any  new  space  it  is  advisable  to  explore 
this  with  the  blunt  probe  as  described  above.  If  the  space  is  an  air-cell 
it  will  be  felt  to  have  a  definite  deep  bony  wall ;  if  it  be  a  lateral  sinus 
or  cranial  cavity  the  soft  yielding  dura  mater  will  be  felt.  Haemorrhage 
is  not  often  troublesome  :  blood  is  best  mopped  away  by  small  strips  of 
sterilised  lint  or  gauze  introduced  into  the  depths  of  the  wound  by 
means  of  fine  bayonet-shaped  forceps.  It  is  a  not  uncommon  mistake 
for  the  surgeon  to  rest  content  with  opening  and  draining  the  abscess 
cavity.  This,  however,  is  not  sufficient  :  the  mastoid  antrum,  which 
is  the  cause  of  the  abscess  and  which  is  always  infected,  must  also  be 
opened  and  drained.  If  this  is  not  done  chronic  inflammation  with 
further  caries  and  necrosis  is  bound  to  continue  and  will  probably  lead 
to  a  persistent  sinus  behind  the  ear  as  well  as  to  a  further  extension 
of  the  septic  process  in  the  bone. 

In  many  cases  the  probe  will  readily  pass  along  a  channel  leading 
in  an  upward  and  forward  direction  to  the  antrum,  which  is  then  easily 
opened  up.  In  other  cases,  though  it  certainly  exists,  the  channel  may  be  so 
narrow  and  sinuous  that  it  is  not  found  by  the  probe.  It  will  then  be  again 
necessary  to  identify  Macewen's  triangle  and  the  posterior  root  of  the 
zygoma.  Bone  must  then  be  gouged  away  in  a  forward  and  upward 
direction  and  the  antrum 
will  soon  be  found  beneath  ^^^  '^^^ 
this  spot.  The  antrum 
can  be  identified  by  the 
following  tests :  (a)  In- 
vestigation by  the  probe 
shows  that  its  deep  wall  is 
bony  ;    (6)  A  bent  probe  Fig.  146.    Stacke's  guide, 

can  be  made  to  pass  in  a 

forward  and  upward  direction  towards  the  tympanic  cavity.  The 
antrum  must  be  thoroughly  exposed  by  the  removal  of  any  over- 
hanging edges  and  must  then  be  carefully  curetted  by  a  small  Volkmann 
spoon  to  remove  all  septic  granulation  tissue  and  carious  bone.  The 
mastoid  cells  must  be  treated  in  the  same  manner. 


342  OPERATIONS  ON  THE  HEAD  AND  NECK 

B.  If  no  opening  or  discoloured  bone  is  seen,  it  is  best  at  once  to 
proceed  to  open  the  antrum.  To  effect  this  the  operator  should,  after 
having  first  identified  the  superficial  landmarks  mentioned  above, 
proceed  to  cut  a  shallow  groove  with  a  half-inch  gouge.  The  upper 
limit  of  the  groove  is  the  root  of  the  zygoma,  while  its  posterior  limit 
should  be  rather  less  than  three-quarters  of  an  inch  behind  the  posterior 
wall  of  the  meatus.  When  the  depth  of  the  groove  is  about  a  quarter  of 
an  inch  a  smaller  gouge  should  be  selected  and  bone  now  be  taken  from 
the  region  of  the  antrum,  immediately  above  and  behind  the  external 
auditory  meatus.  As  this  is  done  one  or  more  cells,  probably  containing 
pus,  may  be  opened  :  that  they  are  air-cells  and  not  the  antrum  may  be 
determined  by  examination  wdth  the  probe  as  described  above.  Any 
cavity  which  is  opened  must  be  carefully  investigated,  as  the  middle  fossa 
does  occasionally  descend  below  the  level  of  the  root  of  the  zygoma.  The 
depth  of  the  antrum  varies  within  wide  limits.  It  may  be  only  a  quarter 
of  an  inch  from  the  surface  or  as  much  as  three-quarters  of  an  inch.  In 
the  latter  case,  if  the  bone  is  sclerosed,  as  does  sometimes  happen,  the 
exposure  of  the  antrum  may  be  a  matter  of  considerable  difficulty.  If 
the  surface  marking  is  remembered  and  is  carefully  followed,  however, 
a  small  antrum  a\411  be  found  even  under  these  conditions.  When 
it  is  opened  its  roof  is  examined  both  by  direct  inspection  and  by  the 
probe  for  any  carious  patch  or  perforation  which  will  open  the  middle  fossa 
and  expose  the  dura.  The  infected  mastoid  cells  are  then  opened  up  as 
described  above  and  the  whole  cavity  is  thoroughly  curetted  and  scraped 
to  remove  all  septic  granulation  tissue. 

All  loose  chips  of  bone  are  then  sought  for  and  removed  by  the  curette 
or  forceps  and  the  whole  cavity  is  irrigated  with  lot.  hydrogen  peroxide 
(5  per  cent.),  which  probably  will  find  its  way  through  the  tympanum  to  the 
external  auditory  meatus.  In  any  case  the  meatus  should  also  be  washed 
out. 

The  wound  behind  the  ear  is  then  lightly  packed  with  a  strip  of 
sterilised  ribbon  gauze  and  a  small  length  of  the  same  material  is  intro- 
duced into  the  external  auditory  meatus.  A  few  fishing-gut  sutures 
may  be  used  to  close  the  upper  part  of  the  wound,  but  free  drainage 
must  be  secured.  A  gauze  pad  is  applied  and  a  thick  layer  of  absorbent 
wool,  and  the  whole  is  firmly  bandaged. 

After-treatment.  The  first  dressing  may  remain  unchanged  for  forty- 
eight  hours  :  the  gauze  plugs  are  then  removed,  after  moistening  with 
hydrogen  peroxide.  The  post-aural  wound  is  then  gently  syringed 
with  the  same  lotion,  which  will  probably,  in  part,  escape  through  the 
meatus.  Should  it  not  do  so  the  meatus  must  be  cleansed  separately. 
The  gauze  plugs  and  the  external  dressings  are  then  replaced.  For  a 
time  the  dressing  will  have  to  be  changed  daily,  but  as  the  discharge 
lessens,  they  may  remain  untouched  for  two  and  then  three  days.  The 
wound  soon  shows  healthy  granulations  with  but  little  discharge,  and  the 
escape  of  pus  from  the  meatus  also  soon  ceases  in  most  cases.  Should 
this,  however,  continue,  and  should  a  fistulous  opening  behind  the  ear  also 
persist,  further  treatment  will  be  called  for  {see  p.  344). 

Possible  accidents  and  complications.  (1)  Injury  to  the  Lateral  Sinus. 
This  may  be  brought  about  by  the  gouge  or  by  the  sharp  spoon  or  curette 
during  the  removal  of  the  septic  granulations.  In  either  case  there  is 
severe  haemorrhage  and  the  wound  becomes  at  once  flooded  with  blood. 
Fortunately  this  can  at  once  be  checked  by  pressure.     While  an  assistant 


iMASTOID  DISEASE  AND  OTITIS  MEDIA  tUii 

thus  controls  the  bkuHliiig  a  piece  of  ribbon  gauze  is  prepared,  and,  when 
the  pressure  is  removed,  the  end  of  this  is  placed  over  the  opening  into 
the  vessel  by  the  help  of  a  director.  More  gauze  is  then  packed  in,  and 
the  operation  is  proceeded  with.  It  may  be  necessary  to  leave  a  special 
piece  of  gauze  over  the  opening  at  the  conclusion  of  the  operation.  The 
greatest  care  must  be  taken  to  avoid  injury  to  the  sinus,  on  account  of  the 
possibility  of  a  resulting  septic  thrombosis  of  the  vessel.  Should  the 
sinus  be  accidentally  wounded  every  precaution  must  be  taken  to  guard 
against  infection. 

(2)  Opening  the  middle  or  posterior  fossa  of  the  skull.  Should  this 
happen,  without  injury  to  the  dura,  serious  consequences  arc  very  iniprob- 
able.     Should,  however,  the  dura  be  injured,  there  is  a  possibility  of 


Fig.  147.  A  preparation  of  tlie  right  temporal  bone  to  show  the  l)one  which 
must  be  removed  in  Stiicke's  operation.  A,  The  antrum.  B,  The  aqucductu.s 
fallopii.  C,  The  external  auditory  meatus.  D,  The  remains  of  the  posterior 
wall  of  the  external  auditory  meatus.     E.  The  external  semicircular  canal. 

septic  infection  extending  to  the  brain  or  the  meninges.  Thus  when  the 
dura  is  known  to  be  exposed  the  gouge  and  curette  must  be  used  in  that 
region  with  great  caution. 

(3)  Injury  to  the  facial  nerve.  This  is  very  unlikely  to  occur  in  the  opera- 
tion described  above  except  in  the  case  of  children  {see  footnote,  p.  339). 
It  may,  however,  be  damaged  if,  when  curetting  the  antrum,  the  curette 
is  introduced  so  as  to  press  against  the  posterior  part  of  the  floor  of  the 
additus.  When  working  in  this  situation  the  curette  must  be  used  with 
caution,  and  a  watch  kept  for  any  twitching  of  the  face. 

THE  RADICAL  MASTOID  OPERATION 

It  will  now  be  necessary  to  consider  the  indications  for  the  more 
complete,  or  radical,  operation,  founded  on  that  originally  described  by 
Stacke.     In  this  operation  the  mastoid  cells  and  antrum  are  opened 


344  OPERATIONS  ON  THE  HEAD  AND  NECK 

up,  the  posterior  wall  of  the  meatus  is  removed,  so  that  antrum,  mastoid 
cells,  attic,  tympanic  cavity,  and  external  auditory  meatus  are  thrown 
into  one  cavity.  The  aim  of  the  surgeon  is  to  remove  all  septic 
granulation  tissue  and  all  the  diseased  bone  including  the  ossicles,  and 
then  to  get  the  cavity  completely  covered  by  epithelium,  thus  leading  to 
a  cessation  of  the  discharge.  Generally  speaking,  the  operation  is  called 
for  in  chronic  suppuration  in  the  middle  ear  and  mastoid.  The  following 
are  the  chief  indications  for  the  operation  in  a  patient  suffering  from 
chronic  otitis  media. 

(1)  When  acute  mastoid  disease  becomes  chronic,  i.e.  the  wound 
behind  the  ear  does  not  heal  and  discharge  of  pus  from  the  ear  persists. 

(2)  Recurring  attacks  of  swelling  and  pain  over  the  mastoid  process. 

(3)  The  spontaneous  occurrence  of  facial  paralysis. 

(4)  Recurrent  attacks  of  vertigo,  either  spontaneous  or  from  syringing. 
This  shows  erosion  of  the  bony  wall  of  some  part  of  the  labyrinth. 

(5)  When  cholesteatomata  are  present  in  the  attic  and  the  mastoid. 
These  masses  of  epithelium  are  usually  regarded  as  derived  from  pro- 
liferation of  the  epithelium  of  the  external  auditory  meatus  through  a 
perforation  in  the  tympanic  membrane.  They  may  reach  the  size  of  a 
marble,  are  accompanied  by  a  foul  purulent  discharge,  cause  absorption  of 
the  bone  by  pressure,  and  may  penetrate  the  cranial  wall  opening  up  one 
of  the  fossae  of  the  skull. 

(6)  For  tuberculous  disease  of  the  mastoid. 

(7)  For  necrosis  of  the  temporal  bone  or  for  recurring  masses  of 
granulation  springing  from  carious  areas. 

(8)  When  occlusion  of  the  meatus  is  associated  with  a  chronic  puaulent 
discharge. 

(9)  When  intracranial  complications  are  present;. 

(10)  In  addition  to  these  there  are  a  number  of  cases  in  which  a  chronic 
otitis  media  persists,  resisting  all  means  of  treatment.  It  is  often  very 
difficult  to  decide  if  operation  is  required  in  these  cases.  If  the  perfora- 
tion is  in  the  postero-superior  quadrant  of  the  membrane  and  is  marginal 
in  position  bone  disease  is  likely  to  be  present.  In  some  of  these  cases 
removal  of  the  ossicles  or  providing  free  drainage  by  removing  the  outer 
wall  of  the  attic  ^  may  suffice.  Should  these  operations  fail  the  more 
complete  operation  is  indicated. 

In  chronic  disease  of  the  mastoid  it  is  often  surprising  to  find  the 
extent  to  which  the  bone  has  been  destroyed  with  very  slight  symptoms. 
It  is  quite  possible  to  find  the  mastoid  process  a  mere  shell,  containing 
pus  and  granulation  tissue  with  possibly  one  of  the  fossae  of  the  skull 
opened  and  the  dura  mater  in  contact  with  the  septic  cavity,  and  yet  no 
symptoms  beyond  the  discharge  from  the  ear. 

In  other  cases  one  of  the  acute  intracranial  complications  to  be 
described  below  may  suddenly  develop  without  previous  warning. 

The  Operation.  This  may  be  considered  in  two  stages,  (1)  the  operation 
on  the  bone,  (2)  the  plastic  operation  to  provide  the  resulting  bony  cavity 
with  an  epithelial  covering. 

The  operation  on  the  bone  will,  to  a  great  extent,  follow  the  lines  of  the 
operation  described  above  for  acute  abscess.  The  preliminary  prepara- 
tions, the  incision,  and  the  exposure  of  the  field  of  operation  are  similar, 
but  the  cartilaginous  meatus  must  be  separated  from  the  bony  meatus, 

1  For  the  indications  for,  and  the  mode  of  performing,  these  operations,  the  reader  is 
r  eferred  to  some  standard  work  on  diseases  of  the  ear. 


MASTOID  DISEASE  AND  OTITIS  MEDIA  345 

without  tearing  or  injuring  the  former.  In  Stilcke's  original  opera- 
tion the  antrum  was  exposed  by  chiselling  away  the  postero-superior 
part  of  the  meatal  wall.  It  is,  however,  easier  and  more  satisfactory 
to  open  the  antrum  in  the  manner  described  above  by  gouging  the 
bone  in  the  area  bounded  above  by  the  posterior  root  of  the  zygoma, 
and  in  front  by  the  wall  of  the  meatus.  The  position  of  the  lateral  sinus 
must  be  remembered  and  the  posterior  limit  of  the  field  of  operation 
should  not  extend  farther  back  than  half  an  inch  behind  the  rim  of  the 
meatus.  When  the  antrum  has  been  exposed  any  diseased  mastoid  cells 
are  to  be  thoroughly  opened  up  in  the  way  described  above.  A  probe, 
or  a  Stiicke's  gui(ki  (Fig.  1 4(1),  is  now  passed  from  the  antrum  into  the 
tympanic  cavity  to  exactly  identify  the  position  of  the  additus.  The 
posterior  wall  of  the  external  auditory  meatus  must  now  be  gouged  away, 
so  as  to  expose  the  additus,  or  communication  between  the  antrum  and  the 
tympanic  attic.  At  first  the  bone  may  be  freely  removed,  but  as  the 
bridge  of  bone  between  the  two  cavities  is  diminished  in  size  the  greatest 
caution  must  be  exercised,  for  it  is  at  this  stage  that  the  facial  nerve  and 
the  horizontal  semicircular  canal  are  in  considerable  danger.  The  semi- 
circular canal  is  contained  in  a  smooth  white  ridge  of  bone  at  the  junction 
of  the  floor  of  the  additus  with  its  inner  wall.  The  aqueductus  Fallopii, 
which  encloses  the  facial  nerve,  is  situated  immediately  below  and  in  front 
of  this.  Both  these  bony  canals  are  extremely  thin,  and,  should  the  gouge 
slip  through  the  last  portion  of  the  bridge  of  bone  between  the  antrum  and 
the  attic,  and  impinge  against  them,  these  structures  are  very  liable  to 
be  injured.  Injury  to  the  facial  nerve  will  result  in  complete  paralysis  of 
the  muscles  supplied  by  it ;  while  injury  to  the  semicircular  canal,  besides 
causing  serious  vertigo,  may  be  the  starting-point  of  labyrinthine  suppura- 
tion. The  utmost  caution  must  therefore  be  exercised  in  removing  the 
last  portion  of  the  bridge  of  bone.  After  each  chip  of  bone  has  been  cut 
away  the  wound  must  be  carefully  dried  by  a  pledget  of  sterilised  gauze 
introduced  into  the  depths  of  the  wound.  A  Stacke's  guide  may  be  left 
in  situ  in  the  additus  witli  the  view  of  protecting  the  nerve,  or  a  piece  of 
gauze  may  be  packed  into  this  cavity  with  the  same  object.  When  only 
a  narrow  bridge  remains,  this  should  be  divided  by  the  gouge  cutting  from 
above  downwards  just  below  the  level  of  the  tegmen  tympani,  i.e.  as  far 
from  the  nerve  as  possible.  The  removal  of  this  piece  of  bone  allows  a 
probe  to  pass  freely  from  the  antrum  into  the  attic  and  the  tympanum. 
All  overhanging  edges,  beneath  which  suppuration  might  possibly  be  kept 
up,  must  be  carefully  removed  until  the  cavity  has  the  appearance  shown 
in  Fig.  147.  This  refers  especially  to  the  outer  wall  of  the  attic,  which 
is  in  part  formed  by  a  plate  of  bone  projecting  down  from  the  tegmen 
tympani,  and  to  the  spur  formed  by  the  remains  of  the  posterior  wall  of  the 
meatus.  The  latter  must  be  cautiously  carried  out,  for  the  facial  nerve 
is  again  in  danger  while  the  deeper  part  of  this  is  being  rounded  off  to 
secure  a  good  view  of  the  posterior  part  of  the  tympanic  cavity.  When 
these  edges  have  been  gouged  away  the  whole  cavity  must  be  carefully 
curetted.  All  granulations  must  be  removed  and  all  carious  patches  in 
the  bone  thoroughly  but  gently  scraped.  A  careful  and  systematic 
inspection  of  all  parts  of  the  cavity,  including  the  tegmen  tympani  and 
tegmen  antri,  must  be  made  with  the  help  of  a  bright  light.  All  discoloured 
or  suspicious  areas  must  be  followed  up  with  the  curette,  and,  if  necessary, 
he  gouge.  When  the  attic  and  the  tympanum  are  curetted  the  incus  and 
he  malleus  will  very  probably  be  found  in  a  carious  condition  and  more 


si 


\ 


346  OPERATIONS  ON  THE  HEAD  AND  NECK 

or  less  embedded  in  granulation  tissue.^  They  should  be  removed.  The 
curette  must  always  be  used  with  care  and  gentleness  :  the  wall  of  the 
cavity  is  in  many  places  extremely  thin  and  is  in  relation  with  very 
important  structures.  Thus  in  the  floor  of  the  tympanum  a  thin  plate 
of  bone  alone  separates  it  from  the  bulb  of  the  jugular  vein  ;  the  front  of 
the  tympanum  is  in  close  relation  with  the  internal  carotid  artery  ;  while 
the  proximity  of  the  lateral  sinus  to  the  posterior  part  of  the  cavity,  the 
dura  of  the  middle  fossa  to  the  tegmen  tympani,  and  of  the  semicircular 

canal  and  the  facial  nerve 
to     the     additus,     have 
already     been     insisted 
upon.     It   may  here    be 
pointed  out  that  the  facial 
nerve   may  be    quite    as 
readily  damaged  by  the 
curette  as  by  the  gouge, 
for  the  bony  aqueductus 
Fallopii  is  extremely  thin 
and  it  is  deficient  in  places 
or    may    be    opened    by 
caries  of  its  walls. '^  While 
curetting  in  its  neighbour- 
hood it  is  therefore  wnse 
to  keep  a  close  watch  for 
any  twitching  of  the  face. 
When  the  curetting    has 
been  satisfactorily  carried 
out  all  edges  and  angles 
must  be  rounded  off,  and 
a  search  nnist   be   made 
for  any  loose  chips  of  bone 
which  are  removed.     The 
The  vertical  cut  cavity  is  then  washed  out 
with    hot   lot.    hydrogen 
peroxide  (5  per  cent.). 
The  Plastic  Operation.     In  all  cases,  except  where  there  is  some  intra- 
cranial complication  which  requires  drainage,  the  wound  behind  the  ear 
should  be  closed  and  a  flap  be  cut  from  the  cutaneous  lining  of  the  meatus, 
to  ensure  drainage  of  the  entire  cavity  and,  at  the  same  time,  to  provide  a 
covering  for  part  of  it  from  which  epithelium  will  eventually  grow  to 
cover  the  whole.     There  are  a  number  of  ways  in  which  this  can  be 
accomplished. 

(1)  Stackers  metJiod.  This  is  described  in  the  following  words  by 
Heine.^  "  After  the  tympanic  cavity  and  the  rest  of  the  Avound  have  been 
temporarily  packed  with  gauze,  one  hand  (for  the  left  ear  the  left  hand, 

^  The  stapes  should  not  be  disturbed  on  account  of  the  danger  of  opening  the  laby- 
rinth. 

•^  In  such  cases  even  gentle  pres.sure  by  a  piece  of  gauze  for  the  jiurpose  of  drying 
the  wound  may  cause  twitching  of  the  face.  In  the-^-e  cases  paralysis  of  the  face  coming 
on  some  hours  after  the  operation  is  not  uncommon  and  is  probably  due  to  inflammatory 
exudation  pressing  upon  the  nerve  in  its  canal.  8uch  paralysis  will  disappear,  though 
sometimes  tediously.  This  paralysis  is  especially  likely  to  occur  when  there  is  any 
natural  gap  or  iiathological  erosion.  Paralysis  noticed  immediately  after  the  operation 
is  probably  due  to  injury,  and  is  likely  to  be  permanent. 

*  Operations  on  the  Ear,  translated  by  W.  L.  Murphjr,  1908. 


Fig.  148.     Stacko's  plastic  operation 
is  shown  with  the    edges  gaping.      The  position  of  the 
horizontal  cut  is  indicated  by  the  dotted  line. 


MASTOID  DISEASE  AND  OTITIS  MEDIA 


347 


ami  vice  versa)  holds  the  auricl(>  and  turns  it  forwards,  while  with  the 
otiier  hand  a  narrow  scalpel  is  pushed  from  behind  through  the  soft  parts 
at  the  level  of  the  superior  wall  of  the  meatus,  until  the  point  appears  in 
the  entrance  of  the  meatus  at  the  j unction  of  the  posterioi'  and  superior 
walls  (Fig.  I4S).  The  ]>oint  at  wliieh  the  knife  is  inserted  lies  close  behind 
the  anterior  lip  of  the  wound.  The  auricle  must  be  turned  a  little  back- 
wards while  the  blade  is  being  pushed  through  from  behind,  in  order  that 
the  surgeon  may  make  sure  that  it  emerges  at  the  proper  spot.  Care 
must  also  be  taken  not  to  wound  the  anterior  meatal  wall.  When  the 
point  is  seen  to  appear  at  the  spot  indicated,  the  knifes  is  cai'ried  vertically 
downwards  ;  that  is,  towards  the  apex  of  the  mastoid,  and  in  a  direction 
perpendicular  to  the  long  axis  of  the  auditory  canal.  In  doing  this  the 
posterior  part  of  the  meatus  itself  and  the  soft  parts  behind  it  are  cut 


A.  B.  ('. 

Fig.  149.     A.  Koiner's  Rap.     B.  Pause's  flap.     C.  Milligan's  flap. 


through.  The  point  of  the  knife  must  divide  the  skin  of  the  meatus  in 
the  line  where  it  passes  on  to  the  auricle.  If  the  incision  is  lateral  to  this 
line,  it  will  divide  the  cartilage  of  the  ear  ;  if  it  is  to  the  median  side,  the 
outer  end  of  the  meatus  will  remain  attached  to  the  auricle  and  the  opening 
into  the  operation  cavity  will  be  too  narrow.  The  second  incision  for 
the  formation  of  the  flap  runs  horizontally  at  the  junction  of  the  posterior 
and  superior  walls  of  the  meatus,  and  splits  the  canal  in  its  long  axis.  A 
small  retractor  is  inserted  into  the  slit  in  the  posterior  meatal  wall  and 
pulled  forwards,  in  order  to  bring  the  lumen  of  the  canal  into  view.  The 
wall  of  the  meatus  is  then  grasped  from  behind  with  toothed  forceps, 
and  the  soft  parts  are  pulled  backwards  and  outwards  until  the  lumen 
gaps  sufficiently.  The  gauze  packing  is  now  removed,  and  straight 
scissors  are  inserted  through  the  vertical  incision  in  such  a  manner  that 
one  blade  lies  in  the  meatus  and  the  other  outside.  The  scissors  are 
brought  as  high  as  possible,  and  are  pushed  inwards  until  the  point  of  the 
blade  lying  inside  the  canal  comes  into  view  deep  in  the  wound.  A  single 
cut  is  then  made  with  the  scissors  in  the  desired  direction  (Fig.  148)  and 
the  formation  of  the  flap  is  complete."  In  order  that  the  flap  shall  fall 
nicely  into  position  it  is  necessary  to  snip  away  with  a  sharp  knife  some 
of  the  thick  soft  tissues  at  the  outer  end,  taking  care  that  the  skin  itself 
is  uninjured.  The  flap  is  not  kept  in  position  by  sutures,  but  is  pressed 
against  the  lower  and  posterior  part  of  the  bony  cavity  by  gauze  packed 
through  the  external  auditory  meatus.  The  wound  behind  the  ear  is 
then  completely  closed  by  a  few  silkworm-gut  sutures. 

Various  modifications  of  the  mode  of  cutting  the  flap  have  been 


348  OPERATIONS  ON  THE  HEAD  AND  NECK 

suggested.  Korner  (Fig.  149  A)  cuts  a  rectangular  flap  by  two  incisions, 
one  at  the  junction  of  the  superior  and  the  posterior  walls  and  the  other 
at  the  junction  of  the  posterior  and  inferior  walls  of  the  meatus.  These 
incisions  are  continued  outwards  for  a  short  distance  on  to  the  concha. 
After  the  cartilage  has  been  dissected  away  this  tongue-shaped  flap  is 
turned  backwards,  and,  after  the  post-aural  wound  has  been  closed,  is 
kept  in  position  by  ribbon  gauze  packed  into  the  cavity  through  the 
external  auditory  meatus.  In  Pause's  method  (Fig.  149  B)  a  single 
incision  is  made  in  the  axis  of  the  canal,  along  the  middle  of  the 
posterior  wall  of  the  meatus.  This  extends  to  the  concha  :  at  its  outer 
end  two  small  cuts  are  made  at  right  angles  to  the  first,  one  in  an 
upward  direction  and  the  other  downwards.  In  this  way  two  small 
flaps  are  formed,  one  of  which  is  sutured  to  the  upper  and  the  other  to  the 
lower  angle  of  the  wound. 

Milligan's  flap  (Fig.  149  C)  is  thus  described  by  its  originator  :  ^  "  A 
long  and  thin-bladed  knife  is  inserted  into  the  cartilaginous  meatus  at 
the  junction  of  its  upper  and  posterior  walls  and  an  incision  made 
vertically  outwards  into  the  concha.  With  a  sweeping  motion  an 
incision  is  made  through  the  concha  parallel  to  the  curve  of  the  antihelix 
down  to  the  floor  of  the  meatus  (Fig.  149  C).  The  flap  thus  formed  is 
turned  downwards  on  to  the  floor  of  the  bone  wound  and  is  kept  in 
position  by  means  of  a  couple  of  sutures  passed  through  it  and  the 
adjacent  skin  and  tied  over  a  piece  of  rubber  tubing." 

Mr.  Ballance  ^  recommends  a  different  plan  of  after-treatment,  which, 
when  successful,  saves  much  time,  and  avoids  frequent  dressings  and 
pluggings — a  point  of  great  importance  in  hospital  patients  and  in  those 
who  are  timid.  The  first  special  point  in  Mr.  Ballance's  treatment 
concerns  the  cartilaginous  canal.  After  the  completion  of  the  post-aural 
operation  he  introduces  a  long  thin  knife  along  the  meatus  and  divides 
the  inferior  wall  in  a  vertical  direction  :  the  incision  is  then  continued  in 
an  upward  and  backward  direction  into  the  concha  until  it  reaches 
the  anterior  commencement  of  the  helix  {see  Figs.  150, 151).  After  the 
flap  has  been  thinned  by  the  removal  of  all  redundant  soft  parts  it  is 
turned  backwards  and  its  raw  surface  is  attached  by  a  few  salmon-gut 
sutures  to  the  interior  surfaceof  the  original  mastoid  flap  (Figs.  152, 153). 
The  post-aural  wound  is  then  closed  .At  the  end  of  about  ten  or  fourteen 
days  an  anaesthetic  is  given  and  the  original  wound  is  opened  up  and  the 
pinna  displaced  forwards  as  at  the  first  operation.  The  cavity  in  the  bone, 
now  covered  by  healthy  granulations,  is  thus  exposed.  All  oozing  is  now 
stopped  by  irrigating  the  wound  with  hot  saline  solution,  or,  if  necessary, 
by  the  application  of  adrenalin  (1  in  1000).  A  large  thin  skin  graft  is 
cut  from  a  previously  sterilised  area  of  skin  on  the  thigh.  If  possible 
this  should  be  of  such  size  as  to  cover  the  whole  of  the  cavity.  It  should 
be  transferred  to  the  wound  by  a  large  microscopical  section  lifter,  and 
is  then,  by  careful  manipulation,  worked  by  needles  so  as  to  come  evenly 
into  contact  with  the  whole  raw  area,  care  being  taken  that  all  air  bubbles 
and  blood  have  been  removed.  Should  the  first  graft  be  of  insufficient 
size,  one  or  more  further  grafts  must  be  cut  until  the  whole  surface 
is  covered.  As  a  protection  for  the  grafts  Mr.  Ballance  employs  thin 
gold  leaf,  which,  after  being  cut  to  the  requisite  size,  is  placed  in  exact 
position  over  the  grafts.     A  strip  of  dry  sterilised  gauze  is  now  evenly 

1  Latham's  System  of  Treatment,  vol.  iii,  p.  925. 
^  Med.-Chir.  Trans.,  vol.  Ixxxiii. 


MASTOID  DISEASE  AND  OTITIS  MEDIA 


349 


packed  into  the  cavity  and  the  retro-auricular  wound  again  closed  and  the 
usual  external  dressings  applied.  At  the  end  of  four  days  the  plug  of 
gauze  is  removed  from  the  external  aiulitoiv  meatus  and  the  gold  leaf 
then  picked  out  with  for- 


ceps or  by  gentle  syring- 
ing. In  a  successful  case 
rapid  liealing  results, but, 
to  ensure  success,  it  is  es- 
sential that  no  infective 
material  shall  have  been 
left  behind  and  that  the 
bony  surface  must  have 
been  thoroughly  smoothed 
at  the  orginal  operation. 

After-treatment.  When 
skin-grafting  is  not  em- 
ployed the  outer  dressings 
should  be  changed  on 
alternate  days,  but  it  is 
advisable,  to  avoid  dis- 
turbing the  flap,  not  to 
remove  the  packing  for  five 
or  six  days,  unless  there  is 
some  special  indication  for 
so  doing,  such  as  pain,  a 
rise  of  temperature,  or  ex- 
cessive or  foul  discharge. 


Fig.  151.  The  white  line  here 
shows  the  direction  of  .the  in- 
cision in  the  concha.  The 
knife  is  first  carried  through 
the  concha  backwards,  and 
then  backwards  and  upwards 
till  the  anterior  extremity  of 
the  helix  is  reached.  (Ballance.) 


Fig.  150.  The  posterior  edge  of  the  inner  extremity  of 
the  cartilaginous  meatus  is  shown  dislocated  outwards, 
and  a  long  narrow  knife  has  been  passed  along  the  length 
of  the  meatus  through  the  conchal  opening.  The  white 
space  shown  in  this  and  in  Figs.  152  and  153  represents 
the  bony  area  which  has  been  operated  on.    ( Ballance. ) 

The  removal  of  the  plug  is  facilitated  by  soak- 
ing it  with  hydrogen  peroxide  (3  per  cent.). 
The  packing  should  be  renewed  every  second 
day  and  the  cavity  then  be  syringed  with 
saline  solution  or  some  mild  antiseptic.  Later 
on  the  packing  is  omitted,  and  the  granu- 
lating surface  treated  with  drops  of  a  solution 
of  boracic  acid  in  alcohol.  Any  excessive 
formation  of  granulations  must  be  kept  in 
check  by  the  application  of  lactic  acid  (20 
per  cent.),  or  of  trichloracetic  acid,  or  by 
touching  with  a  bead  of  chromic  acid. 

The  Treatment  of  the  Intracranial  Com- 
plications of  Otitis  Media.  These  are  extra 
dural  abscess,  cerebral  or  cerebellar  abscess, 
thrombosis  of  the  lateral  sinus  and  meningitis.^ 
In  all  except  the  last  immediate  operation  is 
indicated,  while  in  some  cases  of  early  men- 
ingitis operation  oSers  a  possibihty  of  recovery 


1  A  more  unusual  condition  than  these  is  an  intra- 
dural abscess  (pachymeningitis  Interna  Circumscripta). 
"  A  circumscribed  collection  of  pus  internal  to  the  dura 
mater,  between  it  and  the  surface  of  the  brain  covered 
by  the  pia  mater,  occurs  mostly  when  there  is  a  fistulous 
perforation  of  the  dura,  provided  an  adhesion  of  the 
dura  with  the  pia  mater  takes  place  in  the  neighbour- 
hood of  the  ulceration.  Such  a  coUection  of  pus  either  leads  to  ulceration  and  softening 
of  the  cortex  of  the  brain  or  to  a  brain  abscess.     (Politzer.) 


350 


OPERATIONS  ON  THE  HEAD  AND  NECK 


When,   however,   pus  is  diffused  over  the  whole   hemisphere,    surgical 
interference  offers    no  prospect  of  success.     In  the  great   majority  of 


Fig.  152.  The  concho-meatal  flap  is  seen  behind  the  mastoid  flap.  Supporting 
stitches  (one,  two,  or  three,  as  the  case  may  be)  are  carried  through  the  edge  of 
the  conchal  cartilage.  The  two  threads  of  each  stitch  are  now  threaded  on  one 
needle,  so  that  they  can  be  passed  through  the  skin  and  other  tissues  of  the 
mastoid  flap  without  constricting  them.  Before  the  supporting  stitches  are 
passed  the  thick  layer  of  tissue  behind  the  posterior  wall  of  the  meatus  is  cut 
away  so  as  to  facilitate  the  application  of  the  mcatal  to  the  skin  flap.     ( Ballance. ) 

cases  the  septic  process  reaches  the  cranial  cavity  by  direct  extension 

from  the  tympanum  or  the  an- 
trum by  gradual  destruction  of 
their  bony  walls.  Destruction 
of  the  thin  tegmen  tympani 
will  open  the  middle  fossa  and 
will  allow  of  the  development 
of  meningitis  or  of  a  cerebral 
abscess,  while  an  extension 
backwards  through  the  pos- 
terior wall  of  the  antrum  will 
admit  of  an  extension  of  the 
septic  process  to  the  posterior 
fossa  resulting  in  the  formation 
of  a  cerebellar  abscess,  or  of 
thrombosis  of  the  lateral  sinus. 
In  unusual  cases  no  such  direct 
track  may  be  seen.  In  such 
cases  the  intracranial  infection 
may  have  been  caused  in  one 
of  the  following  ways  :  (1)  By 
extension  through  the  labyrinth 
(2)    By   extension   through   the 


Fig.  1.53.  The  supporting  stitches  are 
shown  drawn  tight,  and  supporting  the  raw 
surface  of  the  concho-meatal  flap  against  the 
raw  surface  of  the  mastoid  flap.     (BaUance.) 

and   the    internal   auditory    meatus. 


ABSCESS  IN  TIIK  HKAIN 


;551 


floor  of  the  tynipanuin  to  tlie  hiilbot  the  jugular  vein.  (3)  By  exten- 
sion along  some  of  the  minute  canals  for  emissary  veins.  (4)  By 
extension  through  the  anterior  wall  of  the  tympanum  to  the  carotid  canal 
and  thence  to  the  apex  of  the  petrous.  (5)  An  abscess  may  be  pysemic, 
and  situated  at  some  distance  from  the  affected  ear,  even  in  the  opposite 
hemisphere. 

In  typical  cases,  the  diagnosis  of  an  intracranial  complication  is 
easy,  biit  occasionally  it  is  exceedingly  diflicult.  More  than  one  of  the 
above  may  co-exist,  which  increases  the  dithculty  of  an  exact  diagnosis. 
Occasionally  a  cerebral  abscess  may  be  present  with  few  or  no  symptoms, 
while  it  is  often  only  possible  to  suspect  some  intracranial  trouble  without 


Fig.  154.  The  .supporting  stitches  are  shown  passing  through  the  angle  of 
junction  of  the  pinna  and  the  mastoid  flaj].  They  were  two  in  number  in  the 
case  from  which  the  drawing  was  made.  They  are  tied  over  pieces  of  rubber 
tubing.  This  is  shown  too  small,  and  the  threads  are  tied  too  tightly.  Ihe 
curved  incision  is  entirely  closed  by  gossamer  silkworm-gut  svitures.     (Ballance. ) 

being  able  to  locate  it  or  to  be  certain  of  its  nature.  Needless  to  say  the 
appearance  of  such  symptoms  as  a  rigor,  severe  pain,  marked  rise  of 
temperature,  convulsions,  or  drowsiness,  will  be  an  indication  for  an 
immediate  exploratory  operation. 

Extradural  Abscess.  The  pus  will  be  found  between  the  bone  and  the 
dura  mater.  These  abscesses  occur  more  frequently  in  the  posterior  fossa, 
especially  as  a  collection  of  pus  and  granulation  tissue  in  the  sigmoid 
groove — a  peri-sinous  abscess.  The  symptoms  vary  very  much  indeed. 
Not  infrequently,  in  the  case  of  a  peri-sinous  abscess,  they  may  be  com- 
pletely absent,  the  condition  being  found  unexpected  during  a  radical 
mastoid  operation.  In  other  cases  there  may  be  very  severe  pain,  while 
in  others  this  symptom  varies  from  time  to  time  owing  to  the  pus  being 
able  to  drain  and  the  abscess  occasionally  to  empty  itself  through  the 
middle  ear. 

Abscess  in  the  Brain.  When  in  the  cerebrum  the  collection  of  pus 
is  usually  in  the    middle  and    back  part  of    the   temporo-sphenoidal 


352  OPERATIONS  OX  THE  HEAD  AND  NECK 

lobe  ;  when  in  the  cerebellum,  in  the  front  and  outer  part  of  the  lateral 
lobe. 

Symptoms.     These  may  be  divided  into  the  following  three  groups  : 

I.  General.  There  may  be  pyrexia,  which  is,  however,  usually  due  to 
the  otitis  or  to  some  other  complication.  A  typical  cerebral  abscess  will 
show  a  slightly  subnormal  temperature.  A  rigor  may  occur  at  the  early 
stages  but  is  rarely  repeated.  In  an  old-standing  case  there  will  be  loss  of 
flesh  and  constipation. 

II.  General  symptoms  of  cerebral  disturbance.  Headache  is  a  very 
constant  symptom,  though  the  position  of  the  headache  is  not,  as  a  rule, 
any  indication  as  to  the  situation  of  the  abscess.  Nausea  and  vomiting 
are  common,  the  latter  having  no  relation  to  the  taking  of  food.  Some 
mental  disturbance  is  nearly  always  present.  In  the  earlier  stages 
there  is  mental  dulness  and  apathy  :  later  on  there  is  stupor,  or  more 
or  less  complete  coma.  Optic  neuritis  may  be  present,  but,  on  the  other 
hand,  is  often  absent.     The  pulse  in  a  typical  case  is  slow. 

III.  Localising  symptoms.  These  are  usually  but  slightly  marked 
and  are  often  entirely  absent.  A  temporo-sphenoidal  abscess  may, 
owing  to  pressure  on  the  internal  capsule,  produce  some  paresis  in  the 
opposite  arm  and  leg.  Occasionally  there  will  be  some  paralysis  of  the 
ocular  muscles  or  alteration  in  the  pupil.  The  symptoms  vary  a  great 
deal  and  are  often  very  indefinite.  "  Abscess  in  the  brain  may  be  latent,^ 
producing  no  symptoms  directly  referable  to  the  brain,  only  general 
symptoms  of  ill-health,  until  excited  to  activity  by  a  blow,  or  some  minor 
operation,  such  as  the  removal  of  a  polypus  "  (Ballance).  Such  latent 
abscesses  possess  a  well-marked  capsule.  This  is  of  twofold  importance. 
It  prevents  the  risk  of  rupture  and,  as  will  be  seen  later,  it  may  baffle 
attempts  to  find  the  pus.  On  the  other  hand  a  rapidly  enlarging  abscess 
is  very  likely  to  rupture  into  the  lateral  ventricle,  and  the  more  acute 
the  abscess  the  more  will  it  be  accompanied  by  an  advancing  affection  of 
the  surrounding  brain. 

This  condition,  by  causing  such  symptoms  as  a  high  temperature 
and  dehrium,  will  be  an  additional  cause  of  the  masking  of  the  typical 
symptoms  of  cerebral  abscess.  By  leading  to  a  diagnosis  of  meningitis, 
they  may  cause  the  abscess  to  be  overlooked. 

Abscess  in  the  Cerebellum.  The  above  i;pmarks  also  apply  to  abscesses 
in  the  cerebellum.  Abscesses  in  this  situation  may,  however,  present 
well-marked  symptoms  which  aid  in  the  locahsation  of  the  trouble. 
Such  are  vertigo  and  ataxy,  rigidity  of  the  muscles  of  the  neck,  and  in  some 
cases  well-marked  optic  neuritis.  Dr.  Acland  and  Mr.  Ballance  "  have 
carefully  gone  into  the  question  in  an  elaborate  article.  They  throw 
some  doubt  upon  the  opinion  usually  held,  that  abscess  in  the  temporo- 
sphenoidal  lobe  is  more  common  than  in  the  cerebellum.  They  quote 
statistics  by  Korner,  shoA\"ing  that  in  100  cases  of  abscess  in  the  brain, 
secondary  to  ear  disease,  62  were  in  the  cerebellum  and  32  in  the  cerebrum, 
and  in  6  in  both  cerebrum  and  cerebellum.  Of  3.3  cases  collected  from 
St.  Thomas's  and  the  Great  Ormond  Street  hospitals,  24  were  cerebellar 

^  With  reference  to  the  diagnosLs  of  latent  cerebral  abscess  the  reader  is  referred  to 
a  valuable  paper  read  by  Sir  Victor  Horsley  before  the  Otological  section  of  the  Royal 
Society  of  Medicine  (Proc.  Roy.  Soc.  Med.,  February  1912,  p.  45).  In  this  paper  Sir 
Victor  Horsley  discusses  also  the  significance  and  importance  of  a  number  of  symptoms 
such  as  optic  neuritis,  subnormal  temperatures,  and  insists  on  the  importance  of  a  careful 
neurological  examination. 

*  St.  Thomas's  Hospital  Be  ports,  vol.  xxiii,  p.  133. 


MENINGITIS  353 

and  11  temporo-sphenoidal.  In  two  cases  an  abscess  was  present  in  both 
the  temporo-sphenoidal  lobe  and  in  the  cerebolhim.  Dr.  Acland  and 
Mr.  Ballance  drew  attention  to  the  fact  that  in  their  case  certain  symptoms 
were  present  which  so  closely  resembled  the  effects  produced  by  removal 
of  one  lateral  lobe  of  the  cerebellum,  that  they  deserve  to  be  fully  con- 
sidered. These  are  :  (i)  Paralysis  of  the  upper  extremity  on  the  same 
side  as  the  lesion,  (ii)  Conjugate  deviation  of  the  eyes  towards  the 
opposite  side,  (iii)  Lateral  nystagmus,  (iv)  Exaggerated  knee-jerk 
on  the  same  side  as  the  cerebellar  lesion.  (v)  A  tendency  to  face 
towards  the  side  of  the  lesion  in  walking,  (vi)  Staggering  gait,  and  a 
tendency  to  fall  towards  the  side  opposite  to  the  lesion,  (vii)  Atti- 
tude in  bed  :  the  patient  tends  to  lie  on  the  side  opposite  to  the  lesion 
with  the  limbs  flexed,  and  with  the  side  of  the  face  corresponding  to  the 
lesion  uppermost. 

Thrombosis  o£  the  Lateral  Sinus.  This  is  a  grave  comphcation, 
from  its  tendency  to  cause  general  pyaemia  and  distant  suppurations.  The 
onset  is  usually  sudden  and  is  accompanied  by  a  rigor,  headache,  and 
vomiting.  Mr.  Ballance  ^  believes  that  the  following  group  of  symptoms, 
when  present  together,  are  pathognomonic  of  septic  thrombosis  :  (i)  A 
history  of  purulent  discharge  from  the  ear  for  a  period  of  more  than  a  year, 
(ii)  The  sudden  onset  of  the  illness,  with  headache,  vomiting,  rigor,  and 
pain  in  the  affected  ear.  (iii)  An  oscillating  temperature,  i.e.  104°  in  the 
evening  and  98  in  the  morning,  (iv)  Vomiting  repeated  day  by  day. 
(v)  Repeated  rigors,  (vi)  Local  oedema  and  tenderness  over  the  mastoid, 
or  in  the  course  of  the  internal  jugular  vein.^  (vii)  Tenderness  on  deep 
pressure  at  the  posterior  border  of  the  mastoid  and  below  the  external 
occipital  protuberance,  (viii)  Stiffness  of  the  muscles  of  the  back  or  side 
of  the  neck,     (ix)  Optic  neuritis.^ 

In  the  great  majority  of  cases  metastatic  abscesses  are  fomid  in  the 
lungs,  though  occasionally  the  toxaemia  causes  typhoid  fever-like  symp- 
toms. 

Meningitis.  Several  forms  of  this  serious  complication  must  be 
recognised,  (a)  Suppurative  meningitis,  in  which  pus  is  widely  diffused 
over  the  hemisphere  in  the  pia-arachnoid.  In  this  condition  the  tempera- 
ture rises  to  102  or  103°  and  there  may  be  a  rigor  :  there  is  intense  head- 
ache with  dehrium  and  more  or  less  loss  of  consciousness.  There  is 
rigidity  of  the  neck  muscles  and  Kernig's  sign  will  be  present.  Other 
symptoms  are  optic  neuritis,  vomiting,  and  there  may  be  convulsions  or 
paralysis  of  the  opposite  arm  and  leg.  Later  there  will  be  coma,  Cheyne 
Stokes  breathing  and  a  rapid  irregular  pulse.  The  prognosis  in  this  diffuse 
form  is  absolutely  unfavourable.'* 

(6)  In  rare  cases,  though  the  infection  has  penetrated  the  dura  the 
suppuration  remains  localised  forming  a  subdural  abscess,  i.e.  an  abscess 
between  the  dura  and  arachnoid,  while  the  latter  membrane  and  the  pia 
mater  escape  infection. 

(c)  In  some  cases  there  will  be  a  serous  meningitis  in  which  there  is  an 

1  Loc-  supra  cit- 

*  (Edema  or  tenderness  over  the  internal  jugular  may  be  due  to  extension  of  the  clotting 
and  phlebitis,  or  to  enlargement  of  the  deep  lymphatic  glands.  Any  examination  of  the 
internal  jugular  should  be  conducted  with  the  utmost  gentleness  for  fear  of  detaching 
thrombi. 

^  The  occurrence  of  optic  neuritis  is  very  variable.  It  may  be  present  in  any  of  the 
intracranial  complications  of  otitis  media,  but  on  the  other  hand  is  often  absent. 

*  Lumbar  puncture  offers  an  excellent  help  to  the  diagnosis  of  the  various  forms  of 
meningitis. 

SURGERY    I  23 


354  OPERATIONS  ON  THE  HEAD  AND  NECK 

increased  amount  of  clear  fluid  in  the  subarachnoid  space.  There  may 
be  symptoms  suggesting  suppurative  meningitis,  or  the  condition  ma'y 
only  be  found  and  recognised  during  an  operation.  This  form  of  menin- 
gitis can  seldom  or  never  be  diagnosed  with  certainty.  Though  general 
suppurative  meningitis  will  not  be  benefited  by  operation,  the  latter  two 
forms  of  this  disease  are  amenable  to  operative  treatment. 

"  If  the  clinical  picture  makes  the  diagnosis  of  suppurative  meningitis  probable, 
lumbar  puncture  should  be  carried  out  to  remove  any  doubt  that  may  remain. 
If  the  cerebro-spinal  fluid  is  found  to  be  purulent  and  to  contain  bacteria,  further 
operative  measures  are  useless.  If  the  fluid  is  only  turbid,  even  though  bacteria 
are  found,  the  cranium  should  be  opened.  If  the  fluid  is  purulent  without  micro- 
organisms or  clear  with  micro-organisms,  I  now  always  operate.  When  a  patient 
is  so  weak  that  any  operation  is  dangerous,  lumbar  puncture  should  be  done,  so 
that  the  surgeon  may  learn  whether  there  is  anything  to  be  hoped  for  from  further 
interference  or  not."  ^ 

For  further  information  on  this  subject  reference  may  be  made  to  an  interesting 
paper  by  Mr.  F.  G.  Wrigleyon  "  The  Cerebro-spinal  Fluid  as  an  Aid  to  Diagnosis  in 
Suppurative  Meningitis  of  Otitic  Origin,"  with  subsequent  discussion.^  Mr.  Wrigley 
says  :  "  The  diagnosis  of  suppiu'ative  meningitis  cannot  be  made  with  certainty 
(though  it  may  exist)  without  the  presence  of  bacteria  in  the  cerebro-spinal  fluid, 
and  I  consider  that  the  following  features  are  usually  necessary  before  an  absolute 
diagnosis  can  be  made  :  The  fluid  is  either  turbid  or  deposits  a  coagulum  quickly 
on  standing.  The  albumen  is  increased  0- 1  Esbach  or  above.  Microscopic  ex- 
amination shows  a  polymorphonuclear  leucocytosis,  and  bacteria  are  found  either 
in  Alms  or  cultures.  If  these  features  are  present  the  diagnosis  may  be  made  with 
certainty." 

Operations  for  the  treatment  of  intracranial  complications  of  Otitis 
Media.  In  former  days  these  were  usually  carried  out  by  trephining  in  the 
region  of  the  suspected  disease.  It  is  now,  however,  recognised  that  the 
intracranial  complication  should,  as  a  rule,  be  exposed  and  treated  via 
the  mastoid  process  and  the  antrum  or  tympanum.  The  reasons  for 
this  are  as  follows  :  (1)  Suppuration  in  the  mastoid  antrum  and  cells 
is  the  cause  of  the  intracranial  trouble.  If  the  latter  alone  is  treated 
the  septic  process  continues  in  the  bone  and  may  extend,  in  other 
directions,  to  the  cranial  cavity. 

(2)  Usually  there  will  be  a  direct  track  through  the  bone  from  the 
antrum  leading  to  the  intracranial  lesion.  As  will  have  been  gathered 
from  the  remarks  above  the  operation  is  often  of  an  exploratory  nature, 
and  the  information  thus  gathered  is  of  the  greatest  service  in  discovering 
the  nature  and  the  situation  of  the  lesion. 

(3)  The  pus  will  in  this  way  be  found  where  it  is  nearest  the  surface 
and  will  thus  be  drained  with  the  minimum  amount  of  damage  to  the 
normal  brain  tissue.  (4)  Occasionally  pus  will  have  made  its  way  into 
both  fossae.  In  this  case  there  will  be  probably  a  direct  track  from  the 
antrum  through  its  roof  and  posterior  wall.  By  trephining  to  expose  one 
fossa,  it  is  very  likely  that  the  suppuration  in  the  other  fossa  might  be 
overlooked. 

There  may,  however,  be  cases  where  it  may  be  desirable  to  trephine 
directly  over  the  situation  of  the  pus.  For  example,  there  may  be  distinct 
localising  signs  of  an  abscess  in  the  brain  at  some  little  distance  from  the 
situation  of  the  antrum,  or  possibly  the  condition  of  the  patient  may  be 
so  grave  that  it  may  be  felt  advisable  to  drain  the  pus  at  once,  leaving  the 
treatment  of  the  antrum  and  the  mastoid  cells  until  the  condition  of  the 
patient  has  improved. 

^  Heine,  Operations  on  the  Ear,  p.  196. 

2  Proc.  Roy.  Soc.  Med.  Otol.  Sec,  July  1912,  p.  171. 


OPERATION  FOR  OTITIS  MEDIA 


355 


The  difToront  sites  for  ap|)lyinp;  the  trephine  are  shown  in  Fig.  155  .  Mr.  BaMance 
advises  tliat  the  point  of  the  trepliine  shouki  he  applied,  f(jr  (h-aining  a  cerebral 
abscess,  ^  iiu-h  above  the  siipratueatal  spin(%  tiu;  obj(;(d  being  to  ex])osc  the 
lowest  ])art  of  the  middle  fos.sa  just  above  tiie  tegnien  antri  and  tegnien  tyinjjani. 
Inimediateiy  at)<)V(^  tiie  tegniina  are  the  tissues  in  wiiieh,  as  a  rule,  the  infective 
process  develops.  Sir  \V.  Macewen  gives  the  following  rule  for  exploring  a 
tenii)oro-s|)henoidal  ab.scess  :  The  centre-pin  should  be  placed  in  a  line  with  the 
posterior  wall  of  the  meatus,  and  three-(|uarters  of  an  inch  above  the  ])osterior 
root  of  the  zygoma.     IMr.  Barker  tliinks  that  nine-tenths  of  the  abscesses  in  the  brain 


Fig.  155.  The  figure  shows  the  relations  of  the  lateral  sinus  to  the  outer  wall  of 
the  skull,  and  the  position  of  the  trephine-opening,  a,  for  exploring  it.  Reid's 
base-line  is  shown  passing  through  the  middle  of  the  external  auditory  meatus 
and  touching  the  lower  margin  of  the  orbit,  x  x  indicate  the  site  of  the  tentorium 
as  far  as  it  is  in  relation  to  the  outer  wall  of  the  skull.  The  anterior  x  shows 
the  point  where  the  tentorium  leaves  the  skull  and  is  attached  to  the  upper 
border  of  the  petrous  bone,  a,  Trephine-opening  to  expose  lateral  sinus,  its 
centre  being  1  inch  behind  and  j  inch  above  the  centre  of  the  meatus.  This 
opening  can  easily  be  enlarged  upwards,  backwards,  downwards,  and  forwards 
(see  the  dotted  lines),  by  suitable  forceps.  It  is  always  well  to  extend  it 
forwards  so  as  to  open  up  the  mastoid  antrum,  c.  b,  Trephine-opening  to 
explore  the  anterior  surface  of  the  petrous  bone,  the  roof  of  the  tympanum 
and  the  petro-sc^uamous  fissure,  its  centre  being  situated  a  short  inch  above  the 
centre  of  the  meatus.  At  the  lower  margin  of  this  treiihine-opening  a  probe 
can  be  insinuated  between  the  dura  and  the  bone,  and  made  to  search  the  whole 
of  the  anterior  surface  of  the  petrous,  c,  Trephine-opening  for  exposing  antrum, 
J  inch  above  and  behind  the  centre  of  the  meatus,  d,  Trephine-opening  for 
temporo-sphenoidal  abscess  (Barker),  1;^  inch  behind  and  above  centre  of 
meatus.  The  needle  should  be  directed  at  first  inwards,  and  a  little  downwards 
and  forwards,  e,  Trephine-opening  for  cerebellar  abscess,  1  ^  inch  behind  and 
1  inch  below  the  meatus.  The  anterior  border  of  the  trephine  should  be  just 
under  cover  of  the  posterior  border  of  the  mastoid  process.  Such  an  opening  is 
well  removed  from  the  lateral  sinus,  and  a  needle,  if  directed  forwards,  inwards. 
and  upwards,  would  enter  an  abscess  occuj^ying  the  anterior  portion  of  the 
lateral  lobe  of  the  cerebellum,  the  usual  site  of  an  abscess  in  this  part  of  the 

brain.     (Barker.) 

are  within  a  circle  with  a  |  inch  radius,  whose  centre  lies  an  inch  and  a  quarter  above 
and  the  same  distance  behind  the  centre  of  the  bony  meatus. 

For  a  cerebellar  abscess  Mr.  Barker  advises  a  point  an  inch  and  a  half  behind 
the  centre  of  the  meatus  and  an  inch  below  Reid's  base  line  (a  line  running  from 
the  lower  border  of  the  orbit  backwards  through  the  centre  of  the  meatus).  Mr. 
Ballance  writes  -A  "  A  cerebellar  abscess  arising  from  ear  disease  is  usually  in  the 
anterior  part  of  the  lateral  lobe,  close  to  the  diseased  bone  (inner  side  of  the 
mastoid  or  posterior  surface  of  the  petrous)  which  has  caused  the  infection.  Place 
the  trephine  so  that  its  anterior  border  is  just  behind  the  posterior  border  of  the 
mastoid  process,  and  so  that  its  upper  border  is  below  Reid's  base  line. 

^  Loc.  supra  cit. 


356  OPERATIONS  ON  THE  HEAD  AND  NECK 

For  exploring  the  lateral  sinus  Mr.  Dean  recommends  that  the  pin  of  the  trephine 
should  be  applied  an  inch  and  a  quarter  behind  and  a  quarter  of  an  inch  above 
the  centre  of  the  external  auditory  meatus.  Bone  is  then  removed  by  bone  forceps 
in  an  upward  and  downward  direction  so  as  to  admit  of  exploration  both  of  the 
temporo-sphenoidal  lobe  and  of  the  cerebellum. 

Treatment  oJ  extra  dural  Abscess.  The  mastoid  cells  and  the  antrum 
having  been  opened  in  the  way  described  above,  and  the  tympanum 
ha\dng  been  exposed  by  removal  of  the  posterior  meatal  wall  as  has  been 
described  in  the  account  of  the  complete  mastoid  operation,  a  careful 
inspection  is  made  of  the  tegmina  and  the  posterior  antral  wall.  This 
will  probably  show  a  carious  patch  through  which  a  probe  may  be  passed 
into  the  aft'ected  fossa  :  pus  in  some  quantity  may  be  seen  escaping 
through  the  opening.  In  the  case  of  the  middle  fossa  a  few  cuts  with  the 
gouge  in  an  upward  direction  will  suffice  to  expose  more  freely  the  abscess 
cavity.  As  soon  as  a  sufficiently  large  opening  has  been  made  for  their 
introduction  a  pair  of  gouge  forceps  may  be  employed  to  remove  sufficient 
bone  to  secure  free  drainage.  The  dura  should  be  exposed  until  its  surface 
is  devoid  of  granulations  and  is  practically  normal  in  appearance.  Septic 
granulations  and  pus  should  be  washed  and  sponged  from  the  surface  of  the 
dura  :  the  curette  must  not  be  applied  to  it  for  fear  of  injuring  the  mem- 
brane and  thus  opening  up  a  fresh  channel  for  the  extension  of  infection. 

An  extra  dural  abscess  in  the  posterior  fossa  means  that  the  infection 
has  extended  through  the  posterior  wall  of  the  antrum,  and  thus  pus  and 
granulation  tissue  are  present  in  the  sigmoid  groove  (perisinous  abscess). 
This  condition  may  be  present  with  few  or  no  symptoms  and  without 
thrombosis  of  the  sinus.  When  the  antrum  is  opened  inspection  and 
careful  investigation  with  the  probe  will  reveal  a  track  leading  directly 
backwards  to  the  posterior  fossa.  This  must  be  opened  up  by  removing 
bone  in  a  backward  direction  with  gouge  or  cutting  forceps.  This  must 
be  carried  out  most  carefully  on  account  of  the  risk  of  injury  to  the 
sinus.  Should  it  be  accidentally  opened  it  must  be  treated  on  the  lines 
described  at  p.  342.  Drainage  must  be  secured  and  the  diseased  dura 
exposed  and  treated  in  the  same  way  as  for  an  abscess  in  the  middle 
fossa.  In  all  these  cases  the  retro-auricular  wound  ought  not  to  be 
completely  closed  even  when  the  abscess  is  unexpectedly  found  in  the 
course  of  a  radical  mastoid  operation. 

Operation  for  Abscess  in  the  Temporo-sphenoidal  lobe.  The  antrum 
and  the  mastoid  cells  having  been  opened  up  as  rapidly  as  possible  the 
middle  ear  is  exposed  by  removal  of  the  posterior  wall  of  the  meatus  and 
the  external  wall  of  the  aditus.  Examination  of  the  tegmen  will  then 
probably  show  a  carious  area  opening  the  middle  fossa.  Bone  is  next 
gouged  away  in  an  upward  direction  above  the  posterior  root  of  the 
zygoma,  and  the  whole  of  the  diseased  portion  of  the  tegmen  is  also  removed. 
With  Hoffmann's  forceps  or  gouge  forceps  the  dura  is  now  widely  exposed 
for  an  inch  and  a  half  above  the  level  of  the  meatus  and  is  then  carefully 
examined.  If  an  abscess  is  present  the  membrane  will  be  unduly  tense 
and  will  bulge  forward  into  the  wound  :  its  surface  may  be  dull, 
hypersemic,  or  show  an  area  covered  by  granulations,  while  in  other 
cases  it  may  appear  to  be  normal.  Typically  the  usual  pulsation  of  the 
brain  cannot  be  felt.  A  pulsation  may,  however,  be  present  \yith.  a 
small  abscess  with  firm  walls  rather  deeply  placed,  and  hence,  though 
pulsation  of  the  brain  is  noticed,  if  the  symptoms  point  to  the  presence 
of  an  abscess  a  search  must  be  made  for  pus. 


OPERATION  FOR  ABSCESSES  357 

The  presouce  of  pus  should  be  verified  and  its  situation  determined  by 
means  of  an  exploring  syringe  fitted  with  a  large  bore  needle  :  this  is  a 
point  of  considerable  importance,  for  a  small  needle  may  easily  get  blocked 
by  brain  substance.  Other  operators  use  a  grooved  director,  an  expand- 
ing trocar,  or  an  ex])l()ratorv  incision.  The  needle  nuist  not  be  pushed 
too  deeply  for  fear  of  wounding  and  infecting  the  lateral  ventricle,  which 
is  always  in  close  proximity  to  the  deep  aspect  of  the  abscess.  As  soon 
as  the  pus  is  found  the  abscess  is  opened  by  a  thin-bladed  knife  introduced 
by  the  side  of  the  needle  which  is  then  withdrawn.  A  free  incision  must 
be  made,  not  a  mere  puncture,  or  the  drainage  will  not  be  satisfactory. 
If  the  pus  is  found  to  one  side  of,  or  above  the  opening  in  the  skull,  more 
bone  must  be  removed  so  as  to  allow  of  direct  access  to  the  abscess  cavity. 
The  pus  is  often  remarkably  offensive  :  the  quantity  may  be  only  3j  or  3ij , 
but  on  the  other  hand  there  may  be  a  large  collection  amounting  to  §j  or 
§ij,  or  even  more.  The  smaller  abscesses  will  be  the  more  difficult  to  find  : 
the  larger  ones  will  be  in  dangerous  proximity  to  the  lateral  ventricle. 

The  question  of  drainage  is  a  difficult  one  owing  to  the  soft  consistency 
of  the  brain  substance  and  the  likelihood  of  portions  of  the  soft  brain 
tissue  blocking  up  the  lumen  of  drainage  tubes.  When  a  tube  is  removed 
its  satisfactory  replacement,  for  the  same  reason,  may  be  a  difficult  matter. 
The  tube  must  be  of  sufficient  length  to  enter  the  abscess  cavity,  but 
nmst  not  press  against  its  inner  wall  on  account  of  the  danger  of  opening 
and  infecting  the  lateral  ventricle.  A  couple  of  windows  may  be  cut 
close  to  its  inner  extremity  and  it  should  be  securely  fixed  in  position 
by  a  stitch  passing  through  the  margins  of  the  skin  incision,  or  to  the  dura 
mater.  Mr.  West,  in  the  discussion  before  the  Otological  Society  referred 
to  above,  says  :  "  Where  the  abscess  is  well  defined,  I  think  it  will  be 
generally  admitted  that  tubes  form  a  satisfactory  means  of  drainage.  I 
use  rubber  tubes  of  good  size,  up  to  the  thickness  of  the  little  finger,  or  a 
pair  of  tubes  of  smaller  size  stitched  together  with  a  silkworm-gut  suture. 
If  the  tube  is  stitched  to  the  edge  of  the  dura  mater,  or  to  some  other 
convenient  point,  and  is  of  good  size,  it  will  not  be  pressed  out  by  the 
brain.  I  have  abandoned  all  lateral  holes  in  tubes.  They  become 
blocked  immediately,  and  large  plugs  of  brain  are  torn  away  each  time 
the  tube  is  rotated  or  removed,  exposing  fresh  surfaces  to  infection.  The 
problem  of  drainage  of  areas  of  diffuse  infection  seems  to  me  one  of  extreme 
difficulty.  Tubes  are  ineffective  and  gauze,  in  my  hands,  has  been  very 
unsatisfactory.  In  bad  cases  I  believe  that  the  only  method  which  offers 
any  hope  is  the  bold  removal  of  a  wide  area  of  bone  and  dura  mater,  and 
then  of  the  overlying  cortex,  so  that  a  large  amomit  of  the  infected  brain 
is  exposed,  and  free  to  drain  on  the  surface.  In  this  way,  free  drainage 
is  secured,  and  I  can  testify  that  the  result  may  be  little  short  of  miracu- 
lous." Sir  Victor  Horsley  recommends  concentric  tubes,  so  that,  as  far  as 
possible,  there  is  always  a  tube  in  the  wound  until  final  granulation 
occurs.  In  any  case  the  tube  should  be  left  in  position  for  six  days  before 
it  is  removed. 

The  lower  part  of  the  wound  is  drained  separately  by  a  strip  of  ribbon 
gauze  which  is  lightly  packed  into  the  antrum  and  the  cavity  in  the 
mastoid.  A  similar  strip  is  inserted  into  the  meatus,  and  the  size  of  the 
wound  may  then  be  diminished  by  a  few  sutures  at  its  upper  and  lower 
extremities. 

The  after-treatment  of  the  abscess  has  been  indicated  above.  The 
external  dressing  must  at  first  be  changed  daily.     The  gauze  plugs  will 


358  OPERATIONS  ON  THE  HEAD  AND  NECK 

require  changing  daily  or  on  alternate  days  according  to  the  amount  of 
suppuration,  and  the  cavity  in  the  bone  must  be  kept  clean  by  gentle 
syringing  with  some  dilute  antiseptic  lotion. 

In  a  successful  case  the  pressure  symptoms,  such  as  coma  and  paralysis, 
usually  disappear  at  once,  but  death  may  occur  some  time  after  the 
operation.  This  may  be  due  to  infection  of  the  lateral  ventricle  or  to 
a  diffuse  infection  of  the  brain,  while  in  other  cases  no  definite  cause  of 
death  may  be  found  at  the  post-mortem.  An  occasional  complication  is 
the  appearance  of  a  hernia  cerebri.  This  may  be  cut  away,  or,  as  in  the 
following  case,  be  allowed  to  slough  away. 

A.  J.,  a  boy  ast.  10  years,  was  admitted  to  Guy's  Hosjiital  in  March  1910  with 
the  following  history  :  For  three  weeks  he  had  suffered  from  headache  which  was 
occasionally  very  severe.  There  had  also  been  vomiting  and  troublesome  constipa- 
tion. For  a  few  days  he  had  been  very  drowsy.  There  was  a  purulent  discharge 
from  the  right  ear,  but  the  cause  and  the  duration  of  this  were  not  known.  On 
admission  the  pulse  rate  was  52  and  the  temperature  subnormal.  The  right  pupil 
was  dilated  and  fixed,  there  was  ptosis  of  the  right  eyelid,  some  paresis  of  the 
left  arm  and  leg,  and  double  optic  neuritis.  There  was  no  tenderness  over  the 
mastoid.  A  radical  mastoid  o^jcration  was  quckly  performt'd,  when  pus  and 
granulations  were  found  in  the  antrum  and  the  mastoid  cells,  while  the  tegmen 
was  carious.  On  removing  bone  in  an  upward  diiection  tense,  non-pulsating  dura 
mater  covered  by  granulations  was  found  in  the  middle  fossa.  A  large  temporo- 
sphenoidal  abscess  was  opened  and  drained.  On  the  following  day  all  pressme 
symptoms  had  completely  disappeared.  In  the  next  few  days  a  hernia  cerebri  the 
size  of  a  golf  ball  appeared.  The  superficial  part  of  this  eventually  sloughed  away, 
when  the  rest  of  the  hernia  receded.  The  wound  tlien  healed,  and  he  was  discharged 
seven  weeks  after  the  operation.  Fifteen  months  later  he  was  re-admitted  for  a 
polypus  in  the  right  ear.     This  was  removed  and  he  made  a  complete  recovery. 

Operation  for  an  abscess  in  the  cerebellum.  The  method  of  trephining 
for  an  abscess  in  this  situation  has  been  described  above.  When  the 
abscess  is  found  in  this  situation  drainage  is  likely  to  be  unsatisfactory, 
since  the  abscess  is  usually  close  to  the  posterior  surface  of  the  petrous 
and  hence  will  only  be  reached  after  traversing  a  considerable  distance 
through  normal  brain  tissue.  A  cerebellar  abscess  may  thus  usually  be 
found  and  drained  in  the  front  of  the  vertical  portion  of  the  lateral  sinus 
in  the  small  area  bounded  by  the  superior  petrosal  sinus,  the  vertical 
part  of  the  lateral  sinus  and  the  posterior  surface  of  the  petrous.  In 
the  case  of  a  large  abscess  a  counter  incision  below  the  horizontal  part 
of  the  lateral  sinus  may  also  be  indicated. 

Exploration  of  the  posterior  fossa  is  indicated  if  the  symptoms  point 
to  the  presence  of  a  cerebellar  abscess,  or  if  symptoms  of  an  abscess  in  the 
brain  are  present  and  exploration  of  the  temporo-sphenoidal  lobe  has 
been  negative. 

The  mastoid  cells  and  antrum  having  been  opened  the  posterior  wall 
of  the  bony  cavity  is  examined  and  in  the  majority  of  cases  an  opening  into 
the  posterior  fossa  will  be  found  so  that  the  dura  mater  is  here  exposed. 
Bone  is  then  removed  in  a  backward  direction,  at  first  with  the  gouge 
and  then  with  the  bone-cutting  forceps,  due  care  being  taken 
to  avoid  injury  to  the  lateral  sinus,  which  must,  however,  be  freely 
exposed.  The  dura  in  this  situation  is  then  inspected  and  pus  is 
sought  for  by  one  of  the  methods  described  for  abscess  in  the  temporo- 
sphenoidal  lobe.  The  opening  of  the  abscess  and  the  mode  of  securing 
drainage  will  be  similar  to  that  described  above.  Should  a  counter 
opening  be  considered  desirable  the  lateral  lobe  of  the  cerebellum  may  be 
exposed  bv  removing  bone  in  a  backward  and  downward  direction  :  should 


OPERATION  FOR  SEPTIC  THROMBOSIS         359 

pus  not  be  I'ouiul  in  tlu>  foinior  situation  a  second  exploration  may  be 
made  here.  The  after-treatment  will  be  similar  to  that  described  for  a 
tem])on)-sp]ienoi(lal  abscess. 

Operation  for  septic  thrombosis  of  the  Lateral  Sinus.  The  great 
danger  in  these  cases  is  tliat  tlu^  thrombosis  may  ext<'nd  in  a  downward 
direction  to  the  jugular  bulb  and  to  the  internal  jugular  vein,  and 
also  that  portions  of  the  septic  clot  may  become  detached,  with  the 
result  that  metastatic  pyemic  abscesses  are  formed  in  the  lungs.  Tiie 
treatment  of  these  cases  nmst  thus,  in  the  words  of  Mr.  Ballance, 
"  be  twofold — viz.  the  free  exposure  and  removal  of  the  focus  from  which 
the  pyajmic  infection  has  occurred  or  is  threatening  ;  and  secondly, 
the  establishment  of  a  block  in  the  highway  along  which  the 
infecting  agents  are  travelling  from  the  local  focus  into  the  general 
circulation."  The  operation  will  thus  be  considered  in  two  stages  : 
(a)  The  treatment  of  the  infected  sinus  ;  (b)  The  treatment  of  the  internal 
jugular  vein  along  which  the  mfective  process  travels.  When  septic 
thrombosis  can  be  diagnosed  with  certainty  the  latter  may  be  carried  out 
before  the  former. 

(a)  The  exposure  and  treatment  of  an  injected  sinus.  After  the  antrum 
and  mastoid  cells  have  been  opened,  the  posterior  fossa  is  thoroughly 
exposed  in  the  manner  described  for  the  opening  of  a  cerebellar  abscess. 
Sufficient  bone  must  be  removed  to  secure  a  good  view  of  the  sinus.  If 
necessary,  the  sinus  can  be  laid  bare,  with  the  help  of  gouge  forceps  from 
the  torcula  herophili  to  the  jugular  bulb,  but  this  will  not  be  necessary 
at  this  stage  of  the  operation.  The  appearance  of  the  sinus  will  vary  : 
it  may  be  hard  and  bulging,  or  its  outer  wall  may  be  covered  by  granula- 
tions or  may  be  gray  or  green  in  colour.  Sometimes  a  perforation  will  be 
seen  through  which  pus  is  oozing.  In  doubtful  cases  a  sterilised  needle 
may  be  inserted  obliquely  through  the  outer  wall,  or  even  an  exploratory 
incision  made  into  the  interior  of  the  sinus.  It  must,  however  be  re- 
membered that  such  interference  with  a  normal  sinus  may  result  in  septic 
infection  occurring,  as  the  puncture  is  necessarily  made  through  septic 
tissues.  If  possible  the  sinus  should  be  exposed  in  a  backward  direction 
until  it  appears  to  be  healthy.  The  sinus  is  then  incised  here  and  the 
bleeding  arrested  by  packing  sterilised  ribbon  gauze  into  the  cavity.  The 
whole  of  the  exposed  and  thrombosed  portion  of  the  sinus  is  now  slit 
open  by  a  small  thin-bladed  knife  and  the  septic  clot  removed  by  a  small 
Volkman's  spoon,  which  is  also  used  to  scrape  the  clot  from  the  lower 
part  of  the  sinus  as  near  the  jugular  bulb  as  is  possible.  If  bleeding  then 
occurs  from  the  lower  end  of  the  vessel,  it  also  should  be  plugged  with  gauze. 

In  some  cases  the  sinus  may  be  found  to  be  thrombosed,  but  the  clot 
is  not  infected.  This  condition  may  be  found  unexpectedly  in  the 
course  of  a  radical  mastoid  operation  when  there  is  a  perisinous  abscess. 
Needless  to  say,  in  these  cases,  the  lateral  sinus  should  not  be  interfered 
with.  The  aseptic  nature  of  the  thrombus  may  be  inferred  from  the 
absence  or  slightness  of  the  symptoms. 

(6)  Treatment  oj  the  internal  jugular  vein.  This  is  still,  to  a  consider- 
able extent,  under  discussion.  In  those  cases  where  the  clot  in  the  sinus 
is  locahsed  and  where  its  lower  extent  is  reached,  ligature  or  other  treat- 
ment of  the  internal  jugular  is  not  indicated.  Too  often,  however,  it  is 
found  that  the  thrombus  extends  downwards  to  the  jugular  bulb  and 
vein.  Hence  the  whole  of  the  septic  clot  cannot  be  removed  from  above 
and  some  treatment  of  the  internal  jugular  is  then  indicated.     The  vein 


360  OPERATIONS  ON  THE  HEAD  AND  NECK 

may  be  exposed  low  down  in  the  neck  and  then  be  divided  between  two 
ligatures,  or  the  vein  may,  after  ligature,  be  freed  up  to  the  base  of  the 
skull  and  then  excised.  If  the  vein  is  merely  ligatured  a  considerable 
amount  of  infected  clot  will  be  left,  from  which  the  septic  process  may 
easily  extend  along  the  tributaries  of  the  internal  jugular  above  the 
ligature,  and  so  still  lead  to  pyaemia  or  septicaemia.  Removal  of  the  infected 
portionof  the  vein,  though  a  more  severe  operation, is  the  ideal  procedure, 
for,  since  it  has  been  shown  that  the  lateral  sinus  can  be  opened  up  as  far 
as  the  torcula  herophili,  it  permits  of  removal  or  opening  up  of  the  whole 
infected  venous  trunk  with  the  exception  of  the  bulb  which  is  in  relation 
with  such  important  structures  that  its  exposure  is  practically  impossible. 
It  must  be  understood  that  in  any  case  infection  may  spread  via  the 
petrosal  sinuses  or  some  emissary  veins  and  so  render  pyaemia  possible 
in  spite  of  all  treatment  of  the  internal  jugular  vein.^  To  expose  the 
internal  jugular  vein  an  incision  three  inches  in  length  is  made  along  the 
anterior  border  of  the  sterno-mastoid  which  is  made  tense  by  turning 
the  patient's  head  well  over  to  the  sound  side  :  the  centre  of  the  incision  is 
opposite  the  cricoid  cartilage.  The  platysma  and  the  deep  fascia  having 
been  divided  the  sterno-mastoid  is  well  retracted,  thus  bringing  the 
carotid  sheath  into  view.  The  position  of  the  carotid  artery  may  be 
recognised  by  feeling  for  its  pulsation  :  the  internal  jugular  vein  is 
external  to  this  and  at  rather  a  deeper  level.  It  is  exposed  by  incising 
the  carotid  sheath.  The  vessel  may  appear  empty  and  collapsed  and 
its  wall  thickened,  or  a  definite  thrombus  may  be  felt.  In  the  latter  case 
it  must  be  followed  lower  in  the  neck  until  the  lower  limit  of  the  thrombus 
is  reached.  An  aneurysm  needle  is  then  passed  and  the  vessel  is  divided 
between  two  ligatures.  It  is  next  traced  upwards  until  the  common  facial 
is  reached,  the  latter  vessel  being  also  ligatured  as  far  as  possible  from  the 
jugular,  which  is  again  tied  above  the  common  facial  and  the  portion 
between  the  upper  and  lower  ligatures  completely  removed.  If  a  more 
extensive  removal  is  considered  desirable  and  the  condition  of  the 
patient  permits,  the  vein  may  be  dissected  away  as  high  up  as  possible  and 
then  ligatured  just  below  the  jugular  foramen.  Any  tributaries  that 
may  be  met  with  are,  of  course,  ligatured  and  divided  as  far  as 
possible  from  the  jugular.  It  has  been  suggested  that  the  septic  clot 
in  the  bulb  may  be  syringed  away  by  means  of  a  small  syringe  inserted 
into  the  upper  end  of  the  divided  vein,  the  fluid  escaping  through  the 
opened  lateral  sinus  exposed  in  the  retro-auricular  wound.  If  the  upper 
end  of  the  vein  is  drawn  forwards  and  fixed  by  a  stitch  in  the  upper  end 
of  the  wound  in  the  neck,  this  process  may  be  repeated  at  the  first  few 
dressings. 

The  wound  in  the  lateral  sinus  is  then  packed  with  sterihsed  ribbon 
gauze  and  a  second  strip  of  the  same  material  loosely  inserted  into  the  bony 
cavity.  If  the  skin  wound  is  very  extensive  a  few  silkworm-gut  sutures  may 
be  used  to  reduce  its  size,  but  free  drainage  is  essential.     The  wound 

^  Prof.  Heine  (loc.  supra  cit.,  p.  116),  says  :  "  Many  writers  under-estimate  the  im- 
portance of  the  collateral  circulation  and  of  the  back-flow.  Some  even  state  that  it  is 
impossible  for  metastatic  deposits  to  be  carried  in  a  direction  opposite  to  the  normal 
course  of  the  blood-stream.  It  is  well  known  that  fever  and  rigors  often  persist  after 
ligature  of  the  jugular  vein,  but  these  are  mostly  put  down  to  metastases  which  were 
formed  before  the  operation.  The  autopsy,  however,  provides  a  different  explanation  in 
many  cases.  The  direct  path  to  the  heart  is  found  to  be  closed,  but  it  is  obvious  that 
infective  material  has  entered  the  circulation  from  the  emissary  veins,  from  the  other 
sinuses,  or  even  from  the  distal  end  of  the  decomposing  thrombus,  which  has  been  found 
extending  as  far  as  the  lateral  sinus  of  the  opposite  side." 


OPERATION  FOR  SUrPURATIVE  MENINGITIS    ;361 

ill  the  neck  may  be  partly  closed,  but  here  also,  as  infection  must  neces- 
sarily have  occurred,  drainage  is  essential.  Both  wounds  will  require 
dressing  with  removal  of  the  gauze  plugs  at  the  end  of  forty-eight  hours, 
by  which  time  there  will  probably  be  no  further  bleeding  from  the  sinus. ^ 
After  gentle  syringing  with  saline  solution,  or  with  lot.  hydrogen 
peroxide  (3  per  cent.),  the  drains  must  be  replaced.  The  dressings  will 
then  require  to  be  changed  daily  at  first,  and  later,  when  the  discharge 
has  diminished,  every  second  day. 

It  must  always  be  remembered  that  thrombosis  of  the  lateral  sinus 
may  occur  in  addition  to  some  other  intracranial  lesion,  especially  cere- 
bellar abscess,  or  even  suppuration  in  the  middle  fossa.  Any  indications 
of  these  troubles  should,  theiefore,  always  be  carefully  looked  for.  Should 
such  be  present  the  thrombosis  should  be  treated  first  and  the  abscess 
subsequently  opened  and  drained  with  freshly  sterilised  instruments. 

Operation  for  Suppurative  Meningitis.  If  diffuse  suppurative  meningitis 
can  be  diagnosed  with  certainty,  operation  will  not  be  successful  and  hence 
is  not  indicated.  This  condition  may,  however,  be  closely  simulated  by 
other  lesions,  especially  cerebellar  abscess,  serous  meningitis,  and  localised 
suppurative  meningitis  (subdural  abscess).  In  doubtful  cases  an  ex- 
ploratory operation  will  be  undertaken  and  hence  suppurative  meningitis 
may  be  unexpectedly  met  with. 

Prof.  Heine  ^  says  :  "  The  operation  for  suppurative  meningitis  consists  in  elimi- 
nating the  focus  of  disease  in  the  bone  and  exposing  the  dura  as  far  as  it  is 
affected.  If  necessary,  the  membranes  may  be  incised  to  allow  of  the  escape  of 
fluid,  as  is  done  in  the  serous  forms  of  meningitis.  Following  Witzel's  suggestion, 
Hinsberg  recommends  the  insertion  of  large  strips  of  absorbent  gauze  in  the 
neighbourhood  of  the  focus  of  suppuration  in  order  to  drain  the  subarachnoid 
space.  As  I  have  already  stated,  I  doubt  if  effective  drainage  of  this  space  is 
possible.  Finally,  lumbar  puncture  may  be  performed  for  the  removal  of  some  of 
the  purulent  cerebro-spinal  fluid." 

For  further  information  as  to  the  diagnosis  and  treatment  of  these  very  grave 
and  difficult  cases  reference  may  be  made  to  a  discussion  on  the  "  Treatment  of 
Meningitis  of  Otitic  Origin,"  opened  by  Dr.  W.  Milligan  before  the  Otological 
Section  of  the  Royal  Society  of  Medicine.3  Dr.  Milligan  in  his  opening  remarks 
said  :  "  Some  form  of  decompressive  operation  is  called  for,  the  essential  feature  of 
which  is  to  provide  by  a  sufficiently  free  removal  of  bone  a  window  large  enough 
to  efficiently  relieve  existing  pressure,  and  at  the  same  time  to  provide  a  means  of 
freely  draining  the  infected  meninges.  .  .  .  Some  operators  content  themselves 
with  the  making  of  such  a  window  and  with  the  relief  of  pressure  thus  obtained. 
No  doubt  in  certain  cases  of  incipient  meningitis  this  is  sufficient,  but  in  purulent 
meningitis  it  merely  delays  the  fatal  issue.  To  drain  the  pia-arachnoid  cavity 
the  dura  may  be  dealt  with  in  several  ways:  (1)  By  excising  narrow  strips  in 
parallel  rows  ;  (2)  by  raising  as  large  a  flap  as  the  bone  womid  permits  of,  and 
(3)  by  removing  entirely  the  dura  corresponding  to  the  bone  womid.  To  Charles 
Ballance  we  owe  the  suggestion  of  attacking  meningitis  by  the  occipital  route.  In 
1891  he  performed  the  now  classical  operation  of  draining  the  posterior  subaraclmoid 
space  after  trephining  the  occipital  bone  on  both  sides  of  the  mid-line  close  to  the 
foramen  magnum.  In  1893  Alfred  Parkin  proposed  drainage  of  the  cisterna  magna, 
while  in  the  same  year  Ord  and  Waterhouse  drained  the  posterior  fossa  after  removal 
of  a  portion  of  the  occipital  bone  and  incision  of  the  miderlying  membranes. 
Whether  decompression  be  performed  over  the  temporo-sphenoidal  or  cerebellar 
area,  great  difficulty  is  encomitered  in  dealing  with  the  brain  substance.  The 
moment  the  dura  has  been  incised  the  cortex  is  thrust  into  the  wound  and  not 
only  prevents  the  escape  of  infected  cerebro-spinal  fluid,  but  tends  to  lacerate  its 
substance  against  the  edges  of  the  bone.     To  obviate  this  tendency,  Haynes,  of 

^  Should  bleeding  occur  it  may  readily  be  checked  by  packing  a  fresh  strip  of  gauze 
into  the  opening  of  the  sinus. 
^  Loc.  supra  cit.,  p.  194. 
3  Proc.  Roy.  Soc.  Med.,  Oiol.  Sec,  February  1913,  p.  41- 


362  OPERATIONS  ON  THE  HEAD  AND  NECK 

New  York,  has  suggested  drainage  of  the  cisterna  magna  through  the  cerebello- 
medullary  angk'  as  there  is  here  no  brain  tissue  in  the  immediate  neighbourhood, 
and  also  because  infected  fluid  is  prone  to  collect  here.  An  incision  is  made  in  the 
mid-line  from  the  occiijital  protruberance  to  the  spine  of  the  axis,  the  soft  parts 
retracted,  and  a  disc  of  bone  removed  by  a  trephine  about  one  inch  above  the 
margin  of  the  foramen  magnum.  The  dura  is  then  separated  from  the  bone  and 
two  grooves  made  through  the  bone  into  the  foramen  magnum.  When  this 
triangular  piece  of  bone  has  been  removed,  the  dura  presents  mider  pressure.  A 
small  incision  is  then  made  through  the  diira  and  the  arachnoid  with  the  im- 
mediate escape  of  cerebro-spinal  fluid.  The  incision  is  enlarged  and  an  inspection 
made  of  the  posterior  poles  of  the  cerebellum,  the  notch  between  them  and  the 
posterior  surface  of  the  medulla.  A  drain  is  then  inserted  into  the  cisterna  magna 
and  suitable  di-essings  applied."  This  operation  has  been  performed  a  number  of 
times,  but  does  not  appear  to  have  been  attended  with  nmch  success.  Dr.  Milligan 
and  other  speakers  point  out  the  necessity  of  early  diagnosis  if  operation  is  to  have 
any  chance  of  success,  and  give  many  valuable  hints  with  regard  to  this  point. 


CHAPTER  XVII 

OPERATIONS  ON  THE  FACE.  OPERATIONS  ON  THE  FIFTH 
NERVE.  OPERATIVE  TREATMENT  OF  LUPUS,  RODENT 
ULCER  AND  NiEVI.    REMOVAL  OF  PAROTID  GROV^^THS 

OPERATIONS  ON  THE  FIFTH  NERVE 

Preliminary  remarks.  As  the  surgeon  will  not  be  called  in  until  all 
other  treatment  has  failed,  and  as  the  patient  will  be  desirous  of  relief 
as  radical  as  may  be,  neurectomy  alone  will  be  described  here.  Opera- 
tions with  this  end  fall  into  Peripheral  and  Central  groups.  Of  the 
former  or  extracranial  operations,  some,  the  truly  peripheral,  are  slight  ; 
others  performed  near  the  base  of  the  skull,  are  severe,  not  without 
risk,  and  leave  considerable  scars,  which  may  greatly  interfere  with  the 
use  of  the  mandible.  The  central  intracranial,  or  removal  of  the  Gas- 
serian  ganglion,  is  a  severe  and  difficult  operation,  wdth  many  risks  and 
a  mortality  that  is  not  a  small  one,  but  it  is  the  only  one  which  can  be 
relied  upon  to  give,  with  very  few  exceptions,  a  complete  cure.  It  is 
greatly  to  be  desired  that  both  the  peripheral  and  central  operations  be 
performed  at  an  earher  date  than  has  hitherto  been  done.  In  the  case 
of  the  former  the  earlier  the  operation  the  greater  the  probabihty  that 
the  neuralgia  is  limited  to  one  trunk,  and  the  longer  will  be  the  interval  of 
relief.  In  the  case  of  the  intracranial  operations,  the  still  high  mortality 
is  largely  due  to  the  depressed  vitality  of  the  patients  from  the  long  con- 
tinued inability  to  take  food,  the  exhausting  effects  of  the  pain,  the 
inability  to  sleep,  and,  perhaps,  the  morphia  habit.  We  will  suppose 
that  all  local  causes  connected  with  the  teeth,  nose,  eye,  ear,  and  cranial 
sinuses  have  been  excluded,  together  with  those  such  as  growths  or 
foreign  bodies  in  the  course  of  the  nerves,  and  that  medical  treatment  ^ 
has  been  fully  tried  where  syphilis,  alcohol,  influenza,  rheumatism, 
anaemia,   &c.,  are  possible  causes.- 

The  first  question  which  will  now  arise  is  the  value  of  peripheral 
operations,  to  what  extent  are  they  justifiable  in  severe  trigeminal 
neuralgia  ?  To  begin  with,  the  answer  must  be  that  all  mere  neurotomies 
and  nerve  stretchings  are  absolutely  futile.  Radical  lasting  cures  by 
peripheral  neurectomies  are  practically  unknown.^  All  that  can  be 
promised  is  that,  if  performed  with  as  thorough  extraction  as  possible 

^  Injection  of  alcohol,  a  most  successful  form  of  treatment,  should  also  be  tried.  For 
information  on  this  method  of  treatment  see  two  papers  by  Dr.  Wilfred  Harris  (Brit. 
Med.  Journ..  1910.  vol.  i,  p.  1404  :   and  vol.  ii,  p.  1051). 

'  The  pathology  of  tic  douloureux  is  fully  discussed  by  jMt.  J.  Hutchinson,  jun.  {The 
Surgical  Treatment  of  Facial  Neuralgia,  p.  26),  and  Murphy  and  Neff  (Journ.  Amer.  Med. 
Assoc,  October  11  and  18,  1902;. 

'  Prof.  Billroth,  who  had  performed  peripheral  operations  thirty  times,  stated  that 
he  never  met  with  permanent  cure. 

363 


364  OPERATIONS  ON  THE  HEAD  AND  NECK 

of  the  peripheral  branches^  they  will  give  relief  for  varying  periods. 
Hitherto  the  majority  of  authorities  have  held  that  peripheral  opera- 
tions should  be  performed  first,  intracranial  neurectomy  being  taken  as 
the  last  step. 

Thus  Prof.  Keen  considers  that  this  is  the  right  step  to  take,  and  on 
these  grounds  :  (1)  the  balance  of  evidence  points  to  the  ganglion  itself 
being  the  last  of  all  to  suffer,  the  disease  being  in  many  cases  at  least 
primarily  peripheral,  and  the  ganglion  involved  by  extension  upwards. 
This  view  of  an  ascending  neuritis  has  the  support  of  Sir  V.  Horsley, 
who  holds  that  the  inflammation  often  begins  in  the  small  dental  nerves 
and  spreads  upwards  to  the  ganglion. ^  (2)  While  the  mortality  of  peri- 
pheral operations,  which  usually  relieve  for  some  time,  is  very  slight,  that 
following  on  operations  on  the  ganglion  is  high  (p.  379). 

Mr.  J.  Hutchinson,  jun.,  whose  successful  experience  enables  him  to 
speak  as  an  authority,  tabulates  the  following  rules  for  the  use  of  peri- 
pheral operations  in  epileptiform  neuralgia. ^  With  regard  to  the  first 
division  of  the  fifth,  a  case  may  now  and  then  arise  in  which  resection  of 
the  nerve  is  justified.  "  If  the  neuralgia  be  limited  to  the  infra-orbital 
branches,  resection  of  the  nerve  by  following  back  the  canal  in  the 
orbital  floor  may  be  tried.  If  the  neuralgia  concern  also  the  palatine 
branches,  intracranial  resection  of  the  superior  maxillary  trunk  should 
be  carried  out.  If  the  inferior  dental  nerve  be  alone  affected,  it  should 
be  resected  through  a  trephine  aperture  in  the  outer  table  of  the  lower 
jaw.  When  the  neuralgia  concerns  several  branches  of  the  inferior 
maxillary  division  (e.g.  the  inferior  dental  and  the  auriculo-temporal), 
intracranial  resection  of  the  trunk  and  adjacent  part  of  the  Gasserian 
ganglion  is  indicated. 

"  For  all  other  cases,  those  in  which  the  neuralgia  has  already  in- 
vaded two  of  the  main  divisions  of  the  fifth  nerve,  the  major  operation 
on  the  ganglion  should  be  carried  out  as  affording  the  only  hope  of  per- 
manent cure. 

"  If  these  rules  be  followed  the  subject  is  rendered  simple,  a  host  of 
elaborate  operations  may  be  discarded,  and  the  disappointing  results 
which  have  followed  them  in  the  past  may  be  avoided." 

Neurectomy  of  the  First  Division  of  the  Fifth  Nerve.  The  eyebrow 
having  been  shaved,  and  the  parts  sterilised,  the  incision  should  be 
horizontal  and  lie  below  the  margin  of  the  eyebrow,  thus  leaving  little 

^  Prof.  Krause  (Von  Bergmann's  "  Syst.  Prac.  Surg.,"  Amcr.  Trans.,  vol.  i,  p.  565) 
insists  that  in  order  to  prevent  regeneration  of  the  excited  nerve  it  should  be  extracted  as 
extensively  as  possible,  both  centrally  and  peripherally,  by  Thiersch's  method.  This 
consists  in  dissecting  the  nerve  freely  from  its  surroundings,  grasping  it  transversely  in 
forceps  which  will  not  cut  it  through,  then  rotating  these  very  slowly  until  the  nerve  trunk 
comes  away.  Where  the  nerve  runs  in  soft  parts  or  is  not  adherent  in  a  bony  canal  a 
very  long  piece  of  the  central  portion  can  be  removed.  Occasionally  paralysis,  especially 
of  the  muscles  of  the  upper  lip  and  ala  nasi,  follow  the  operation  owing  to  the  endings  of  the 
anastomosing  filaments  of  the  facial  nerve  being  also  removed.  These  paralyses  generally 
disappear  in  a  short  time.  In  all  peripheral  nerve  operations  the  neuralgic  pains  do  not 
always  disappear  immediately.  They  frequently  come  on  as  before  during  the  first  days 
after  the  operation,  but  they  soon  diminish  and  fuially  disappear.  The  attention  of  the 
patient  should  be  drawn  to  this  fact  before  the  operation.  On  the  value  of  this  step 
the  experience  of  Mr.  J.  Hutchinson,  jun.,  The  Surgical  Treatment  of  Trigeminal  Neu- 
ralgia, p.  43,  is  contradictory.  "  Unfortunately  the  results  obtained  by  avulsion  with 
Thiersch's  forceps  are  little  if  at  all  superior  to  a  well-planned  neurectomy." 

^  Mr.  J.  Hutchinson,  jun.,  from  the  negative  results  found  in  many  cases  of  the 
excised  Gasserian  ganghon  and  peripheral  nerves  after  removal  dissents  from  this  view. 
He  considers  that  "  the  pathology  of  epileptiform  neuralgia  is  still  unknown." 

'  Loc  supra  cit.,  p.  74. 


OPERATIONS  ON  THE  FIFTH  NERVE 


365 


scar.  The  supra-orbital  notch  ^  being  made  out  by  firm  pressure 
when  the  patient  is  under  an  anaesthetic,  the  eyebrow  is  drawn  up  and 
the  eyelid  down,  and  an  incision  an  inch  and  a  half  long  is  made 
along  the  supra-orbital  margin,  with  its  centre  opposite  to  the  notch. 
The  skin,  occipito-frontalis,  orbicularis,  and  palpebral  ligament  being 
divided,  the  cellular  tissue  is  separated,  the  nerve  found  in  the  notch 
set  free — if  a  complete  foramen  be  present,  part  of  the  ring  of  bone  must 
be  removed  with  a  small  chisel — traced  back  as  far  as  possible  so  as  to 
include  the  supra-trochlear,  if  that  be  feasible,  drawn  up  with  a  stra- 
bismus hook,  and  a  full  inch  removed.  Thiersch's  method,  if  employed 
here,  might  involve  some  risk  to  the  cornea. 

A  small  spatula  will  best  depress  the  orbital  fat.  It  is  difficult  to 
avoid  injury  to  the  closely  contiguous  supra-orbital  vessels,  which  may 
cause  a  little  trouble.  As  with  the  other  branches  of  the  fifth,  the 
supra-orbital  often  appears  smaller  than  it  does 
in  the  dissecting  room,  and  the  arrangement  of 
its  branches  is  not  constant.  The  wound  should 
be  closed  by  a  few  horsehair  sutures. 

Supra-trochlear  Nerve.  In  an  inveterate  case 
of  neiu-algia  of  the  first  division  of  the  fifth 
nerve,  if  the  surgeon  does  not  feel  sure  that  he 
has  in  the  preceding  operation  got  behind  the 
point  of  origin  of  the  supra-trochlear.  this  nerve 
must  be  cut  down  upon.  Sir  W.  MacCormac  - 
gives  the  following  advice  :  "  The  position  of 
the  supra-trochlear  nerve  is  indicated  by  an 
imaginary  line  drawn  from  the  outer  angle  of 
the  mouth  through  the  inner  canthus  of  the  eye 
to  the  orbital  margin  ;  at  this  point  the  nerve 
will  be  found  as  a  single  branch,  or  as  two  or 
three  slender  filaments,  escaping  from  the  orbit 
above  the  pulley  of  the  superior  oblique.  ...  To 
reach  the  nerve,  make  a  convex  incision  at  the 
superior  internal  angle  of  the  orbit,  immediately 
below  the  eyebrow,  and  search  for  the  pulley  of  the 
superior  oblique,  above  which  the  nerve  runs." 

Neurectomy  of  the  Second  Division  of  the  Fifth  Nerve.  While  this 
nerve,  being  most  frequently  the  seat  of  neuralgia,  has  been  most  ofteii 
subjected  to  peripheral  neurectomy,  there  is  no  agreement  as  to  the  best 
route.  The  following  have  been  proposed.  Each  has  its  advocates, 
and  each  its  disadvantages. 

A.  Infra-orbital  Route.  An  attempt  is  here  made  to  follow  the  nerve 
along  the  infra-orbital  groove  as  far  back  as  the  sphenomaxillary  fossa. 
The  disadvantages  are  great.  The  field  of  operation  is  very  cramped, 
the  oozing  troublesome,  and  the  operator  is  liable  to  divide  the  soft  and 
comparatively  slender  nerve  prematurely  and  to  remove  part  only  with 
the  anterior  dental  branch,  and  haemorrhage  into  the  orbit  and  exom- 
phalos  have  followed  this  operation. 

^  The  supra-orbital  notch  or  foramen  occupies  about  the  junction  of  the  inner  with 
the  middle  third  of  the  supra-orbital  margin.  From  this  point  a  perpendicular  line, 
drawn  with  a  slight  inclination  outwards,  so  as  to  cross  the  interval  between  the  two 
bicuspid  teeth  in  both  jaws,  passes  over  the  infra-orbital  and  the  mental  foramina. 
The  clirection  of  these  two  lower  foramina  look  towards  the  angle  of  the  nose.     (Fig.  15 6-) 

^  Operations,  part  2,  p.  467. 


Fig.  156.  A,  Position  of 
the  supra-orbital  foramen. 
A  line  drawn  downward 
from  this,  passing  through 
the  interval  between  the 
two  bicuspid  teeth,  passes 
through  B,  the  infra-orbital 
foramen,  and  C,  the  mental 
foramen.  D,  Incision  for 
exposing  the  supra-orbital 
nerve.  E,  Incision  for 
Carnochan's  operation. 


366         OPERATIONS  ON  THE  HEAD  AND  NECK 

B.  Antral  Route.  Either  the  modified  Carnochan's  operation  or 
that  which  bears  Prof.  Kocher's  name.  The  first  is  described  below, 
and  the  second  at  p.  368. 

C.  PterygomaxiUary  Route.  Krause's  operation.  The  nerve  is  here 
reached  in  the  sphenomaxillary  fossa,  not  from  the  front,  but  at  the 
side  by  turning  down  the  zygoma  and  masseter.  Prof.  Krause,  finding 
that  the  flap  made  by  previous  surgeons,  Luke,  Loosen,  and  Braun, 
injured  the  branches  to  the  orbicularis  and  thus  led  to  damage  to  the 
cornea,  modified  the  operation  so  as  to  protect  the  branches  of  the 
facial  running  over  the  malar  bone.  The  advantages  of  this  route  are 
that  it  enables  the  surgeon  to  get  at  the  nerve  before  this  has  given 
off  its  posterior  dental  and  palatine  branches,  and  to  resect  the  third 
di^asion  as  well,  if  this  be  affected.  The  disadvantages  are  that,  even  if 
the  wound  heals  by  primary  union,  the  troubles  of  the  patient  and  surgeon 
are  not  over  ;  they  are  best  shown  by  Prof.  Krause's  own  words  :  ^  "  As 
soon  as  cicatricial  contraction  sets  in,  the  mobility  of  the  lower  jaw  is 
impeded  in  many  cases.  This  may  reach  a  very  high  degree,  and  will 
require  careful  treatment  with  Heister's  mouth-gag."  As  the  second 
di\'ision  of  the  fifth  nerve  is  often  affected  alone,  and  as  it  is  to  be  hoped 
that  in  future  patients  will  apply  for  surgical  treatment  earlier,  before  the 
palatine  and  posterior  dental  nerves  are  involved,  two  operations  are 
described  here,  \az.  the  modified  Carnochan's  antral  operation  and 
that  of  Prof.  Kocher.  Where  the  patient  comes  late  and  the  second 
division  is  involved  far  back,  or  where  the  third  division  is  involved  as  well, 
the  surgeon  must  decide  between  adopting  the  pterygomaxillary  route, 
and  resecting  the  two  divisions  by  an  intracranial  operation,  as  strongly 
advised  by  Mr.  J.  Hutchinson,  jun.,  on  the  grounds  that  this  step  is  no 
more  difficult,  while  it  is  certainly  more  radical. 

Blodified  Carnochan's  Operation.  This  has  the  advantage,  if  success- 
fully performed,  of  removing  the  whole  of  the  second  division  of  the  fifth, 
together  with  the  spheno-palatine  ganglion  as  far  back  as  the  foramen 
rotmidum,  the  nerve  forming  the  guide  to  the  surgeon  from  the  surface 
backwards.  Carnochan  2  looked  upon  the  removal  of  Meckel's  ganglion 
as  the  key  of  the  operation.  Whilst  his  view  was  that  this  body  could  be 
likened  to  a  galvanic  battery,  keeping  up  a  continuous  supply  of  "  morbid 
nervous  sensibility,"  there  is  no  doubt  that  removal  of  the  nerve  beyond 
the  ganghon  is  absolutely  necessary,  as  by  this  step  the  spheno-palatine 
branches  to  the  gums  and  the  posterior  dental  branch  are  also  removed.  ^ 

Carnochan's  antral  operation  is,  for  the  reasons  already  given  when 
the  infra-orbital  route  was  spoken  of,  an  extremely  difficult  one.  Owing 
to  these  difficulties  it  is  very  often  rendered  incomplete,  and  the  neuralgia 
tends  to  return  after  an  interval  varying  from  a  few  months  to  a  year  or 
two.  Mr.  J.  Hutchinson,  jun.,  who  speaks  with  authority,  considers 
that  this  operation  should  be  abandoned.^     He  holds  that  if  any  extra- 

1  Von  Bergmann'.s  "  Syst.  Pract.  Surg.,"  Amer.  Trans.,  vol.  i,  p.  583. 

2  Amer.  Journ.  Med.  Sci.,  1858,  p.  136. 

3  Chavasse,  Med.-Chir.  Trans.,  vol.  Ixvi.  p.  151  ;  and  Clutton,  St.  Thomas's  Hospital 
Reports,  vol.  xv,  p.  213. 

In  both  of  Mr  Chavasse's  cases  the  commencement  of  the  pain  was  invariably  re- 
ferred to  the  periphery  of  the  posterior  dental  branches,  and  it  appeared  very  doubtful 
if  stretching  would  have  any  effect  on  slender  branches  at  some  distance  from  the  extension 
point.  Both  of  th?se  cases  remained  practically  well  two  years  and  a  year  and  a  half 
respectivel}'  after  the  operation.  Recurrence,  "  slight  and  relieved  by  quinint,"  ensued 
in  both  of  Mr.  Clu:ton's  cases  within  the  year. 

*  Loc,  supra  cit.,  pp.  58  and  66. 


OPEHATIONS  ON  THE  FIFTH  NERVE  tm 

cranial  operation  on  the  superior  maxillary  nerve  be  performed,  the 
best  one  is  that  of  Storrs,  described  by  Dr.  Cooke. ^  It  is  stated  that  Dr. 
Storrs  operated  on  some  ten  or  twelve  patients,  and  that  of  these  at  least 
two  remained  free  from  neuralgia  for  over  ten  years,  an  unusually  favour- 
able result  for  any  form  of  peripheral  operation. 

As  the  antrum  will  be  opened,  the  mouth  and  accessory  cavities 
must  possess  at  least  the  normal  germicidal  power  of  health.  The 
parts  having  been  shaved  and  cleansed,  and  an  anesthetic  given,  a 
horizontal  incision  is  made  reaching  from  canthus  to  canthus  just  below 
the  orbit,  and  a  vertical  one  nmning  downwards  added  if  needful  (Fig. 
156).  The  flaps  thus  marked  out  being  reflected,  and  all  haemorrhage 
stopped,  the  infra-orbital  nerve  is  defined,  its  terminal  branches  dissected 
out  as  long  as  possible,  and  a  piece  of  silk  tied  round  it  to  make  it  serve  as  a 
guide.  The  periosteum  is  next  incised  horizontally  down  to  the  bone,  and 
elevated  with  a  blunt  instrument  from  the  floor  of  the  orbit  until  the 
sphenomaxillary  fissure  is  well  exposed.  The  eyeball  must  be  raised 
with  a  retractor  under  the  periosteum.  A  bluish  spot  usually  denotes 
the  site  of  the  nerve,  thinly  covered  by  bone,  or  the  canal  is  found  by  a 
fuie  probe  passed  in  through  the  foramen. 

With  a  fine  chisel  the  anterior  wall  of  the  antrum,  including  the 
foramen,  is  cut  away  for  a  space  of  half  an  inch  square,  and  with  the  same 
instrument,  aided  by  small  and  medium-sized  bradawls,  the  roof  of  the 
antrum  and  its  posterior  wall — the  latter  for  the  same  area  as  its  anterior 
wall — are  removed,  so  as  to  expose  the  sphenomaxillary  fossa.  Free  and 
most  troublesome  haemorrhage  must  be  expected,  partly  from  the  vascular 
bone,^  partly  from  the  mucous  membrane  of  the  antrum  and  in  the  fossa 
itself,  where  the  bleeding  is  always  copious  from  the  terminal  branches 
of  the  internal  maxillary.  Pressm'e  with  small  gauze  pledgets,  wrung 
out  of  very  hot  sterile  saline  or  adrenalin  solution  in  holders,  must  be 
relied  upon. 

A  good  light  is  essential,  and  an  electric  lamp  on  the  surgeon's  forehead 
will  be  his  best  aid. 

The  rest  of  the  operation  will  be  given  from  the  article  above  quoted 
from  the  Annals  of  Surgery  :  "  By  making  slight  traction  on  the  Hgature 
on  the  nerve,  we  can  bring  it  into  view,  and  by  following  it  on  can  readily 
crush  down  the  thin  wall  of  the  canal,  removing  the  bone  fragments  with 
suitable  forceps.  When  the  nerve  enters  the  sphenomaxillary  fissure  it 
passes  out  of  the  bony  canal  and  is  only  surrounded  by  soft  structures, 
which  can  easily  be  hooked  or  wiped  away.  Should  the  sphenomaxillary 
fissure  be  narrow  and  not  readily  admit  the  introduction  of  instruments, 
it  can  easily  be  widened  by  inserting  a  suitable  blunt  instrument,  and  by 
wedging  or  widening  the  walls.  It  is  to  be  remembered  that  the  upper 
wall  of  this  fissure  is  the  strong  wing  of  the  sphenoid,  and  that  the  lower 
angle  is  the  thin  wall  of  the  antrum.  If  either  bone  should  break,  it 
would  be  the  wall  of  the  antrum,  which  would  be  crushed  down  and  out 
of  the  way,  and  would  cause  no  trouble.  Having  the  nerve  thus  free 
to  the  foramen  rotmidum,  next  slip  the  ends  of  the  silk  through  a  loop 
of  wire  held  with  a  small  nasal  snare.  The  loop  of  wire  is  passed  down 
the  nerve  to  the  foramen  rotundum.  It  is  then  closed,  and  the  nerve 
is  cut  and  removed."     To  return  now  to  the  distal  end  of  the  nerve. 

1  Ann.  of  Surg.,  1903,  p.  854. 

^  The  superficial  haemorrhage  will  be  all  the  freer  iii  proportion  as  the  part  has  been 
recently  submitted  to  blistering,  liniments,  &c. 


368  OPERATIONS  ON  THE  HEAD  AND  NECK 

The  plexus  of  nerves  going  to  the  cheek,  nose  and  Up  is  gathered  up  with  a 
hook,  and  the  distal  end  drawn  out  of  the  foramen.  Storrs  then  put  the 
nerve  into  the  loop  of  a  threaded  needle  and  carried  it  down  into  the 
mouth,  leaving  the  end  which  had  been  in  the  infra-orbital  canal  between 
the  alveolus  and  upper  lip  ;  this  end  he  cut  off,  even  with  the  mucous 
membrane.  This  was  to  prevent  any  restoration  between  the  distal  end 
of  the  nerve  and  the  stump  left  at  the  formamen  rotimdum.  Arrest  of 
bleeding,  drainage,  and,  if  needful,  packing  the  wound  and  suturing, 
complete  the  operation. 

Prof.  Kocher's  Antral  Operation.  This  surgeon,  by  dividing  the  malar 
bone  in  front  and  behind,  and  turning  it  upwards  and  outwards,  gains 
much  freer  access  to  the  foramen  rotundum.^  The  skin  incision  is 
Tjlanned  so  as  to  avoid  division  of  the  branches  of  the  facial  nerve.  It 
begins  just  internal  to  the  infra-orbital  foramen  and  below  the  inner 
edge  of  the  orbital  margin,  and  is  carried  outwards  and  shghtly  downwards 
over  the  lower  part  of  the  malar  bone  to  the  zygoma.  The  angular 
arterv  is  drawn  aside  or  tied  at  the  inner  end  of  the  incision  ;  Steno's 
duct  lies  below  it.  At  its  inner  end  the  incision  passes  do'vsni  to  the  bone 
between  the  lowest  fibres  of  the  orbicularis  and  above  the  origin  of  the 
levator  labii.  The  former  muscle,  along  with  the  periosteum,  is  dis- 
sected up  as  far  as  the  orbit ;  the  latter  is  separated  downwards 
sub-periosteally,  so  that  the  nerve  may  be  exposed  at  the  foramen  and 
secured. 

The  outer  part  of  the  incision  passes  above  the  origin  of  the  zygo- 
matici,  which  are  separated  downwards,  and  the  anterior  fibres  of  the 
ma-^scter  are  detached  from  the  lower  and  inner  aspect  of  the  malar  bone. 
The  outer  and  inner  surfaces  of  the  malar  bone  are  next  laid  bare  with  a 
periosteal  elevator,  and  the  three  sutures — malo-maxillary,  fronto -malar, 
and  zygomatico-malar — are  exposed  previous  to  their  being  chiselled 
through.  The  malar  process  of  the  upper  jaw  must  be  exposed  on  its 
anterior  surface  up  to  the  infra-orbital  foramen,  and  upon  its  upper 
surface  as  far  back  as  the  sphenomaxillary  fissure.  Anteriorly,  the  pro- 
cess is  chiselled  through  from  above  the  infra-orbital  nerve  downwards 
and  outwards  to  just  below  the  anterior  fibres  of  the  masseter,  and 
superiorly  along  the  orbital  plate.  In  this  way  the  outer  part  of  the 
orbital  plate  and  the  superior  external  wall  of  the  antrum,  together 
with  its  posterior  angle,  remains  in  connection  with  the  malar  bone,  and 
are  levered  out  with  it.  Before  this  can  be  done  the  fronto-malar  suture, 
exposed  by  upward  retraction  of  the  upper  edge  of  the  wound,  is  so 
chiselled  through  towards  the  back  of  the  sphenomaxillary  fissure,  that 
its  upper  border,  together  with  part  of  the  zygomatic  crest  and  of  the 
orbital  plate  of  the  sphenoid,  is  removed  along  with  it. 

The  malar  bone  is  dislocated  upwards  and  outwards  with  a  strong 
hook,  and  the  orbital  fat  carefully  raised  vnth  a  blunt  retractor.  The 
nerve,  which  is  kept  drawn  upon,  can  now  be  readily  followed  above  the 
opened-up  antral  cavity  as  far  as  the  foramen  rotundum.  A  small  hook 
is  now  passed  behind  the  descending  sphenopalatine  nerves  around  the 
main  trunk,  which  is  either  cut  across,  or,  better,  removed  by  Thiersch's 
method.  The  infra-orbital  artery  is  avoided  or  tied.  The  operation  is 
completed  by  replacing  the  malar  bone  (fixation  sutures  being  unneces- 
sary) and  closing  the  woimd  with  sutures.  No  bad  results  have  followed 
the  free  opening  of  the  antrum.  The  resulting  scar  is  not  disfiguring. 
1  Kocher's  Operative  Surgery,  translated  by  Stiles  and  Paul,  p.  221. 


OPERATIONS  ON  THE  FIFTH  NERVE  369 

Operations  on  the  Third  Division  of  the  Fifth  Nerve.  Immediately 
below  the  foramen  ovale  this  division  of  the  iifth  nerve  consists  of  a  large 
sensory  portion  and  a  smaller  motor  portion  which  supplies  the  muscles 
of  mastication.  These  two  parts  are  intimately  bound  together  so  that 
division  of  the  trunk  in  this  situation  will  be  followed  by  paralysis  of 
these  nuiscles.  Neurectomy  of  the  individual  branches  is  thus  to  be 
preferred  to  division  of  the  main  trunk.  Neurectomy,  first  of  the  in- 
ferior dental,  a  nerve  so  commonly  the  seat  of  neuralgia,  and  then  of 
the  lingual  gustatory,  which  is  much  less  frequently  afiected,  will  be 
described  here. 

Inferior  Dental  :  Neurectomy.  This  nerve  may  be  attacked  in  three 
•places ;  at  the  mental  foramen,  in  the  dental  canal,  and  above  the  dental 
canal.  Experience  has  shown  that  the  relief  after  the  first  two  methods 
is  so  transitory  that  the  higher  operation  should  always  be  resorted  to. 
Neurectomy  here  usually  gives  relief  for  one,  two,  or  more  years.  The 
face  having  been  shaved  and  cleansed,  the  external  auditory  meatus 
cleansed  and  plugged  with  aseptic  gauze,  the  patient  is  angesthetised. 
The  surgeon  then  identifies  the  point  of  bone  to  be  aimed  at  on  the  ascend- 
ing ramus  by  taking  the  point  of  meeting  of  the  two  following  lines — 
one  perpendicular  to  the  lower  border  of  the  jaw  passing  upwards  from 
its  angle,  and  the  other  a  continuation  backwards  of  the  alveolar  margin 
(Hutchinson).  This  point  on  the  cheek  is  well  below  the  parotid  duct  and 
behind  the  facial  vein.  The  skin  incision  here  should  be  about  an 
inch  and  a  half  long,  mainly  horizontal,  to  avoid  the  facial  nerve,  but 
curved  slightly  upwards.  Kocher's  incision  is  a  curved  one,  with  the 
angle  of  the  jaw  for  its  centre. 

The  subjacent  periosteum  and  masseter  are  separated  from  the  bone, 
and  the  pin  of  a  three-quarter  inch  trephine  is  then  applied  exactly 
over  the  spot  above  mentioned,  and  when  the  outer  table  has  been  cut 
through  the  crown  is  removed  by  an  elevator.^ 

The  inferior  dental  nerve  and  vessels  will  almost  certainly  be  exposed 
in  their  groove.  This  is  carefully  enlarged  by  a  small  gouge  or  chisel,  until 
the  nerve,  now  freely  exposed,  can  be  raised  on  a  blunt  hook.  It  is  then 
treated  by  Thiersch's  method  (neurexeresis),  or  as  long  a  piece  as  possible 
resected.  Care  must  be  taken  to  avoid  injury  to  the  vessels  which  he 
just  behind  the  nerve.  Another  method  ^  is  to  expose  the  bone  more 
freely  by  a  larger  flap,  and  to  turn  this  upwards.  The  sigmoid  notch 
and  adjacent  parts  of  the  condyle  and  coronoid  process  are  next  laid 
bare.  Care  must  be  taken  not  to  injure  any  of  the  branches  of  the 
facial  nerve  or  lobules  of  the  parotid  gland  during  these  steps.  When 
the  bone  is  reached,  smart  oozing  must  be  expected  from  the  mesenteric 
artery,  and  arrested  by  firmly  apphed  sponge  pressure.  The  next 
step  consists  in  enlarging  the  sigmoid  notch  as  far  as  the  upper  orifice 
of  the  dental  canal.  This  is  done  by  applying  a  three-quarter  inch 
trephine  exactly  on  the  spot  mentioned  above,  the  narrow  bridge  of 
bone  between  it  and  the  sigmoid  notch  being  subsequently  clipped  away 
wHth  gouge  forceps.  Great  care  must  be  taken,  owing  to  the  varying 
thickness  of  the  bone,  in  the  use  of  the  trephine ;  otherwise  the  inferior 
dental  artery  will  be  wounded  or  the  bone  fractured.  DeVilbiss's  forceps 
are  likely  to  be  useful  for  this  purpose.     The  bone  having  been  removed 

^  If  preferred  the  bone  may  be  removed  by  means  of  a  gouge  or  chisel. 
2  Sir  V.  Horsley,  Brit.  Med.  Journ.,  1891,  vol.  ii,  p.  119;     Sir  W.  Rose,  ibid.,    1892, 
vol.  i,  p.  160. 

SURGERY  I  24 


370  OPERATIONS  ON  THE  HEAD  AND  NECK 

suflSciently,  the  inferior  dental  artery,  and  the  internal  maxillary,  if  this  be 
in  the  way,  should  be  secured  between  two  ligatures.  The  inferior  dental 
nerve  is  next  identified  and  secured  by  a  silk  ligature.  The  external 
pterygoid  having  been  levered  upwards,  or  divided  if  needful,  the  nerve  is 
traced  close  up  to  the  foramen  ovale,  and  divided  as  high  up  and  as 
low  down  as  possible,  or  dealt  with  by  the  method  of  Thiersch.  If  need- 
ful the  lingual  nerve,  which  lies  somewhat  anteriorly  and  on  a  deeper  plane, 
is  then  treated  in  a  similar  way.  Any  venous  bleeding  which  cannot  be 
dealt  ^\■ith  by  ligature  should  be  controlled  by  firm  pressure  with  small 
aseptic  swabs.  There  is  no  need  to  replace  any  bone.  The  Avound, 
carefully  kept  aseptic  throughout,  is  now  thoroughly  dried,  a  small 
drainage  tube  inserted  if  there  be  still  much  oozing,  or  if  the  parts  have 
been  much  disturbed,  and  the  incision  accurately  sutured.  If  primary 
union  occurs  there  is  no  interference  with  the  movements  of  the  mandible. 
Lingual  Nerve.  Neurectomy  within  the  mouth.  In  a  few  cases  of 
epithelioma  of  the  mouth,  not  admitting  of  removal,  this  operation  may 
be  performed  in  the  hope  of  relieving  the  pain,  and  diminishing  the 
rapidity  of  the  growth,  the  profuseness  of  the  dribbhng  sahva,  &c.  In 
another  small  group  of  cases,  neuralgia  of  the  tongue,  resisting  other 
treatment,  this  operation  may  be  resorted  to  with  complete  success. 

The  best  method  is  that  of  Roser,  of  Marburg,  who  introduced  it  in 
1855.  The  mouth  having  been  AAadely  opened  in  a  good  light,  and  the 
tongue  drawn  over  to  the  opposite  side,  an  incision  is  made  in  the  fold  of 
mucous  membrane  between  the  side  of  the  tongue  and  the  gum,  the 
centre  of  the  incision  being  opposite  to  the  last  molar  tooth.  The  over- 
lying mucous  membrane  is  here  so  thin  that  the  nerve  can  usually  be  seen 
below  it.  The  nerve  having  been  exposed  where  it  lies,  beneath  mucous 
membrane  only,  just  before  it  dips  beneath  the  mylohyoid,  is  raised  with 
an  aneurysm  needle,  and  a  full  inch  removed.  The  only  after-treatment 
is  the  frequent  use  of  a  mouth  wash.  Mr.  Jacobson  performed  this 
operation  on  two  occasions.  In  one  the  patient  remained  absolutely 
free  from  her  neuralgia  for  twelve  months,  after  which  there  was  some 
recurrence  owing  to  her  entire  neglect  to  avail  herself  of  the  fresh  air 
and  rest  which  were  so  necessary  in  the  after-treatment.  The  second 
patient  remained  free  from  the  neuralgia  for  the  six  months  she  was  kept 
under  observation. 

Neurectomy  of  the  Second  and  Third  Divisions  of  the  Fifth  Nerve  in 
Front  of  the  Ganglion  inside  the  Skull.  Peripheral  operations  on  the 
second  division  of  the  fifth  nerve  in  cases  where  the  palatine  and  posterior 
dental  branches  are  not  yet  involved,  and  one  on  the  inferior  dental  and 
the  lingual  gustatory  in  cases  where  these  branches  are  alone  affected,  and 
the  mischief  has  not  spread  to  other  branches,  e.g.  the  auriculo-temporal, 
have  now  been  given.  It  remains  to  consider  the  operative  treatment 
of  cases  in  which  the  second  or  third  division  of  the  fifth  is  more  deeply 
affected,  cases  in  which  peripheral  operations  have  failed,  and  lastly  those 
in  which  the  neuralgia  has  already  invaded  two  of  the  main  di\"isions  of 
the  fifth  nerve.  Reference  to  p.  364  will  show  that  Mr.  J.  Hutchinson,  jun., 
is  emphatic  in  his  opinion  that  in  these  cases  the  operation  should 
be  intracranial,  as  this  method  alone  gives  radical  relief.  We  have 
seen,  however,  that  the  extracranial  routes  which  attack  the  nerves  at 
their  exit  from  the  skull  may  be  followed  by  serious  fixity  of  the  jaw 
(p.  366). 

The  following  is  an  instance  in  which  Mr.  Hutchinson  put  his  opinion 


OPERATIONS  OX  THE  (iASSERIAN  GANGLION     371 

to  the  test  by  resecting  the  second  division  of  the  fifth  intracranially.' 
The  case  was  one  of  typical  epiIej)tifonn  neural<fia  confined  to  the  dis- 
tribution of  the  second  division,  occurring  in  a  robust  patient  of  GO. 

The  cranial  wall  having  been  roinovi'cl  as  described  at  p.  37.'}.  tlic  dura  mater 
and  brain  were  then  carefully  jjuslu-d  ui)wards  and  inward.s,  the  foramen  rotunduni 
beiuii;  aimed  at  a,s  a  landnlark.  Mucli  dilUculty  was  exjierienced  in  doing  this 
owing  to  the  thinness  of  the  dura  mater,  and  some  cerebro-spinal  iluid  escaped. 
The  trunk  of  the  second  division  and  the  ganglion  were  thoroughly  exposed  and 
the  whole  intracranial  part  of  the  nerve  was  removed,  the  nerve  being  divided 
close  to  the  Gasserian  ganglion  and  again  at  the  foramen  rotundum.  A  small 
drain  Wiis  ascd.  but  no  bone  replaced.  Primary  healing  followed,  and  for  eighteen 
months  the  patient  had  not  had  the  least  return  of  his  trouble. 

Mr.  Hutchinson  considers  this  operation  in  every  way  superior  to  that 
of  Carnochan,  and  where,  as  in  this  case,  the  second  division  is  alone 
affected,  removal  of  the  Gasserian  ganghon  is  unnecessary.  He  ex- 
presses liiniself  as  confident  that  no  recurrence  is  likely  to  take  place. 

Operation  on  the  Gasserian  Ganglion.  Indications.  For  these  see 
Mr.  Hutchinson's  rules  quoted  on  p.  ;3()4.  This  structure  has  been 
reached  by  two  routes,  (i)  The  Extracranial. 
This  method  was  brought  into  prominence  by 
Sir  W.  Rose,  whose  name  it  bears.  By  it  the 
ganglion  and  the  nerve  trunks  are  reached  by 
trephining  at  the  base  of  the  skull  from  ^\ith- 
out.  (ii)  The  Intracranial.  Here  the  gang- 
lion and  nerve  trunks  are  got  at  ^^ithin  the 
middle  fossa,  through  the  side  of  the  skull. 
This  is  the  Hartley-Krause  method.  Of  the 
above  the  first  has  been  abandoned  o^ing 
to  the  difficulties,  the  possible  bad  results, 
which  are  given  below,  and  the  uncertainties 
of  its  results.  It  will  therefore  not  be 
described  here.  While,  as  will  be  fully 
shown,  the  intracranial  method  is  not  %\'it'hout 
its  own  serious  difficulties  and  dangers,  it 
gives  far  better  access,  and  its  results  are  incomparably  better. 

Those  who  desire  full  details  of  the  extracranial  route  will  find  them 
given  by  Sir  W.  Rose.-  Sir  W.  Rose  himself  gave  up  this  method  and 
advocated  extensive  resection  of,  first,  the  superior  maxillary,  and 
secondly  (after  an  interval  of  a  few  weeks),  of  the  inferior  maxillary, 
di^^sion. 

The  following  are  the  chief  difficulties  and  dangers  of  the  extra- 
cranial route  : 

(1)  The  very  limited  field  in  which  the  surgeon  has  to  work  in  this, 
one  of  the  most  difficult  operations  in  surgery. 

(2)  Haemorrhage.  This,  from  the  presence  of  the  pterygoid  plexus, 
is  certain  to  be  troublesome  and  may  be  baffling. 

(3)  Injury  to  the  Eustachian  tube.  In  one  case  there  was  free 
haemorrhage  from  the  nose  and  mouth  during  the  operation.  The 
necropsy,  five  days  later,  showed-that  injury  to  the  Eustachian  tube  had 
led  to  infection  of  the  wound  and  meningitis. 

(4)  The  di^'ision  of  bone  required,  viz.  zygoma  and  coronoid  process, 
has  been  followed  bv  necrosis. 


Fig.  1.37.     A.  The  incision  for 

the  Hartley-Krause  operation. 

B,     The    incision   for    Rose's 

pterygoid  operation. 


^  Surg.  Treat,  of  Facial  Neuralgia,  p.  70. 


Brit.  Med.  Journ.,  1892,  vol.  i,  p.  261. 


372 


OPERATIONS  ON  THE  HEAD  AND  NECK 


(5)  The  fixity  of  the  jaw  and  a  disfiguring  scar  ;  these,  especially  in 
women,  are  common  sequelae. 

Operations  on  the  Gasserian  Ganglion  by  the  Intracranial  route.     The 

Hartleij-Kraiise  Operation.  The  following  description  is  based  upon  Prof. 
Krause's  article,^  Mr.  J.  Hutchinson,  jun.,-  and  the  account  given  by  Dr. 
Hartley.  =*  As  the  operation,  affording  as  it  does  the  only  complete  cure 
of  inveterate  neuralgia  of  the  epileptiform  type,  is  likely  to  be  increasingly 
performed,  and  as  it  is  hable  to  be  one  of  the  most  difficult  in  surgery,  a 
detailed  account  will  be  given. 

Preparatory  Treatment.     As  shock  from  a  prolonged  operation  and 
haemorrhage  are  the  chief  causes  of  death,  accounting  in  the  published  cases 


C.A 


Fig.  ]o8.  The  cavernous  sinus  and  (iassirian  ganglion  seen  from  above.  P.B., 
The  petrous  bone.  ('.A.,  Carotid  artery,  iii,  iv,  and  .vi,  The  oculomotor 
nerves,  showing  their  relation  to  the  ophthalmic  division  of  the  fifth  nerve. 
The  relative  positions  of  the  middle  meningeal  artery  and  the  inferior  maxillary 
nerve  are  shown.  The  dotted  line  crossing  the  Gasserian  ganglion  represents  the 
section  advised  in  removing  the  latter,  together  with  the  superior  and  inferior 
maxillary  trunks.     (J.  Hutchinson,  Jr.) 


for   nearly  half  the  mortality,  all  the  well-known  precautions  must  be 
taken  before,  during,  and  after  the  operation. 

In  the  previous  sterilisation  of  the  field  of  operation  the  external 
auditory  meatus  should  be  cleansed  and  plugged  with  sterile  gauze. 
Some  writers  advise  paring  and  suture  of  the  centre  of  the  lids  before  the 
operation  is  begun.  Prof.  Krause  does  not  recommend  this  step,  as  it 
interferes  with  examination  of  the  cornea,  and  because  "  healthy  eyes 
in  general  do  not  become  inflamed  after  the  Gasserian  ganglion  is  re- 
moved." ^  He  admits  that  the  danger  is  greater  if  there  is  any  suppura- 
tion about  the  lachrymal  sac,  or  if  earher  peripheral  operations  have 

^  Von  Bergmann's  "  System  of  Surgery,"  Amer.  Trans.,  vol.  i,  p.  585. 

2  The  Surgical  Treatment  of  Facial  Neuralgia,  p.  75. 

3  An7i.  of  Surg.,  1893,  p.  509. 

*  As  will  be  seen  later,  Prof.  Krause  removes  the  entire  ganglion. 


OPERATIONS  ON  THE  GASSEIIIAN  GANGLION     373 

intorfcM'od  with  closure  of  the  lids  by  facial  paralysis.  Mr.  Hutchinson  con- 
siders this  step  not  only  irksome  but  needless,  owing  to  the  great  rarity 
with  which  it  is  needful  to  interfere  with  the  ophthalmic  division,  as  this  is 
so  sel(h)m  the  seat  of  neuralgia.  He  further  points  out  that  temporary 
closure  of  the  lids  affords  no  guarantee  for  the  future  safety  of  the  cornea 
when  the  f)])hthalmic  division  has  been  divided. 

Operation.     This  may  be  considered  in  the  four  following  stages. 

(1)  The  Division  of  the  Soft  Parts.  The  following  special  instruments 
should  be  at  hand  in  addition  to  those  mentioned  at  p.  310  and  the  succeed- 
ing pages  for  removal  of  bone  hi  opening  the  skull :  a  special  broad  flexible 
retractor  (highly  polished  so  as  to  reflect  the  hght)  at  least  8  cm.  long; 
an  aneurysm  needle  with  a  short  curve  and  smaller  than  usual,  or  a  flexible- 
eyed  probe,  which  may  be  useful  for  securing  the  middle  meningeal  artery ; 
sharp  and  blunt-pointed  tenotomy  knives ;  fine-pointed  blunt  dissectors 
and  elevators ;  an  electric  head-lamp ;  and  a  dental  chair  for  raising  the 
patient  to  a  sitting  position.  A  horse-shoe  shaped  flap  is  cut,  the 
base  being  situated  at  the  level  of  the  zygoma  and  the  convex  upper 
border  extending  about  an  inch  and  a  half  or  two  inches  above  this 
level.  The  anterior  border  should  be  just  behind  the  external  angular 
process  and  the  posterior  should  terminate  just  above  the  condyle  of  the 
jaw.  All  the  soft  parts,  including  the  temporal  muscle  and  the  peri- 
cranium, are  divided  down  to  the  bone  and  the  flap  is  turned  down  by 
means  of  an  elevator.  In  order  to  minimise  the  possibility  of  damage  to 
the  branches  of  the  facial  nerve  which  supply  the  muscles  around  the 
orbit,  Prof.  Kocher  employs  an  incision  which  commences  a  finger's 
breadth  behind  the  frontal  process  of  the  malar,  and  is  carried  obliquely 
downwards  and  backwards  to  the  posterior  extremity  of  the  zygomatic 
arch,  and  from  thence  upwards  and  backwards  in  front  of  the  ear  at 
right  angles  to  the  first  part  of  the  incision.  This  second  part  of  the 
incision  is  carried  down  to  the  bone,  the  superficial  temporal  vessels 
being  ligatured.  The  incision  divides  the  skin,  and  the  strong  temporal 
fascia  is  cut  through  a  finger's  breadth  above  the  zygoma.  The  malar  is 
now  exposed  subperiosteally  immediately  behind  its  frontal  process, 
and  is  chiselled  through  vertically.  The  zygoma  is  divided  posteriorly 
close  to  its  root,  and  the  whole  zygomatic  arch  is  then  carefully  drawn 
down  with  a  hook.  The  outer  surface  of  the  temporal  muscle  is  now 
exposed,  and  its  posterior  and  lower  border  is  separated  from  the  skull 
and  drawn  well  forwards  with  a  blunt  hook  over  the  infratemporal  crest, 
at  the  same  time  detaching  the  periosteum  and  soft  parts  from  the  under 
surface  of  the  skull. 

(2)  Opening  the  Skull.  Very  little  need  be  added  here  to  the  directions 
given  at  pp.  310  et  seq..  Here  also  the  operator  will  be  guided  by  his 
experience  and  the  remarks  made  above  as  to  whether  he  will  remove  the 
bone  or  perform  an  osteoplastic  operation,  and  the  means  he  will  adopt 
in  either  case.  Mr.  Hutchinson  gives  the  following  as  a  reason  for  pre- 
ferring removal  of  bone  in  addition  to  the  fact  that  the  gap  will  be  com- 
pletely filled  up.  "  The  bone  forming  the  temporal  fossa  is  thin  and 
deeply  grooved  in  old  subjects  (and  nearly  all  the  patients  are  elderly), 
and  in  using  Gigli's  saw  or  chisel,  &c.,  the  dura  mater  is  readily  injured. 
Although  in  the  late  stage  of  the  operation  this  sometimes  cannot  be 
avoided,  and  the  escape  of  cerebro-spinal  fluid  even  facilitates  access  to 
the  ganglion,  at  an  early  stage  it  is  undesirable.  Should  the  osteoplastic 
method  be  adopted,  the  words  of  Krause  must  be  remembered.     When 


874 


OPERATIONS  ON  THE  HEAD  AND  NECK 


the  base  of  the  flap  is  fractured,  the  fracture  hue  rijns  about  1  cm.  above 
the  zygoma  ;  the  crest  of  bone  which  remains  here  and  which  interferes 
with  the  \iew  is  removed  with  gouge  forceps  down  to  the  base  of  the 
skull — that  is,  to  the  infratemporal  crest.  It  is  absolutely  necessary 
that  the  base  of  the  skull  be  fully  exposed  and  the  dura  down  to  the  point 
where  it  turns  inwards  below.  The  flap  should  be  well  rounded,  with  its 
base  at  the  zygoma  and  its  upper  edge  two  inches  above  this  ridge.  The 
two  extremities  of  the  incision  should  begin  at  the  eminentia  articularis 
behind  and  the  malar  bone  in  front.  The  bone  to  be  removed  is  the 
front  half  of  the  squamous  portion  of  the  temporal. 


Fig.  1.^9.     View  of  the  bony  floor  of  the  temporal  fossa.     The  shaded  area  indi- 
cates the  bone  which  is  removed  in  the  Hartley-Krause  operation.    (Hutchinson.) 


If,  as  is  preferable,  the  bone  is  completely  removed,  the  pin  of  a 
three-quarter-inch  trephine  should  be  inserted  midway  between  the  npper 
border  of  the  external  auditory  meatus  and  the  external  angular  process 
of  the  frontal.  The  opening  thus  made  is  then  enlarged  vdth  Hofimann's 
or  other  suitable  forceps.  The  position  of  the  patient  is  of  the  greatest 
importance.  He  should,  at  this  and  the  subsequent  stages  of  the  opera- 
tion, be  propped  up  into  an  almost  sitting  posture  ;  the  head  rests  upon  the 
occiput,  and  an  assistant  holds  it  as  directed.  In  this  position  the 
blood  and  the  exuding  cerebro-spinal  fluid  which  would  other^\^se  collect 
at  the  bottom  of  the  fmmel-shaped  wound  vnl\  flow  out,  and  thus  the  view 
will  not  be  so  readily  obstructed.  This  position  also  lessens  the  haemor- 
rhage, and  the  brain  moreover  tends  to  fall  back.  Mr.  Hutchinson, 
indeed,  has  found  that,  with  due  care,  the  sitting  position  in  a  dentist's 
chair  will  not  increase  the  difficulties  of  the  anaesthetist,  and  recom- 
mends the  adoption  of  this  posture. 

(3)  Finding  the  Ganglion.  The  Gasserian  ganglion  is  situated  over 
the  apex  of  the  petrous  part  of  the  temporal  bone  outside  the  dura  mater 
and  immediately  external  to  the  cavernous  sinus.  Partly  with  a  blunt 
raspatory  or  closed  curved  blunt-pointed  scissors,  partly  with  the  finger, 
the  surgeon  now  separates  the  dm'a  mater  very  carefully  from  the  base  of 
the  skull,  working  directly  inwards  towards  the  foramen  rotundum  and  the 
foramen  ovale,  which  he  at  a  depth  of  an  inch  and  a  quarter  from  the  wall 
of  the  temporal  fossa.  The  foramen  spinosum  is,  however,  placed  exter- 
nally to,  as  weU  as  shghtly  behind,  the  foramen  ovale,  and  will  therefore 


OPERATIONS  ON  THE  GASSERIAN  GANGLION     375 

probably  be  reached  fir^t.  Mr.  Hutchinson  has  found  that  the  emineiitia 
articularis  is  a  sufficient  landmark  for  the  two,  being  situated  on  the 
same  vertical  plane,  3  cm.  external  to  and  slightly  below  them. 

The  next  step  will  vary  somewhat  according  as  the  middle  meningeal 
is  tied  as  a  rule  or  not.  It  will  be  remembered  that  ha^morihage  of 
different  kinds  and  from  various  sources  is  one  of  the  chief  difficulties,  and 
the  chief  cause  of  prolonging  an  operation  always  difficult  and  usually 
performed  in  patients  of  poor  vitality.  Prof.  Krause  strongly  recom- 
mends this  precaution.  He  allows  that  in  cases  where  the  foramen 
spinosum  is  situated  exceptionally  far  behind  the  foramen  ovale,  this 
step  may  not  be  needful,  "  yet  ligature  and  division  are  nmch  safer  and 
should  be  carried  out  by  all  means."  The  dura  mater  having  been 
separated  and  the  foramen  spinosum  reached,  the  brain  surrounded  by 
the  dura  is  now  carefully  raised  by  a  right-angled  retractor  held  by  an 
assistant.  This  elevation  should  go  no  farther  than  is  absolutely  neces- 
sary to  obtain  a  clear  view.  By  raising  the  dura  with  an  elevator  from 
the  base  of  the  skull  internal  to  the  arterv,  so  that  the  second  and  third 


€^€ 


Scale  k 


m 


c. 


Fig.  160.     A,  Krause's  retractor  for  exj^osing  the  ganglion.     B,  Rose's  blunt 
hook.  *  C,  Rose's  sharp  hook 


divisions  of  the  fifth  nerve  become  visible,  the  artery  with  its  two  com- 
panion veins  comes  into  view  as  a  distinct  strand  running  up  to  the  dura 
from  the  foramen  spinosum,  and  can  be  isolated  on  all  sides  and  divided 
between  two  ligatures  passed  by  the  means  mentioned  on  p.  318.  If  the 
ligatures  slip,  or,  owing  to  other  cause,  cut  through  the  vessel,  Krause 
introduces  a  blunt  right-angled  hook  into  the  foramen,  presses  it  down 
tightly  by  a  raspatory,  and  turns  it  to  and  fro  until  the  bleeding  stops,  or 
leaves  it  in  place.  Ligature  of  the  external  or  the  common  carotid 
should  not  be  performed  as  a  preliminary  step,  or  now,  unless  the  bleeding 
cannot  otherwise  be  arrested  ;  in  one  case  which  occurred  in  Philadelphia, 
death  of  the  flap  and  fatal  septicaemia  followed  this  step.  Mr.  Hutchin- 
son has  found  that  while  it  is  possible  to  remove  the  ganglion  without 
ligature  of  the  middle  meningeal,  its  division  between  two  ligatures  un- 
doubtedly facihtates  the  raising  of  the  dura  mater  and  exposure  of  the 
inferior  maxillary  nerve  and  the  lower  edge  of  the  ganglion.  With 
regard  to  ligature  of  the  external  carotid  he  considers  that  this  procedure 
will  affect  the  arterial  bleeding  very  little,  owing  to  the  free  collateral 
circulation.  He  has  only  once  taken  this  step,  and  in  this  case,  the 
ligature  being  performed  in  the  middle  of  the  operation,  no  apparent 
effect  was  produced.  "  Keeping  the  patient  in  an  upright  sitting  position 
is  far  more  effective  than  ligature  of  the  external  carotid,  since  it  checks 
both  venous  and  arterial  bleeding." 


376  OPERATIONS  ON  THE  HEAD  AND  NECK 

The  dura  mater  is  next  raised  still  farther  towards  the  middle  line, 
very  carefully  on  accomit  of  the  tension  within  the  dura  and  the  vicinity 
of  the  cavernous  sinus.  To  check  the  oozing,  pledgets  of  dry  sterilised 
gauze — :the  wound  should  be  as  dry  as  possible  throughout — on  Spencer- 
Wells  forceps  should  be  used,  they  also  serve  to  raise  the  dura  gently. 
If  the  oozing  be  very  free  the  operation  must  be  interrupted  for  a  few 
minutes  in  order  to  pack  in  dry  gauze,  the  retractor  being  removed,  if 
needful,  or  slightly  displaced  forwards  or  backwards,  a  step  which  Krause 
has  often  found  sufficient  in  checking  bleeding  from  the  dural  veins.  If 
exceptionally  this  should  not  be  the  case,  he  removes  the  retractor  and 
introduces  more  gauze. 

(4)  Dealing  with  the  Nerves  and  Ganglion.  "  If  the  retractor  is 
well  placed,  the  third  branch  is  freed  with  a  fine  elevator,  and  then 
the  second  division,  which  lies  about  half  an  inch  forwards  and  mesially  ; 
the  dura  is  hfted  off  each  from  the  foramina  to  the  ganglion,  and  then 
the  nerves  are  raised  from  the  bone.  The  same  procedure  is  now 
adopted  with  the  ganglion  itself  ;  it  succeeds  perfectly  well  if  several 
thin  but  particularly  firm  strands  of  connective  tissue  are  cut  through 
here  and  there  with  blunt-pointed  scissors.  In  general,  however,  it  is 
sufficient  to  push  back  the  parts  with  small  gauze  pledgets  on  holders." 
Occasionally  there  may  be  a  small  tear  in  the  dura,  and  cerebro-spinal 
fluid  may  flow  out ;  this,  however,  is  of  no  consequence  in  an  aseptic 
operation.  "  This  stage  may  be  simplified  by  grasping  the  third  branch 
with  forceps,  and  rendering  it  tight  so  that  the  ganglion  comes  forward 
somewhat ;  for  this  reason  the  Ibranches  should  be  cut  through  last  of 
all,  since  by  them  the  ganglion  is  anchored,  so  to  speak,  in  its  place."  At 
all  events,  Krause  has  in  every  case  succeeded  in  dissecting  free  the 
ganglion  to  its  inner  edge,  and  so  far  backwards  against  the  upper  border 
of  the  petrous  bone  that  the  trunk  of  the  fifth  just  became  visible.  The 
ganglion  appears  hke  a  network  of  fibres'  and  is  greyish-red,  the  tri- 
geminal trunk  is  almost  white,  and  its  fibres  run  longitudinally. 

"  The  author  has  purposely  exposed  the  first  trigeminal  branch 
only  at  its  immediate  junction  with  the  ganglion,  and  has  not  followed 
up  its  farther  course,  since  it  runs  forwards  in  the  wall  of  the  cavernous 
sinus.  Besides  this,  the  abducent  and  trochlear  nerves  lie  in  its  immediate 
vicinity,  and  more  mesially,  the  oculomotor  nerve  ;  all  injury  to  these 
nerves  must  be  avoided. 

"  Should  the  cavernous  sinus  be  wounded,  the  resulting  alarming 
haemorrhage  can  be  checked  by  pressing  a  small  sponge  on  a  holder 
against  the  site.  As  soon  as  the  brain  falls  into  its  normal  position  the 
haemorrhage  stops  without  further  effort,  otherwise  a  small  strip  of 
gauze  must  be  pressed  against  the  bleeding  site.  It  should  be  left  in  place 
and  the  end  carried  out  of  the  wound.  The  pressure  within  the  sinus  is 
very  slight. 

"  Before  proceeding  farther  the  surgeon  should  grasp  the  exposed 
ganglion  transversely  with  longitudinally  ribbed  forceps  at  its  posterior 
portion,  where  it  passes  into  the  trigeminal  trunk.  This  is  directly  in 
front  of  the  upper  border  of  the  petrous  bone,  and  directly  under  the 
superior  petrosal  sinus.  Great  care  should  be  exercised  that  none  of  the 
structures  lying  mesially,  not  even  the  smallest  fold  of  dura  mater,  is 
caught  in  the  tip  of  the  forceps. 

"  The  surgeon  must  now  cut  through  the  second  and  third  branches 
with  a  sharp  tenotome,  or  small  curved  scissors,  close  to  the  foramen 


OPEllATTONS  ON  THE  GASSERIAN  GANGLION     377 

rotiuuluni.  The  ioiceps  wliicli  have  grasped  tho  giinghon  can  now 
be  slowly  rotated  around  its  axis.  The  entire  ganglion  will  always 
follow,  and  with  it  a  larger  or  smaller  piece  of  the  posteriorly-placed  tri- 
geminal truidv.  The  first  branch  generally  tears  olT  close  to  the  ganglion, 
but  since  only  peiipheral  portions  of  it  remain,  it  is  as  good  as  gone. 

"  In  conclusion  the  author  presses  the  peripheral  stumps  of  the 
second  and  third  branch  as  deep  as  possible  into  the  foramen  rotundum 
and  ovale  with  an  elevator."     (Krause.) 

Opinions  differ  as  to  the  extent  to  which  ganglion  should  be  removed. 
Prof.  Keen,  like  Prof.  Krause,  would  remove  the  entire  ganglion.  He 
believes  that  the  present  methods  of  dealing  with  the  eye  are  so  im- 
proved tliat  its  preservation  is  ensured  though  the  whole  ganglion  be 
removed.  On  this  subject  the  remarks  at  p.  3(S1  should  be  referred  to. 
Secondly,  any  arbitrary  line  of  removing  the  outer  two-thirds  and  leaving 
the  inner  third  will  leave  diseased  ganglionic  cells  if  the  ganglion  is 
affected.  Any  stimulus  from  the  first  division  will  excite  sensation  in 
these,  and  thus  bring  about  a  return  of  pain.^ 

Mr.  Hutchinson,  on  the  other  hand,  would  limit  the  removal  of  the 
ganglion  to  its  lower  and  outer  part  by  the  section  shown  in  Fig.  158. 
The  ganghon  is  exposed  by  removal  of  the  outer  layer  of  its  sheath,  which 
is  always  closely  adherent.  When  this  exposure  has  been  thoroughly 
effected,  and  not  before,  the  superior  and  inferior  divisions  are  cut  cleanly 
across  at  their  foramina  with  a  tenotomy  knife  or  the  hook  (Fig.  160). 
The  ganglion  being  firmly  held  by  toothed  forceps  is  now  divided  so 
as  to  leave  the  ophthalmic  division  intact.  This  method,  which  has  given 
excellent  results  in  his  hands,  is  based  on  the  fact  that  the  ophthalmic 
division  is  not  often  the  seat  of  neuralgia.  Mr.  Hutchinson  has  not 
found  a  case  in  which,  by  leaving  the  ophthalmic  trunk,  neuralgia  occurred 
in  it.  The  advantages  of  the  above  method  are  :  "  (1)  There  is  no 
anaesthesia  of  the  cornea,  and  hence  no  risk  of  loss  of  the  eye.  (2)  There 
should  be  no  danger  of  injuring  the  oculomotor  nerves,  or  the  cavernous 
sinus.  (3)  The  severity  of  the  operation  is  rendered  less,  the  haemor- 
rhage and  the  chance  of  injurious  pressure  on  the  brain  being  both 
materially  diminished." 

Closure  of  the  Wound  and  AJter -Treatment.  In  many  cases  as  soon 
as  the  operation  is  finished  and  the  brain  allowed  to  settle  down  in 
its  place  the  haemorrhage  ceases,  or  can  be  checked  by  temporary 
pressure.  If  serious  bleeding  continue,  the  careful  use  of  tampons 
must  be  trusted  to.  And  here  it  is  necessary  to  point  out  that  the  tem- 
poro-sphenoidal  lobe  has  frequently  been  found  injured  in  necropsies  of 
fatal  cases,  and  that  a  fertile  source  of  such  injury  is  the  use  of  gauze 
during  and  at  the  close  of  the  operation.  During  the  operation  the  use 
of  small  pieces  of  gauze  wrung  out  of  hot  saline,  or  sterilized  adrenalin 
solution,  and  careful  shifting  of  the  retractor,  will  arrest  the  venous  oozing. 
That  from  the  middle  meningeal  has  already  been  alluded  to.  Bleeding 
from  the  cavernous  sinus  is  to  be  avoided  by  not  interfering  with  the 
ophthalmic  division  and  that  part  of  the  ganglion  from  which  it  springs. 
Infective  meningitis  and  fatal  injury  to  the  brain  have  followed  in  several 
cases  on  the  vigorous  gauze  plugging  which  has  been  required  to  arrest 
the  haemorrhage  from  injury  to  these  two  vessels.  The  question  of 
operating  in  two  stages  may  be  mentioned  here.     Prof.  Krause  prefers 

^  The  comparative  infrequency  with  which  the  ganglion  is  found  to  show  any  signs  of 
gross  disease  has  been  alhidcd  to  at  p.  364. 


378  OPERATIONS  ON  THE  HEAD  AND  NECK 

to  finish  the  operation  in  one  sitting,  even  if  it  takes  a  long  time  owing  to 
frequent  interruptions  due  to  the  need  of  resorting  to  repeated  packings  : 
he  only  resorts  to  the  operation  in  two  stages  in  the  extremest  cases.  For 
he  does  not  consider  it  without  risk  to  expose  patients  exhausted  by 
protracted  severe  pains  twice  within  a  short  time  to  the  dangers  of  nar- 
cosis and  an  operative  procedure.  Besides  the  aseptic  course  is  endangered 
if  the  deep  wound  remains  open  long,  even  if  the  flap  is  secured  over  a 
sterilised  tampon  with  a  few  sutures.  In  general,  the  operation  in  one 
sitting,  where  the  bone  was  preserved,  required  an  hour  and  a  half  ;  with 
slight  haemorrhage  he  has  frequently  required  only  twenty  to  twenty-five 
minutes  after  the  bone  has  been  removed.  Mr.  Hutchinson  thinks  that 
while  it  is  desirable  whenever  possible  to  complete  the  operation  at  one 
sitting,  yet  when  exceptional  difficulty  from  haemorrhage  arises,  it  is 
wiser  to  defer  its  completion  for  a  few  days.  Those  with  necessarily 
limited  experience  will  do  well  to  bear  this  advice  in  niind.  It  is  better 
to  meet  the  risks  of  deferring  the  completion  of  the  operation  rather  than 
those  of  fatally  exhausting  their  patient,  or  incompletely  removing  the 
ganglion  because  they  cannot  see  it.  But  with  the  experience  now  before 
us  such  haemorrhage  should  more  rarely  be  met  with.  On  the  completion 
of  the  operation  a  small  drainage-tube  is  passed  through  the  entire  depth 
of  the  wound,  between  the  dura  and  the  skull,  and  brought  out  at  the 
posterior  angle  of  the  incision  in  the  skin.  Should  the  osteoplastic 
method  have  been  employed,  the  bone  must  be  notched  for  this  purpose. 
Where  the  cranial  wall  has  been  removed  it  is  needless  to  put  back  the 
bone.  The  tube  should  be  removed  in  forty-eight  hours.  In  those  cases 
where  the  dura  has  been  opened  accidentally  or  intentionally,  in  order  to 
relieve  the  tension  of  the  brain,  the  escape  of  cerebro-spinal  fluid  for  the 
first  few  days  may  be  such  as  to  require  daily  change  of  the  dressings. 

The  cornea  will  need  careful  attention.  Those  who  suture  the  lids 
will  divide  the  united  portion  in  about  two  weeks,  nothing  stronger  than 
boracic  lotion  having  been  used  m  the  interim,  and  afterwards  large 
protective  glasses  should  be  constantly  worn  to  prevent  access  of  dust. 
Prof.  Krause,  who,  as  we  have  seen,  dispenses  with  suture  of  the  lids, 
uses  a  Buller's  eyeglass  to  be  worn  as  long  as  any  tendency  to  irritation 
remains.  He  advises  that  no  bandage  be  employed  to  protect  the  cornea, 
as  it  always  exerts  some  pressure.  In  two  cases  where  the  facial  nerve 
had  been  injured  by  previous  operation,  he  saw  linear  ulcers  develop, 
which  corresponded  exactly  to  the  edge  of  the  upper  lid.  Mr.  Hutchinson 
states  that  if  the  ganglion  be  completely  removed  there  will  always 
remain  some  risk  of  trophic  ulceration  and  the  loss  of  the  eye.  In  support 
of  this  he  has  collected  ten  cases.  While  the  danger  is  greatest  during  the 
first  few  weeks,  an  anaesthetic  cornea  is  never  really  safe.  This  risk  can 
be  avoided  by  excision  of  the  ganglion  in  the  manner  described  at  p.  376. 

Results  of  the  Operation.  Prof.  Keen,  who  in  1898  had  operated  by 
the  intracranial  method  in  fourteen  cases,  wrote  :  "  What  has  been  the 
history  of  the  cases  as  to  cure  ?  So  far  as  I  know,  there  have  been  only 
four  cases  in  which  the  pain  has  returned  ;  one  reported  by  Rose,  one  by 
Dana,  and  two  by  myself.  But  I  especially  desire  to  call  attention  to  the 
fact  that  my  own  two  cases  of  recurrence  were  my  first  two  operations, 
that  in  Case  1  no  microscopical  examination  of  the  fragments  was  made, 
and  in  Case  2  the  examination  revealed  no  ganglionic  cells  or  nerve 
fibres.  Case  1,  as  I  now  look  at  it,  was  imperfectly  done,  and  Case  2,  still 
more  so.      Therefore  the  recurrence  of  pain  in  these  two  cases  cannot  be 


OPERATIONS  ON  THE  GASSERIAN  GANGLION     379 

used  as  an  argument  against  the  removal  of  the  ganglion."  In  addition  to 
the  above,  Krause  has  reported  one  case  in  which  the  sensory  root  was 
found  diseased,  and  the  pain  returned  on  the  opposite  side  of  the  face. 
We  can  conclude,  therefore,  in  general,  as  the  result  of  this  and  later 
experience,  that,  practically,  the  pain  will  not  return  in  over  1  or  2 
per  cent,  in  any  such  severity  as  to  liken  it  to  the  original  disease,  and 
that  it  will  not  return  at  all  in  more  than  4  or  5  per  cent.  Dr.  Tiffany, 
of  Baltimore,  who  has  afforded  nuich  help  to  surgeons  in  this  matter  by 
his  article  with  a  collection  of  108  cases, ^  shows  that  while  recurrence  of 
pain  may  follow  intracranial  excision  of  branches  of  the  fifth  nerve  close 
to  the  ganglion,  recurrence  has  not  been  observed  in  those  cases  in  which 
the  ganglion  itself  has  been  known  to  be  removed. 

"  The  place  where  the  ganglion  was  supposed  to  be  by  the  operator 
has  been  curetted,  or  pieces  of  tissue  picked  away  with  pincers,  more  or 
less  in  the  dark  ;  this  does  not  constitute  known  removal  ;  it  does  con- 
stitute attempted  removal — a  very  different  thing." 

Prof.  Krause,  writing  in  1902,  with  an  experience  of  thirty-six  cases, 
says  that  he  has  never  seen  a  recurrence  in  any  of  his  cases  in  which  the 
ganglion  was  removed  for  typical  trigeminal  neuralgia,  though  nine  years 
have  elapsed  since  his  first  extirpation. 

Mr.  Hutchinson  writes  that  the  cases  in  which  recurrence  of  epilepti- 
form neuralgia  has  followed  on  the  same  side  as  the  operation  may  be 
put  into  two  classes.  Either  the  patient  was  neurotic  or  hysterical 
{i.e.  not  a  really  suitable  subject  for  the  operation),  or  the  operation  has 
failed  to  deal  adequately  with  (perhaps  has  never  even  touched)  the 
Gasserian  ganglion.  With  regard  to  recurrence  of  the  neuralgia  on  the 
opposite  side,  this  authority  has  only  been  able  to  find  two  or  three 
instances  amongst  the  records  of  several  hmidred  cases. 

Mortality  of  the  Operation.  We  have  seen  that  Prof.  Krause,  writing 
very  briefly,  says  that  of  his  thirty-six  cases,  "  three  died  as  an  immediate 
result  of  the  operation."  Having  collected  128  cases  operated  on  up  to 
the  end  of  189D  by  the  method  he  describes,  Krause  finds  the  mortality  to 
be  one  of  15-6  per  cent. ;  15  to  20  per  cent,  may  be  justly  taken  as  the 
mortahty  of  the  operation  except  in  specially  skilled  hands. ^  Here, 
from  the  special  experience  gained,  the  mortality  of  the  operation  is  much 
lower.  Thus  Mr  Hutchinson  ^  writes,  "  Lexer's  eleven  and  my  own 
eight  cases  amount  to  nineteen  without  a  single  death.  Sir  V.  Horsley 
kindly  tells  me  that  his  personal  experience  has  increased  to  approximately 
120,  with  six  deaths.^  Taking  his  cases  with  Lexer's  and  my  own,  we 
have  140  cases  with  six  deaths,  only  4  per  cent.,  and  this  includes  two 
fatal  cases  which  some  surgeons  might  have  left  out."  Since  the  above 
was  written  (in  1905)  there  is  reason  to  believe  that  the  mortality  has  still 
further  diminished. 

Difficulties  and  Dangers  of  the  Operation.  From  the  account  already 
given  it  vnW  have  been  easy  to  estimate  these.  Perhaps  the  most  striking 
testimony  is  that  given  by  Prof.  Keen,  who,  in  the  paper  quoted  above, 

^  Trans.  Amer.  Surg.  Assoc.  1896,  p.  1. 

^  It  must  be  remembered  that  -whale  the  majority  of  successful  cases  are  published 
— many  after  too  short  an  interval — it  must  also  be  borne  in  mind  that  many  fatal  cases 
have  not  been  recorded  at  all. 

*  Loc.  supra  cit. 

*  "  Of  the  six  fatal  cases,  cerebral  haemorrhage  was  the  cause  in  three ;  one  patient 
died  from  septic  infection.  In  the  other  two  cases  an  interval  of  three  or  four  months 
occurred  after  the  operation,  the  cause  of  death  being  doubtful." 


380  OPERATIONS  ON  THE  HEAD  AND  NECK 

writes  :   "  Even  now,  after  having  operated  on  eleven  cases,    I  always 
approach  the  operation  with  a  certain  amount  of  hesitation." 

But  while  the  Hartley-Krause  operation  will  always  remain  one  of 
the  most  difficult  in  surgery,  and  one  from  the  gravity  of  its  dangers  not 
to  be  undertaken  lightly,  it  has  proved  itself  far  superior  to  the  extra- 
cranial method  from  the  wider  operation-field  which  it  affords,  the  better 
access,  and  thus  the  far  greater  certainty  of  its  results  ;  and  it  may  be 
confidently  expected  that  by  strict  attention  to  the  details  of  technique 
the  mortality  will  now  be  lowered,  especially  if  surgeons  are  able  to 
operate  on  patients  earlier,  before  their  vitality  is  so  much  lowered,  and 
if  they  avail  themselves,  when  it  is  indicated,  of  the  two-stage  method. 
To  recapitulate,  the  chief  difficulties  and  dangers  appear  to  be  . 

(1 )  Those  met  with  in  exposing  the  dura  mater  ;  these  have  been  con- 
sidered at  p.  375. 

(2)  Hcemorrhage.  Troublesome  bleeding  may  proceed  from  several 
sources,  (a)  the  diploe  ;  (b)  the  middle  meningeal  artery.  The  methods 
of  dealing  with  these  have  been  fully  given  at  p.  375.  Harvey  Cushing's 
direct  infra-arterial  method  may  be  briefly  mentioned  here.  In  making 
the  temporal  flap,  and  removing  the  bone,  the  incision  does  not  go  quite 
so  high  as  in  the  Hartley-Krause  method  ;  dishing  also  divides  and 
turns  down  the  zygoma  and  detaches  the  temporal  muscle  and  periosteum 
downwards  with  the  object  of  fully  exposing  the  infratemporal  crest,  and 
thus  making  certain  of  exposing  the  middle  meningeal  artery  low  down 
under  the  anterior  inferior  angle  of  the  parietal,  when  the  skull  is  opened. 
The  great  wing  of  the  sphenoid  is  removed  in  a  downward  and  inward 
direction  until  the  foramen  ovale  and  the  foramen  rotundum  are  exposed. 
Mr.  Hutchinson  considers  that  in  removal  of  the  zygoma  and  in  the  open- 
ing of  the  skull  low  down,  Cushing's  method  shows  a  reversion  to  Rose's 
operation,  and  that  it  is  doubtful  whether  these  slight  modifications 
present  any  real  gain.  On  the  other  hand  Kocher  ^  speaks  very  highly 
of  it  and  maintains  that  it  has  provided  the  most  satisfactory  statistics. 
For  further  details  Cushing's  original  papers  may  be  consulted. ^ 

Other  sources  of  bleeding  are,  (c)  the  veins  of  the  dura  mater  ;  (d)  the 
small  meningeal  artery,  especially  the  branch  running  under  the  ganglion  ; 
(e)  the  veins  of  Santorini ;  (/)  the  cavernous  sinus  ;  and  even  {g)  the  in- 
ternal carotid.  Means  for  dealing  with  the  haemorrhage  have  already 
been  given.  Speaking  generally,  tampons  will  suffice  for  venous  bleeding  ; 
to  be  really  rehable  in  the  case  of  arterial,  it  will  be  necessary  to  push 
the  strip  into  the  bony  foramina  themselves.  But  the  steps  already 
fully  given  should  amply  suffice  for  dealing  with  the  middle  meningeal,  and 
for  avoiding  the  internal  carotid  artery. 

(3)  Tension  and  Bulging  of  the  Dura  Mater.  It  has  been  pointed 
out  that  the  sitting  position  causes  the  brain  to  recede.  This  position, 
and  opening  the  dura  if  needful  to  evacuate  the  fluid,  may  be  trusted  to 
meet  this  difficulty. 

(4)  SJwcJc.  Owing  to  the  usual  condition  of  the  patients  and  the 
severity  of  the  operation,  every  precaution  must  be  taken  before,  during, 
and  after  the  operation  to  meet  and  lessen  this  danger. 

(5)  Infection  of  the  Wound.  During  a  necessarily  prolonged  operation 
this  may  enter  by  many  paths.  It  is  most  likely  to  occur  if  the  dura 
mater  is  opened,  giving  escape  to  cerebro-spinal  fluid,  if  this  membrane 

^  Operative  Surgery,  trans.  Stiles  and  Paul,  p.  207. 

•  Gushing,  Journ.  of  Amer.  Med.  Assoc,  April  28.  1900,  p.  1035. 


OPERATION  FOR  FACIAL  PARALYSIS  381 

and  the  subjacont  ])rain  are  bruised  by  the  retractor,  or  the  use  of  gauze  in 
arn'stintj  Ijlccdiiitr,  and  wlieri^  the  omployniont  of  tampons  is  extensive  or 
prohjiii^'t'd.  Locally.  !nenin<fitis  is  the  commonest  result  of  infection;  in 
one  case  a  cerebral  abscess  proved  fatal  three  months  after  the  operation. 
Here  an  infected  ligature  was  the  cause  of  the  suppuration. 

(6)  In  addition  to  fatal  hemipk'gia  and  other  evidence  of  damage  to 
the  brain,  the  use  of  the  retractor  and  other  manipulations  has  led  to 
|)aralytic  symptoms  which  gradually  cleared  up.  There  is  reason  to 
believe  tliat  collection  of  l)l()()d  under  the  flap  may  also  lead  to  hemiplegia, 
and  call  for  removal  of  the  clot. 

(7)  Ulceration  of  the  Cornea.  This  serious  complication,  which  may 
end  in  destruction  of  the  eyeball,  has  already  been  discussed. 

It  has  not  been  thought  needful  to  go  into  details  with  regard  to 
sparing  the  motor  root  of  the  fifth  by  dividing  the  sensory  root  above. 
While  theoretically  desirable,  this  step  is  not  a  practical  one.  "  Re- 
peated experiment  has  convinced  me  that,  in  the  cavum  Meckelii,  it  is 
impossible  to  divide  the  sensory  portion  completely  without  sacrificing 
the  motor  root ;  above  the  cavum  it  is  so  difficult  as  to  depend  almost 
upon  chance  "  (Hutchinson).  Krause,  after  repeated  attempts  to  pre- 
serve the  motor  root,  has  given  these  up.  Fortunately,  the  trouble  and 
inconvenience  caused  by  the  resulting  unilateral  paralysis  of  the  muscles 
of  mastication  is  very  slight.  The  loss  of  sensation  causes  the  patients 
but  little  discomfort ;  they  are  able  to  take  food  far  better  than  before, 
in  spite  of  some  limitation  of  the  movement  of  the  lower  jaw,  and  the 
disfigurement  is  trifling. 

OPERATIONS  ON  THE  FACIAL   NERVE.    STRETCHING  THE  FACIAL 

NERVE.      OPERATIVE     TREATMENT    OF    INTRACTABLE     FACIAL 

PARALYSIS    OF  PERIPHERAL    ORIGIN 

Stretching  the  Facial  Nerve.  This  operation  is  sometimes  performed 
for  severe  cases  of  spasm  of  the  facial  muscles  not  due  to  any  gross 
lesion,  and  in  which  other  treatment  has  failed.  It  is,  of  course,  to  be 
understood  that  no  patient  would  be  advised  to  submit  to  the  operation 
without  a  thorough  trial  of  other  remedies.  In  any  case,  it  is  extremely 
doubtful  if  anything  more  than  temporary  relief,  of  a  variable  duration, 
can  be  promised  by  this  measure. 

Sir.  R.  J.  Godiee  pubhshed  ^  a  case  in  which  he  stretched  the  facial 
nerve  in  a  case  of  tic  spasmodique  without  pain.  The  steps  given  below^ 
p.  385,  will  serve  for  the  exposure  of  the  nerve. 

The  operation  is  easy  in  thin  patients  ;  more  difficult  in  stout  and  muscular 
ones.  Experimentally  on  the  cadaver  it  was  found  that  the  amount  of  tension 
that  the  nerve  would  bear  differed  very  much  ;  in  some  cases  it  resisted  for  an 
appreciable  time  the  strongest  possible  pull ;  in  others  it  snapped  across  with  the 
greatest  readiness.  The  line  for  the  nerve  is  exactly  parallel  with  the  upper  border 
of  the  digastric,  and  it  will  be  found  about  half  way  down  that  part  of  the 
mastoid  process  which  is  exposed  in  the  wound,  viz.  '  the  free  anterior  border. 
The  great  aiuicular  nerve  will  be  in  part  divided,  but  as  long  as  the  operator 
keeps  in  the  same  plane  as  the  digastric  he  can  scarcely  wound  any  vessel  of  import- 
ance. The  deepest  part  of  the  wound  is  in  close  proximity  to  the  internal  jugular 
vein.  The  only  vessels  which  should  be  met  with  are  the  posterior  am'icular  vein 
superficially,  and  its  artery  more  deeply,  but  a  good  deal  of  haemorrhage  may  arise 
from  glandular  branches  ;  and  Sir  R.  J.  Godlee's  advice  to  keep  the  wound  in  a 
good  light,  well  opened  out  with  retractors,  and  carefully  sponged  dry,  should  be 
remembered. 

1  Clin.  Soc.  Trans.,  vol.  xiv,  p.  45. 


382  OPERATIONS  ON  THE  HEAD  AND  NECK 

Points  which  deserve  attention  : 

(1)  Finding  the  nerve.  To  avoid  needless  injury  and  to  shorten  the  operation, 
Prof.  Keen^  recommends  a  weak  faradic  cm-rent.  A  wet  sponge  was  held  on  the 
cheek,  and  a  fine  wire  at  the  other  end  was  applied  to  various  points  in  the  wound 
till  the  nerve  was  found. 

(2)  Mode  of  stretching  the  nerve.  Prof.  Keen  advises  stretching  from  the 
periphery  towards  the  centre.  The  amount  of  force  to  be  used  he  estimates  at 
four  to  five  pounds,  and  this  he  thinks  can  best  be  achieved  empirically,  by  attempting 
to  lift  the  head  (six  to  seven  pounds),  and  abandoning  the  attempt  the  moment 
any  fibres  give  way.  In  other  words,  the  stretching  should  be  as  severe  as  the 
integrity  of  the  nerve  will  allow.^ 

(3)  Results  of  the  operation.  It  appears  that  while  many  cases  have  been, 
temporarily,  very  much  relieved,  as  a  certain  rule,  when  the  nerve  recovers  itself, 
the  spasms  return. 

Prof.  Keen,  in  the  table  at  the  end  of  his  paper,  gives  two  cases  in  wliich  the 
cure  lasted  much  longer,  if  indeed  it  may  not  be  called  permanent,  viz.  Southam's,^ 
in  which  there  was  absolute  relief  for  five  years  ;  and  one  under  the  care  of  Jesas,* 
in  which  the  cure  had  lasted  two  years  and  eight  months. 

Prof.  Keen's  concluding  words  are  as  follows  :  "It  would  seem, 
therefore,  that,  whether  viewed  from  the  point  of  palliation  or  of  cure,  the 
operation  is,  with  our  present  knowledge,  to  be  looked  upon  favourably." 

Sir  R.  J.  Godlee  in  a  second  paper, ^  in  which  he  published  the  result 
of  his  first  case — ^in  which,  after  practically  remaining  absent  for  nine 
months,  the  convulsions  suddenly  returned  subsequent  to  a  severe 
nervous  shock,  and  gradually  increased  until  they  regained  all  their 
former  intensity — sums  up  less  favourably  :  "  In  discussing  the  question 
of  recommending  the  operation,  we  must  not  forget  that  the  risk,  with 
due  care,  is  almost  nil  ;  that  a  certain  immunity  from  the  trouble  may 
be  safely  promised  for  a  time,  and  that  this  period  may  be  very  consider- 
ably prolonged,  and,  while  Southam's  remarkable  case  remains  completely 
well,  there  is  always  the  hope  that  the  relief  may  be  permanent.  Were 
it  not  for  this,  however,  I  am  afraid  that  the  general  verdict  would  be  that 
the  time  has  come  when  this  small  chapter  of  surgical  therapeutics  .  .  . 
must  be  closed." 

And,  after  submitting  to  the  stretching  of  the  nerve,  patients  should 
be  most  careful  to  avoid  any  exciting  and  predisposing  cause  of  a  return 
of  their  trouble — viz.  exposure  to  cold  chills,  sudden  bright  lights,  mental 
worry,  and  insufficient  or  improper  food. 

OPERATIVE  TREATMENT   OF  INTRACTABLE  FACIAL  PARALYSIS 
OF  PERIPHERAL  ORIGIN 

Operations  have  lately  been  devised  by  anastomosis  of  the  facial 
with  the  spinal  accessory  or  hypoglossal  nerve,  wdth  a  view  of  improving 
intractable  facial  paralysis  originating  from  injury  in  its  course  through 
the  temporal  bone,  or  just  outside  this  bone. 

1  Ann.  of  Surg-,  July  1886,  p.  13.  A  strong  current  will  produce  muscular  spasm 
at  once,  but  a  very  weak  current  will  only  do  so  when  the  nerve  is  touched. 

2  Kocher  advises  that  when  stretching  the  nerve  for  facial  spasm,  a  general  anaes- 
thetic should  not  be  employed,  because  the  stretching  must  be  so  measured  that  it  pro- 
duces a  distinct  but  not  a  total  paresis,  which  can  readily  be  brought  about  by  sUght 
traction  with  an  aneurysm  needle. 

3  Lancet,  August  27,  1881  ;    ibid.,  April  10,  1886. 

*  Wien.  Med.  Woch.,  No.  2,  1884,  and  No.  27,  1887.  It  is  an  interesting  fact  that  no 
paralysis  followed  in  this  case. 

5  Both  Sir  R.  J.  Godlee's  second  paper  {Clin.  Soc.  Trans.,  vol.  xvi,  p.  220)  and  Prof. 
Rene's  {loc.  supra  cit.)  contain  tables,  the  former  giving  thirteen,  the  latter  twenty-one 
cases.  Sir  R.  J.  Codlee's  patient  was  unwilling  to  obtain  relief  from  her  complaint  by 
submitting  to  permanent  paralysis  of  the  affected  side  of  her  face,  owing  to  a  dislike  of  the 
very  obvious  nature  of  the  deformity. 


OPEKATION  FOR  FACIAL  PARALYSIS  383 

Enough  definite  knowledge  from  a  sufficient  number  of  cases  carefully 
watchod  for  a  sufficient  period  is  gradually  accunmlating  to  show  how  far 
this  op(M-ati()n  will  outweigh  the  disadvantages  which  it  entails.  To 
consider  this  in  a  little  detail,  the  operation  can  only  prove  a  cure  if  the 
cortex  can  be  sufficiently  educated,  and  if  the  patient  wdl  persevere  with 
this  education,  so  as  to  accomplish  independent  movements  of  the  face 
dissociated  from  those  of  the  shoulder  or  tongue.  A  few  cases  show  that 
this  result  has  been  coinj)letely  ^  accomplished.  Short  of  this,  the  chief 
advantage  is  that  in  a  certain  luimber  of  cases,  not  in  all,  as  the  facial 
muscles  gain  some  power  of  movement  associated  with  those  of  the 
shoulder  or  tongue,  they  regain  some  tone  also,  and  thus  the  flaccidity  of 
the  face  disappears.  But  if  this  gain  follows,  it  only  shows  itself  when 
the  muscles  are  at  rest.  In  the  great  majority  of  cases  the  paralysed  side 
of  the  face  long  remains  motionless  when  the  opposite  one  is  in  action,  as 
in  laughing.  The  only  movements  possible  on  the  paralysed  side,  e.g. 
after  facio-accessory  anastomosis,  are  those  associated  with  movements  of 
the  shoulder.  If  the  patients  desire  to  contract  the  facial  muscles,  they 
must  moVe  the  shoulder.  This  is  certainly  true  for  a  period  varying  from 
three  to  eighteen  months.  As  the  play  of  the  facial  muscles  is  the  index 
of  the  state  of  the  mind,  it  is  clear  that  as  long  as  they  act  only  in  associ- 
ation with  those  of  the  shoulder,  any  movement  of  the  muscles  of  the 
shoulder  may  cause  an  expression  of  the  face  which  is  not  in  the  least 
in  harmony  with  the  state  of  the  mind.  This  has  been  met  with 
frequently.  A  good  instance  is  given  in  one  of  the  seven  cases  published 
in  a  paper  by  Mr.  C.  A.  Ballance,  Mr.  H.  A.  Ballance,  of  Norwich,  and  Dr. 
Purves  Stewart.-  The  patient  had  been  operated  on  nine  months 
previously. 

"  The  flaccidity  of  the  face  had  disappeared,  so  that  when  at  rest  it  was 
practically  symmetrical.  No  voluntary  movement  could  yet  be  performed  without 
simultaneous  elevation  of  the  shoulder.  Moreover,  the  facial  movements  were  so 
easily  elicited  by  slight  shoulder  movements  that  the  patient  had  to  cany  her 
parasol  or  umbrella  in  the  right  hand  instead  of  the  left,  otherwise  involuntary 
facial  movements  so  readily  occurred  that  awkward  misunderstandings  with 
strangers  resulted." 

Another  inconvenience  is  the  atrophy  of  the  shoulder  muscles  which 
follows,  though  this,  as  a  rule,  disappears  if  the  anastomosis  be  performed 
as  advised  by  Mr.  Ballance  and  others.  As  to  the  nerve  to  be  selected, 
the  conclusion  arrived  at  by  the  writers  of  the  above  paper  is  that  facio- 
hypoglossal  anastomosis  is  preferable  to  facio-accessory,^  for  these  reasons. 

(1)  The  nearness  of  the  cortical  centre  of  the  tongue  to  that  of  the  face. 

(2)  The  fact  that  some  of  the  movements  of  the  tongue  are  closely  asso- 
ciated with  those  of  the  face.  To  these,  it  may  be  added,  that  during  the 
period  in  which  the  movements  of  the  face  continue  dependent  upon  those 

^  In  several  of  the  cases  so  carefully  reported  in  the  paper  alluded  to  below,  evidence 
of  partial  recovery  is  given.  Thus  in  the  one  treated  by  Mr.  H.  A.  Ballance,  of  Norwich, 
the  patient,  eight  months  after  the  operation,  could  close  the  eyelids  completely 
by  a  strong  effort.  Ten  and  a  half  months  after  the  operation  the  food  no  longer  lodged 
in  the  cheek.  Dr.  Kennedy  [Brit.  Med.  Journ.,  June  6,  1903,  p.  1348)  writes  that  his 
patient  had  "  recovered  the  power  to  make  independent  movements  of  the  orbicularis 
palpebrarum,  giving  a  practically  normal  use  of  the  eyelids,  independently  of  any  con- 
tractions of  the  sterno- mastoid  or  of  the  trapezius,  and  also  that  other  imperfectly  co- 
ordinated movements  of  other  muscles  of  the  right  side  of  the  face  were  recovered." 
"  Distinctive  improvement  "  was  still  going  on  four  years  after  the  operation.  Mr.  C.  A. 
Ballance's  latest  results  are  given  below  (p.  385). 

2  Brit.  Med.  Journ.,  May  2,  1903. 

*  In  a  letter  {Brit.  Med.  Journ.,  May  30, 1903)  Mr.  Ballance  shows  that  Prof.  Bernhardt, 
of  Berlin,  also  prefers  facio-hypoglossal  anastomosis. 


384 


OPERATIONS  ON  THE  HEAD  AND  NECK 


of  the  tongue,  less  awkwardness  will  result  owing  to  the  latter  being 
hidden  from  view.  As  to  the  date  of  the  operation,  the  writers  are  of 
opinion  that  when  the  paralysis  has  lasted  six  months,  in  spite  of  massage 
and  other  non-operative  treatment,  no  recovery  is  to  be  expected  by 
these  means,  and  the  sooner  the  operation  is  performed  after  this  date  the 
better. 

Mr.  Ballance  and  Dr.  Kennedy  pointed  out  that  the  surgeon  should 
commmiicate  to  his  patients  as  accurate  a  knowledge  as  possible  of  the 
extent  of  recovery,  partial  or  complete,  which  the  operation  offers. 

In  the  majority  of  cases  the  operation  will  be  performed  for  paralysis 
due  to  disease  of  the  temporal  bone  ;    much  more  rarely  after  fracture  of 

the  base  (Case  v.  operated  on  by 
Mr.  Ballance  ^),  or  of  operation 
wounds,  e.g.  during  the  removal 
of  a  parotid  tumour,  or  wounds 
outside  the  skull. 

Thus  Mr.  Ballance  mentions 
a  case  of  this  kind  in  -which  he 
was  unable  to  complete  the  oper- 
ation as  the  trunk  of  the  facial 
nerve  had  been  carried  away  by 
a  bullet.  Harvey  Gushing,  who 
p  reviews  the  whole  subject,^  also 
reports  a  case  of  paralysis  due  to  a 
2  revolver  bullet. 

.^  After  the  removal  of  the  bullet 
dishing  waited  until  the  wound  was 
soundly  closed,  fearing  that  otherwise 
it  might  cause  infection  of  the  one  which 
he  proposed  to  make.  A  facio-accessory 
anastomosis  was  made  hy  end-to-end 
suture  over  the  posterior  belly  of  the 
digastric.  Improvement  as  to  lachry- 
""^  mation  and  taking  food  followed  very 
early,  and  six  months  after  the  opera- 
tion it  is  stated  that  "considerable  im- 
provement was  appreciable." 

It  is  pointed  out  that  the 
success  of  the  operation  depends 
largely  upon  the  delicacy  with 
which  '  the  nerves  are  handled, 
upon  their  accurate  approxima- 
tion -unth  the  least  possible  suture- 
material,  and  that  placed  only  in 
the  nerve  sheaths^ — Cushing  used  the  most  delicate  strands  of  split 
silk^ — upon  absolute  heemostasis,  and  upon  the  care  vdth  which  the 
tissues  are  handled,  since  it  is  of  the  utmost  importance  that  there  should 
be  a  minimum  of  scar  formation. 

Operation  (Fig.  161).     The  following  steps  will  suffice  for  exposure 
of  the  facial,  the  spinal  accessory,  and  the  hypoglossal  nerves. 

A  free  incision  is  made  along  the  anterior  border  of  the  sterno-mastoid, 

beginning  at  the  level  of  the  base  of  the  mastoid  process.     After  division 

of  the  dense  fibrous  tissue  here  the  muscle  is  retracted,  and  separated  if 

needful  from  the  mastoid  process,  the  anterior  border  of  which  must  be 

1  Loc.  supra  cit.  ^  Ann.  of  Surg.,  May  1903. 


Fig.  161.  P,  Parotid.  D,  Digastric.  S  M, 
Sternomastoid.  At  S  the  branch  of  the 
spinal  accessory  to  the  trapezius,  cut  long, 
has  been  looped  up  over  the  digastric,  and 
united,  end  to  end,  to  the  divided  facial. 
(Faure.) 


OPERATION  FOR  FACIAL  PARALYSIS  385 

exposed.  The  posterior  auricular  vessels  are  cut.  Lying  a  little  anterior 
to  this  point,  and  on  a  deeper  level,  is  the  base  of  the  styloid  process  across 
whicli  the  nerve  runs  towards  the  parotid  gland.  The  lower  and  back  part 
of  this  gland  having  been  freed  and  drawn  forwards  and  the  digastric 
downwards,  the  facial  nerve  will  come  into  view,  and  is  to  be  followed 
up  as  high  as  the  stylo-mastoid  foramen.  The  spinal  accessory  will  be 
found  a  little  below  the  digastric,  running  downwards  and  outwards  to  the 
sterno-mastoid.  When  this  nerve  is  chosen  for  anastomosis,  different 
methods  have  been  employed.  M.  Faure  having  found  the  main  trunk 
preserved  the  branches  to  the  sterno-mastoid.  He  took  the  branch  to 
the  trapezius,  cutting  it  from  this  muscle  as  long  as  possible,  separated  it 
from  the  spinal  portion,  so  as  to  bring  it  up  easily  in  the  form  of  a  loop, 
\nth  the  concavity  upwards  over  the  posterior  belly  of  the  digastric,  where 
it  was  fixed  by  end-to-end  suture  to  the  divided  facial.  Later,  he  preferred 
to  fix  the  branch  to  the  trapezius  "  end-to-side  to  the  uncut  trunk  of  the 
facial  "  (Ballance).  Kennedy  divided  the  spinal  accessory  nerve,  with 
the  exception  of  one  side  of  its  perineurium,  and  sutured,  end-to-side, 
the  divided  trunk  of  the  facial  into  this  gap. 

The  after-treatment  consists  mainly  in  a  judicious  stimulation  by 
daily  galvanism  for  months,  after  the  wound  is  healed.  This  is  continued 
until  faradic  excitability  reappears,  when  faradism  is  substituted. 

Mr.  Ballance  wrote,  June  1905 :  "  I  do  not  do  now  the  end-to-side 
anastomosis.^  In  facio-accessory  anastomosis  I  di\'ide  the  accessory, 
except  a  small  portion  of  the  sheath,  on  one  side,  and  then  unite  the  cut 
end  of  the  facial  end-to-end  to  the  upper  segment  of  the  accessory.  This 
means  temporary  paralysis  (two  to  three  months)  of  the  sterno-mastoid 
and  trapezius.  In  facio-hypoglossal  anastomosis  I  divide  the  hypoglossal 
at  the  posterior  border  of  the  hyoglossus  ;  the  proximal  end  is  united 
to  the  facial  end-to-end.  I  then  di^dde  the  gustatory  and  unite  its 
proximal  end  to  the  distal  end  of  the  hypoglossal  so  as  to  get  a  return  of 
the  movement  in  the  muscles  supplied  by  the  hypoglossal." 

"  Case  vi  had  a  perfect  dissociated  movement  of  the  face  at  the  end 
of  eighteen  months.  Case  vii  is  dead  of  mahgnant  disease,  I  believe. 
Case  viii  has  now  dissociated  movement  in  speaking  and  laughing.  I 
have  been  told  of  two  cases  of  independent  dissociated  movement  appearing 
after  three  months  in  facio-hypoglossal  anastomosis.  This  anastomosis 
appears  the  best,  as  the  centres  for  movement  on  the  cortex  of  the 
tongue  and  face  are  close  together." 

Rlr.  A.  H.  Tubby  has  recorded  an  interesting  case  of  facio-hypoglossal  anastomosis 
for  the  treatment  of  post-operative  division  of  the  facial  nerve.^  The  facial  paralysis 
followed  the  opening  of  an  abscess  at  the  angle  of  the  jaw  by  another  surgeon  in  a 
yomig  man  of  19  in  the  early  part  of  1905.  When  Mr.  Tubby  operated  in  October 
1905  there  was  a  complete  facial  paralysis.  A  long  incision  was  made  and  the 
divided  ends  of  the  facial  nerve  were  found  with  difficulty.  The  hypoglossal  was 
then  freed  and  brought  up  to  the  facial.  An  incision  was  made  into  the  former 
with  a  tenotomy  knife  and  both  ends  of  the  facial  were  implanted  laterally.  The 
head  was  kept  at  rest  for  fourteen  days.  A  week  after  the  operation  it  was  noticed 
that  the  left  eye  could  be  temporarily  closed,  while  two  weeks  after  the  patient 
began  to  move  the  left  angle  of  his  mouth.  In  March  1907  there  was  great  improve- 
ment ;  all  movements  had  been  recovered  but  were  weaker  than  those  of  the  other 
side,  so  that  when  both  sides  of  the  face  were  moved  the  right  muscles  overpowered 
the  left.     There  was  some  atrophy  of  the  left  side  of  the  tongue. 

^  Illustrated  in  Fig.  12,  loc.  supra  cit. 
*  Clin.  Soc.  Trans.,  vol.  xl,  p.  264. 

SURGERY  I  25 


386  OPERATIONS  ON  THE  HEAD  AND  NECK 

RESTORATION  OF  STENOS  DUCT 

Where,  after  burns,  stabs,  ulcerations,  sloughing,  operations  for 
removal  of  growths,  a  most  annoying  salivary  fistula  persists,  the  patient 
suffering  from  disagreeable  hot  dryness  of  the  mouth,  and  from  constant 
irritation  and  inflammation  of  the  soft  parts  from  the  dribbling  of  saliva, 
where  previous  measures — e.g.  collodion  and  heated  wire,  paring  the 
edges — have  failed,  the  surgeon  may  adopt  one  of  the  following  measures  : 

(i)  The  following  will  often  succeed  in  a  recent  case. 

The  opening  into  the  mouth  is  first  found,  or  one  in  its  position  made, 
by  passing  a  fine  silver  probe  from  the  fistula  into  the  mouth. ^  As  soon 
as  the  oral  opening  is  found  or  established,  the  probe  is  passed  from  the 
mouth  along  the  duct,  beyond  the  fistula,  up  to  the  gland  itself.  The 
other  end  of  the  probe  is  then  brought  out  of  the  angle  of  the  mouth, 
curved  and  secured  by  strips  of  gauze  and  collodion  on  the  cheek,  while 
the  fistula  is  kept  as  dry  as  possible,  and  covered  ^ith  collodion,  in  the 
hope  that  it  will  close. ^  now  that  the  oral  opening  is  re-estabUshed ;  other- 
wise the  fistula  must  be  closed  by  operation 

Sir  H.  Morris  ^  has  recorded  a  case  which  he  successfully  treated  on  the 
same  lines,  but  with  a  fine  catgut  bougie,  which  is  much  more  easily  worn 
than  a  probe.  He  also  suggests  that  it  would  be  well,  if,  during  any 
operation  on  the  face  for  removal  of  a  new  growth,  it  be  found  necessary 
to  divide  the  duct,  that  a  bougie  should  be  passed  at  once,  and  the  patency 
of  the  duct  secured. 

(ii)  In  cases  of  longer  standing,  where  the  duct  is  more  obhterated, 
especially  at  its  narrow  oral  end,  and  the  restoration  is  not  so  easy,  some 
such  operation  as  Desault's  must  be  performed.  The  following  modifica- 
tion is  that  of  Kaufmann.  The  account  is  given  by  Prof.  Kuttner.^  A 
fine  trocar  and  cannula  are  pushed  through  the  cheek  from  the  fistula 
forwards  and  inwards  into  the  mouth,  following,  as  far  as  possible,  the 
course  of  the  duct.  '"  A  fine  piece  of  india-rubber  tubing  is  passed  through 
the  cannula,  the  latter  being  then  withdrawn,  so  that  one  end  projects  into 
the  mouth,  while  the  other  is  cut  off  somewhat  obhquely,  and  placed  so 
that  the  saUva  can  flow  directly  into  the  tube.  One  can  also  simply 
permit  the  tube  to  project  upon  the  cheek.  The  tube  remains  in  place 
eight  days,  and  is  then  shortened  at  both  ends  close  to  the  level  of  the 
skin  and  mucous  membrane.  In  eight  or  ten  days  more  it  is  removed 
entirely.  The  sahva  -^ill  now  flow  through  the  new  canal  into  the  mouth, 
and  the  external  fistula  will  close  by  itself  or  after  cauterisation  or  direct 
suture. 

"  Kaufmann's  method  is  simple  and  rational  and  suited  for  buccal  as 
well  as  masseteric  fistulse.  "With  a  buccal  fistula  it  is  simply  necessary 
to  puncture  the  cheek  at  the  abnormal  orifice  in  a  straight  direction, 
or  \\ith  a  shght  deviation  to  the  front  ;  with  a  masseteric  fistula,  however, 
one  must  be  careful  not  to  push  the  cannula  through  the  masseter,  for  a 
foreign  body  in  the  muscle  is  not  borne  well,  since  it  causes  severe  pains  and 
even  trismus  ;  besides,  the  long  track  will  readily  close  again  if  it  runs 
between  muscle  fibres.     Hence,  in  a  masseteric  fistula  the  trocar  must  first 

^  Close  to  the  projection  of  the  mucous  membrane,  which  usually  denotes  the  position 
of  the  orifice  of  the  duct,  opposite  to  the  second  upper  molar  tooth." 

^  If  this  fails,  a  plastic  operation  of  paring  the  edges  and  uniting  them  with  numerous 
sterilised  fishing-gut  and  horsehair  sutures  will  probably  be  required. 

^  Clin.  Soc.  Trans.,  vol.  xiii,  p.  144. 

*  Von  Bergmann'e  "  System  of  Practical  Surgery,"  Amer.  Trans.,  vol.  i,  p.  614. 


OPERATIVE  TREATMENT  OF  LUPUS  387 

be  pushed  from  the  opening  of  the  fistula  subcutaneously  to  the  anterior 
edi^e  of  tlie  niassetcr  ])('foi-e  the  oral  nmcou.s  monibrane  is  perforated."  In 
order  to  thoroughly  ostabiisli  tiio  ])at(MU'y  of  the  new  duet  catgut  or  a  very 
fine  piece  of  laininaria  tent  ^  will  jjiobably  be  rec[uired  to  prevent  the 
tendency  to  close. 

Instances  of  treatment  by  direct  suture  and  different  plastic  operations, 
especially  indicated  in  masseteric  fistulse,  will  be  found  given  by  Prof. 
Kuttner.  If  every  other  step  fails,  he  advises  that  a  partial  resection  of 
the  parotid  gland,  with  careful  avoidance  of  the  facial  nerve,  be  performed. 

When  the  patency  of  the  new  duct  is  thoroughly  established,  the 
external  aperture  maybe  closed  by  collodion,  the  cautery,  or  paring  the 
edges,  according  to  its  size. 

OPERATIVE  TREATMENT  OF  LUPUS  ^ 

Lupus,  a  tuberculous  lesion  of  the  skin,  frequently  attacks  the  face, 
especially  the  nose,  lip,  cheek,  or  eyehd.  It  may  also  invade  or  commence 
in  the  mucous  membrane  of  the  nose,  mouth,  pharynx,  or  larynx.  There 
are  various  ways  in  which  it  may  be  treated,  and  in  each  individual  case, 
the  situation,  extent,  rapidity,  and  the  time  the  patient  can  give  to  treat- 
ment must  be  considered  w^hen  selecting  the  most  desirable  form  of 
treatment.  Lupus  is  frecpiently  met  with  in  this  country,  the  deformities 
which  it  produces  are  so  odious,  and  it  is  so  certainly  arrested  and  cured 
in  many  cases  by  local  treatment  vigorously  applied  and  energetically 
repeated,  that  a  few  practical  remarks  will  be  made  on  the  chief  methods 
of  treatment. 

Before  speaking  in  detail  of  these  methods  it  will  be  well  to  say  a  few 
words  about  the  chief  forms  of  lupus. 

For  the  purpose  of  operative  treatment  the  surgeon  should  keep  two 
great  types  before  his  mind.  In  one  of  these  the  lupus  deposit  takes 
the  shape  of  more  or  less  localised  nodules  or  nests,  reddish  or  yellowish- 
pink,  often  cpiasi-gelatinous,  and  prone  to  attack  the  cheeks  near  the 
junction  of  the  alae  and  the  upper  lip.  In  the  other  the  lupus  deposit 
is  much  more  diffused,  usually,  too,  more  superficial  and  less  inclined 
to  form  nodules  or  nests.  This  type  is  met  with  both  on  the  cheeks  and 
nose,  but  is  best  seen  on  the  latter.  It  is  the  form  most  frequently  met 
with  in  the  surgical  wards  of  a  London  hospital,  and  is  the  one  most  often 
responsible  for  marring  the  above  important  features  in  young  patients, 
usually  girls.  This  type  is  the  lupus  seborrhagicus  of  Prof.  Volkmann,^ 
the  seborrhoea  being  of  secondary  importance,  the  essential  point  being 
the  fine  cell  lupus  infiltration  of  the  cutis,  which  develops  most  freely 
in  the  neighbourhood  of  the  sebaceous  glands,  in  which  the  cheeks  and 

^  Erichsen,  Surgert/,  vol.  Hi,  p.  5.57. 

^  The  following  account,  while  introduced  here  from  the  greater  frequency  of  lupus 
on  the  face,  is,  of  course,  equally  applicable  to  the  disease  elsewhere. 

^  Prof.  Volkmann  gives  the  following  graphic  description  of  this  form  :  Irregular, 
reddish-looking  patches  met  with  on  the  cheeks  and  nose,  often  covered  with  "  dirty 
looking,  thin  crusts,  which  are  distinctly  fatty  to  the  touch.  They  consist,  in  fact, 
of  nothing  further  than  an  excessive  secretion  from  the  sebaceous  glands  of  the  skin 
mixed  with  epidermal  cells.  When  we  have  succeeded,  with  great  difficulty,  in  scraping 
oif  this  fatty  layer  with  the  knife,  the  underlying  skin  appears  red,  sore,  and  as  if  studded 
with  fine  warts.  But  if  you  examine  these  warty  points  more  closely  with  a  glass,  j'ou 
see  that  it  is  by  no  means  a  question  of  papillary  elevations,  but  of  a  large  number  of  fine 
holes  which,  being  closely  adjacent  to  each  other,  pioduce  the  warty  appearance.  These 
holes  are  the  enlarged  openings  of  the  sebaceous  ducts,  and  j'ou  can  also  see  on  peeling  off 
single  fatty  crusts  how  a  fine  prolongation  of  the  latter  becomes  detached  from  each  small 
opening." 


388  OPERATIONS  ON  THE  HEAD  AND  NECK 

nose  are  so  rich,  and  gives  rise  to  an  increased  secretion  on  their  part. 
Of  the  following  modes  of  treatment  (1),  (2),  and  (7)  are  not  operative, 
but,  from  what  has  been  said  above,  it  has  been  thought  desirable  briefly 
to  mention  them.  Though  the  Finsen-light  treatment  has  been  attended 
with  such  remarkable  results  the  operative  methods  can  scarcely  yet  be 
said  to  be  obsolete. 

(1)  Finsen-Light  Treatment  of  Lupus.  This  mode  of  treatment,  originally 
introduced  by  Finsenof  Copenhagen  in  1901,  is  now  universally  admitted 
to  be  a  most  satisfactory  method  of  treating  lupus,  especially  when  the 
disease  attacks  the  face.  The  curative  effect  is  due  to  the  action  of  the 
ultra-violet  rays,  which  are  focu.ssed  on  the  affected  area  by  means  of 
quartz  lenses,  which  permit  these  rays  to  pass  freely.  Either  the  Finsen 
arc  lamp  or  the  Kromayer  mercury  lamp  may  be  used.  The  latter, 
though  shorter  sittings  are  required,  appears  to  be  more  micertain,  and  its 
use  is  not  unaccompanied  by  the  danger  of  severe  dermatitis  or  even 
burns. 

At  the  beginning  of  the  treatment  half-hour  sittings  are  sufficient. 
A  reaction,  with  much  erythema,  and  often  vesication,  follows  at  an 
interval  of  twelve  to  twenty-four  hours.  The  sittings  are  repeated  at 
intervals  of  a  week.  Later  on  the  duration  of  each  may  be  increased  to 
an  hour. 

The  advantages  of  the  method  are  :  (1)  The  resulting  scar  is  thin, 
supple,  and  pliable,  and  is  far  less  disfiguring  than  that  resulting  from 
other  forms  of  treatment.  (2)  Xo  anaesthetic  being  required,  it  is  easy, 
should  there  be  any  evidence  of  recurrence,  to  get  patients  to  again  sub- 
mit to  treatment.  (3)  The  treatment  is  comparatively  painless,  though 
for  the  other  side  of  this  question  reference  may  be  made  to  a  para- 
graph, "  The  Light  Treatment  of  Lupus  from  a  Patient's  Point  of  View."  ^ 

The  disadvantages  must  also  be  considered.  Even  at  the  present 
day  it  is  not  always  possible  for  patients  far  away  in  the  country  to  get 
to  one  of  these  centres  where  light  treatment,  "with  its  very  expensive 
plant,  and  especially  skilled  staff,  is  available.  When  they  are  able 
to  do  so,  the  long  time  required  for  the  treatment  is  an  important  question. 
Even  a  small  patch  will  require  treatment  by  many  sittings  spread  over 
weeks  or  months,  while  an  extensive  case  may  call  for  treatment  for 
one,  two.  or  more  years.  The  expenditure  of  much  time,  and  often  of 
money,  is  thus  called  for.  The  latter  was  strikingly  brought  to  the 
notice  of  the  present  WTiter  when  questioning  a  hospital  patient  who  had 
been  treated  for  a  long  time  for  extensive  lupus.  This  patient,  a  man 
of  the  labouring  class  who  lived  some  thirty  miles  out  of  London,  stated 
that  in  coming  up  for  treatment  he  had  in  all  spent  over  £75  in  railway 
fares.  And  with  lupus,  as  with  all  tuberculous  cases  treated  slowly,  there 
miLst  alwavs  be  the  risk  of  the  disease  spreading  at  one  spot  while  it  is 
being  dealt  with  at  another.  The  light  treatment  is  best  suited  to  cases  in 
which  the  patch  is  limited.  Where  the  disease  takes  the  form  of  diffuse 
spot-hke  nodules,  the  treatment  is  much  more  prolonged,  and  the  same 
may  be  said  of  cases  attended  with  much  scarring  from  previous  opera- 
tions. Lupus  of  the  mucous  membranes,  from  their  inaccessibility,  and 
the  rate  at  which  the  disease  spreads  in  cavities,  always  moist  and  warm 
and  of  low  bactericidal  power,  are  less  suitable  for  light  treatment.- 

1  Brit.  Med.  Journ.,  1902,  vol.  i,  p.  162. 

^  The  conjunctiva,  especially  about  the  inner  canthus.  is  a  region  occasionally 
affected,  and  one  which  requires  special  skill  in  the  necessary  technique. 


OPERATIVE  TREATMENT  OF  LUPUS  389 

In  such  cases  it  is  probably  best  that  light  and  operative  treatment 
should  be  combined. 

(2)  X-Ray  Treatment  of  Lupus.  This  method  of  treatment  is  especially 
indicated  when  there  is  much  ulceration.  Its  action  appears  to  be  less 
penetrating,  and  is  therefore  less  effective  than  the  Finsen  light.  It  is 
frequently  employed  in  conjunction  with  the  latter.  Under  the  action 
of  the  X-rays  the  ulcerated  surfaces  will  usually  (piickly  heal,  and  the 
Finsen  light  may  then  be  employed  to  complete  the  cure.  Most  of  the 
remarks  made  as  to  the  advantages  and  disadvantages  of  light  treat- 
ment also  apply  to  treatment  by  X-rays.  There  are,  however,  two 
additional  dangers  to  be  considered.  These  are  the  supervention  of 
dermatitis  and  of  epithelioma.  The  latter  serious  complication  is  by  no 
means  uncommon.     The  following  case  furnishes  an  excellent  example. 

Alice  L.,  aged  13  years,  was  admitted  to  Guy's  Hospital  in  July  1911  for  lupus 
of  tlie  buttock,  Iviiee  and  right  shoulder.  In  the  latter  situation,  in  the  centre  of  a 
large  patch  of  luj)us  which  was  cicatrizing,  there  was  an  ulcerated  area  with  a 
depressed  base  and  raised  everted  edges.  There  were  also  enlarged  glands  in  the 
right  axilla.  The  disease  appeared  when  she  was  2^  years  old  shortly  after  an  attack 
of  measles.  Six  years  before  admission  the  patches  were  scraped  but  the  disease 
recurred.  Since  then  she  had  light  and  X-ray  treatment :  owing  to  the  extent  of 
the  disease  a  very  large  number  of  sittings  were  required  extending  over  several 
years.  Under  this  treatment  the  patches  on  the  knee  and  buttock  healed  com- 
pletely and  the  shoulder  much  improved,  but  the  deep  ulceration  made  its  appear- 
ance a  few  weeks  before  admission.  The  growth  was  freely  excised  and  the  axillary 
glands  removed.  Histologically  the  former  was  an  epithelioma,  but  the  glands  were 
tuberculous.     The  patient  died  a  year  later  with  extensive  recurrences. 

(3)  Excision.  This  is  a  very  useful  method  for  patches  of  lupus  situated 
on  the  trunk  or  limbs.  For  the  face,  where  lupus  is  chiefly  met  with,  it 
is  more  rarely  applicable,  save  in  the  case  of  small  patches.  It  is  almost 
impossible  to  make  sure,  unless  by  cutting  more  widely  and  deeply  than 
is  permissible  here,^  that  the  incisions  lie  in  really  healthy  tissues.  It 
is  by  no  means  easy  to  get  away  satisfactorily  the  diseased  portion 
owing  to  their  friability  and  the  delicacy  of  the  subjacent  fat,  and  it  is 
only  by  cutting  very  widely  that  it  is  possible  to  make  sure  that  the 
infiltrated  area,  invisible  to  the  unaided  eye,  is  removed.  Hence  the 
frequency  with  which,  within  a  year,  minute  reappearances  are  seen.  It 
is  extremely  difficult  to  maintain  strict  asepsis  during  the  healing  of  wounds 
near  or  on  the  nose  or  lips — very  common  sites  of  the  disease  ;  and  the 
same  fact,  with  the  additional  one  that  it  is  not  always  possible  to  obtain 
a  level  surface  free  from  disturbance,  interferes  with  the  vitality  of  grafts 
in  this  region.  Such  wounds  are  likely  to  be  followed  by  tedious  healing 
largely  by  granulation,  and  scars,  often  prominent  and  keloid.  Later 
on,  when  the  incision  wound  is  healed,  small  red  spots  of  reappearance 
are  very  commonly  met  with  in  and  around  the  scars.  For  these  reasons 
excision  is  not  advised  here,  save  in  the  forehead,  where  the  laxity  of 
the  soft  parts  admits  of  the  free  use  of  the  knife.  If  used  with  the 
freedom  which  is  absolutely  requisite,  it  entails  needless  mutilation, 
especially  on  parts  like  the  nose  and  cheek.  It  will  be  said  that  covering 
the  fresh  wound  with  grafts  of  living  epidermis  will  prevent  any  con- 
traction and  deformity.     Theoretically  it  will,  but  practically  such  a 

^  Mr.  Bidwell,  in  the  discussion  at  the  Medical  Society  on  Mr.  Bruce  Clarke's  paper 
{Med.  Soc.  Trans.,  1893,  p.  298),  "recommended  that  in  long-standing  cases  the  sub- 
cutaneous fat  should  be  removed  in  addition  to  the  skin,  since  it  is  found  to  be  altered  in 
consistence  in  these  cases."  Every  surgeon  who  has  operated  much  on  lupus  will  agree 
with  this  advice,  but  its  result  on  the  face  in  producing  scars,  if  the  grafts  do  not  live,  is 
easily  to  be  foreseen. 


390  OPERATIONS  ON  THE  HEAD  AND  NECK 

result  is  by  no  means  certain  on  the  face,  especially  in  restless  children. 
Finally,  erasion,  if  careful  and  thorough,  and  followed  by  adequate 
scarification,  will  bring  about  quite  as  good  results,  and  with  much  less 
mutilation.  The  only  other  part  of  the  face  where  excision  may  be  widely 
carried  out  is  in  cases  of  extensive  lupus  of  the  lips.  Here  flaps  of  skin 
and  nuicous  membrane  may  be  turned  up  and  down,  and  a  long  inter- 
vening wedge  of  the  lupus-infiltrated  tissue  excised,  the  flaps  being 
united  by  horsehair  sutures.  When  the  wound  has  healed  it  will  be 
found  that  the  teeth  are  somewhat  unduly  exposed,  otherwise  excision 
here  gives  excellent  results.  And  where  long-standing  lupus  of  the  face 
has  extended  to  the  gums,  excision  should  be  used  freely.  Teeth  should  be 
extracted  beyond  the  limits  of  the  disease,  and  the  alveolar  process  should 
be  removed  with  a  gouge,  as  in  the  operation  for  epulis,  p.  419.  Owing 
to  the  freedom  with  which  the  diseased  parts  can  be  cut  away  here,  the 
result  is  a  speedy  and  permanent  cure.  The  skill  of  the  dental  surgeons 
of  the  present  day  will  prevent  any  resulting  disfigurement. 

Those  who  make  use  of  excision  must  cut  wide  of  the  disease,  and  well 
into  the  fat  beneath.  All  haemorrhage  must  be  thoroughly  stopped,  as, 
should  it  be  impossible  to  bring  the  edges  of  the  wound  together,  it  is 
well  to  apply  Thiersch's  grafts  immediately  to  obviate  the  contraction 
which  would  follow  if  the  wound  were  left  to  granulate  for  a  time,  and 
also  to  do  away  with  the  need  of  a  second  anaesthetic.  A  collodion 
gauze  dressing  is  more  secure  than  bandages. 

(4)  Erasion.  This  is  most  strongly  indicated  in  both  the  forms  of  lupus 
mentioned  on  p.  388.  Combined  with  scarification,  it  is  the  mode  of  treat- 
ment best  adapted  to  the  largest  number  of  cases.  The  best  instruments 
are  sharp  steel  spoons,  with  oval  ends  of  varying  size,  some  quite  small  ,- 
the  best  are  two  in  which  the  curette  and  pointed  scarifier  are  combined. 
Several  sizes  of  scoops,  down  to  very  small  ones,  are  most  essential.  One 
prolific  cause  of  the  reappearance  of  lupus  is  that  the  large  spoons  usually 
employed  miss  the  smaller  deposits  lurking  in  depressions  in  the  corium. 
Another  is  that  after  each  application  of  the  curette  this  or  whatever 
instrument  is  used  is  rarely  wiped,  thoroughly  cleaned,  and  placed  in 
some  sterilising  fluid  ;  thus,  of  course,  a  risk  is  present  of  carrying  in- 
fected tissues  into  those  which  are  sound.  This  precaution  is  often 
neglected.  An  anaesthetic  having  been  given,  the  surgeon,  using  first 
one  of  the  larger  spoons,  goes  with  deliberate  thoroughness  over  the  entire 
surface  of  the  patch  of  lupus,  using  the  spoon  from  below  upwards  ;  and 
if  there  are  several  patches,  e.g.  on  the  face,  he  begins  with  the  lowest, 
so  that  his  work  shall  not  be  obscured  by  haemorrhage.  With  the  spoon 
all  the  overlying  yellowish-red,  greasy  crusts,  all  the  surface  below  these 
that  the  spoon  finds  to  be  abnormally  soft,  i.e.  something  like  a  patch  of 
decay  in  an  apple  or  pear,  are  deliberately  and  thoroughly  scraped  away. 
The  bleeding,  which  is  usually  free,  is  now  stopped  by  firm  pressure.  The 
edge  of  the  sore  is  then  in  its  turn  attacked  in  the  same  way,  the  track  of 
the  spoon  being  next  smoothed  down  by  running  a  pair  of  scissors,  curved 
on  the  flat,  around  the  edge  of  the  patch.  The  surgeon,  now  that  the 
haemorrhage  is  arrested,  returns  to  the  surface  of  the  patch.  Any  sus- 
picious spots  are  scraped  again  with  a  smaller  curette.  There  need  be 
no  fear  of  doing  too  nmch  and  thus  causing  needless  scarring.  The 
deeper  layers  of  the  corium  are  naturally  tough  and  dense/  and  there  is 

^  As  pointed  out  by  Prof.  Volkmann  [loc.  supra  cit.,  p.  114),  in  cases  of  lupoid  ulcera- 
tion of  long  standing,  an  almost  fibroid  tissue  becomes  exposed  after  the  diseased  parts 


OPERATIVE  TREATMENT  OF  LUPUS  391 

no  danger  of  tlicii  yielding  to  the  si)oou,  the  acticjn  of  wliich  is  at  (;nce 
cliccked  when  the  operator,  by  tlie  change  in  the  sensation  of  resistance, 
is  aware  tliat  he  has  reached  healthy  tissues.  The  bleeding  having  been 
again  thoroughly  staunched,  minute  nests  may  often  be  found  lying  in 
pockets  amongst  the  meshes  of  the  cerium.  These  are  a  potent  source 
of  reappearance  of  lupus,  being  left  after  all  that  is  soft  and  friable  has 
been  scraped  away.  They  are  to  be  dug  out  with  small  spoons,  or 
destroyed  with  the  scarifier,  finely-pointed  sticks  of  silver  nitrate,  or  fine 
cautery.  While  the  bleeding  is  being  finally  staunched,  the  operator 
turns  his  attention  to  the  vicinity  of  the  lupus  patch  which  he  has  attaclced. 
Jhe  minutest  points,  specks,  and  nests  are  scrutinised  and  destroyed  with 
a  fine-pointed  cautery.  Where  the  nose  or  its  vicinity  is  affected;  the 
inner  aspect  of  the  orifices  should  be  inspected  in  case  the  mucous  mem- 
brane is  invaded.  Before  the  patient  is  allowed  to  come  round  from  the 
aniesthetic,  all  old  lupus  scars  arc  examined.  Any  deposits  in  them  are 
attacked  in  the  same  way,  or,  if  they  are  the  seat  of  a  diffuse  hypera)mia 
and  infiltration,  linear  scarification  (q.v.)  is  thoroughly  resorted  to. 

The  best  application  to  the  surfaces  left  by  erasion  has  been  nuich 
disputed.  Knowing  the  inveterate  tendency  of  the  disease  to  reappear 
in  minute  islets  overlooked  (many  of  them)  at  the  time  of  the  erasion, 
fine-pointed  sticks  of  nitrate  of  silver  should  be  applied  to  the  edge  and 
surface  of  each  erased  patch,  looking  out  especially  for  any  suspicious 
specks  or  nests  in  the  exposed  corium.  It  is  a  painful  remedy,  but  this 
objection  must  give  way  to  its  efficiency. 

Lotions  of  hyd.  perchlor.  (1  in  2000)  have  the  advantage  of  promoting 
asepsis,  and  of  a  germicide  power  which,  may  be  helpful  here  in  destroying 
the  bacillus  with  which  we  have  to  deal.  If  much  pain  be  present,  hot 
boracic  acid  fomentations  should  be  applied.  Powdered  nitrate  of  lead 
is  strongly  recommended  by  Messrs.  Ashby  and  Wright.^  "  The  repeated 
application  of  powdered  nitrate  of  lead  has  been  very  useful  in  our  hands, 
both  for  lupus  and  other  intractable  tuberculous  sores  ;  it  is  somewhat 
painful,  but  very  effective." 

To  two  other  points  in  the  after-treatment  attention  must  be  drawn. 
One,  the  need  of  keeping  the  wounds  clean  and  as  aseptic  as  possible.  It 
is  well  known  how  much  the  ravages  of  lupus  are  due  not  only  to  the  lupus 
itself,  but  also  to  the  presence  of  infecting  cocci,  this  being  especially  the 
case  on  a  part  like  the  face,  exposed  to  the  air,  particularly  in  regions  like 
the  nose  and  mouth.  The  second  point  is  that  as  the  wounds  granulate 
there  is  a  marked  tendency  to  scab-formation.  Nothing  can  be  more 
dangerous  than  the  advice  sometimes  given  to  leave  these  scabs  alone,  as 
the  wounds  will  heal  under  them.  They  should  be  regularly  removed 
daily,  and  some  such  application  as  equal  parts  of  carbolic  oil  and  com- 
pound tincture  of  benzoin  applied  to  the  surface  itself  of  the  sore  that 
remains  to  heal.  Any  prominent  granulations  should  be  sedulously 
shaved  down  with  scissors  curved  on  the  flat.  When  they  become  per- 
sistent, or  the  wound  stationary — and  this  is  certain — erasion  under  an 
anaesthetic  is  to  be  at  once  again  resorted  to.  As  in  all  tuberculous 
diseases  which  cannot  be  cured  by  one  operation,  the  need  of  repetition 
of  this,  the  necessity  of  prolonged  watching  and  after-attendance,  must  be 
clearly  accepted  by  the  patient  or  friends  before  treatment  is  commenced. 

have  been  scraped  off,  a  condition  which  is  to  be  regarded  as  the  expression  of  reaction 
in  the  neighbourhood. 

1  The  Diseases  of  Childhood,  p.  747. 


392  OPERATIONS  ON  THE  HEAD  AND  NECK 

(5)  Scarification.  This  is  only  useful  in  the  more  diffuse  forms,  and  as 
an  aid  to  erasion  ;  it  should  be  employed  in  two  ways. 

(a)  Linear.  With  a  fine  and  very  sharp  scalpel  the  surgeon  makes 
scores  of  fine  delicate  cuts,  parallel  vdth.  each  other,  through  the  diffuse 
lupoid  deposit,  crossing  these  again  mth  similar  delicate  incisions  at  a 
right  angle  to  the  first. ^  Each  incision  should  start  and  end  in  sound 
tissues,  the  knife  being  quickly  drawn  through  the  lupus  deposit.  The 
depth  to  which  the  blade  is  smik  varies  with  the  disease.  All  the  incisions 
must  be  made  quickly  and  with  a  light  hand,  and  care  must  be  taken,  as 
far  as  possible,  not  to  let  them  run  into  each  other.  The  bleeding  is 
extremely  free,  but  is  readily  arrested  by  carefully  maintained  pressure. 
To  save  time  an  assistant  keeps  up  pressure  on  one  patch,  while  the  sur- 
geon attacks  another. 

(6)  Punctiform.  Here  hundreds,  maybe,  of  punctures  are  made  in 
the  diffused  lupoid  deposit,  a  delicate  hand  being  again  required, 
and  a  fine  sharp  scalpel-point,  the  pointed  scarifier,  or  a  large  needle 
being  used.  In  this  case,  also,  every  pains  must  be  taken  to  place  the 
punctures  equidistantly.  After  arresting  the  bleeding,  the  surgeon  looks 
carefully  over  the  patch  ;  if  at  any  spots  his  incisions  or  punctures  are 
crowded  together,  with  intervening  places  but  little  touched,  he  again 
goes  over  the  ground  carefully. 

If,  after  the  completion  of  these  operations,  the  tissues  appear  tallowy 
or  whitish,  there  need  be  no  fear  of  gangrene,  the  parts  being  far  too  well 
supphed  with  blood.  The  object  of  scarification  is  of  course  to  obhterate 
the  lupoid  deposit  by  the  formation  of  scar-tissue.  It  is  also  very  useful 
when  a  scar,  though  not  again  ulcerating,  remains  obstinately  dark 
bluish-red.  Scarification  is  only  to  be  used  as  subsidiary  to  the  sharp 
spoon  or  other  methods,  especially  when  the  lupus  deposit  is  diffuse. 
Used  by  itself  as  a  means  of  cure,  it  is  tedious  and  brings  about  amehora- 
tion,  not  a  cure. 

An  anaesthetic  should  invariably  be  given.  Repetitions  are  usually 
required  in  severe  cases,  two  or  three  times  at  intervals  of  three  weeks  or 
more,  or  whenever  minute  reddish  specks  appear  and  grow. 

(6)  The  Actual  Cautery.  This  method  will  be  found  occasionally  useful 
in  conjmiction  with  erasion,  or  where  lupus  attacks  mucous  sm'faces, 
e.g.  the  palate,  cheek,  &c. 

In  such  cases,  the  patient  being  placed  on  one  side  near  the  edge  of 
the  table,  the  mouth  well  opened  in  a  good  fight,  all  granulating  or 
ulcerated  surfaces  are  first  thoroughly  curetted  with  a  sharp  spoon.  With 
the  blade  of  a  Paquelin's  cautery  these  sm'faces  are  then  repeatedly 
treated,  and  any  infiltrated  tissue  which  has  not  yet  broken  down,  and 
thus  resists  the  sharp  spoon,  thoroughly  destroyed.  Both  the  surface 
and  edges  of  the  lupus  patches  should  be  energetically  attacked,  the 
blade  being  kept  at  a  cherry-red  heat.  Care  must  be  taken  not  to  en- 
croach upon  the  orifice  of  Steno's  duct  or  to  approach  too  closely  the 
upper  apertm-e  of  the  larynx.  As  has  already  been  pointed  out,  another 
and  the  chief  use  of  the  cautery  is  to  destroy  minute  foci  reappearing  in 
scar-tissue  after  the  use  of  the  sharp  spoon  or  other  methods.  As  soon  as 
such  reddish  specks  appear  they  should  be  destroyed  by  the  prickers  or 

^  No  scarring  need  be  feared  from  either  form  of  scarification.  After  three  weeks  have 
elapsed,  the  above  incisions,  however  numerous,  if  done  with  proper  delicacy,  can  only 
be  detected  by  looking  for  them  very  closely.  In  three  months  it  usually  requires  a  lens 
to  find  them. 


OPERATIVE  TREATMENT  OF  RODENT  ULCER     393 

scarifiers  mentioned  above,  or,  failing  these,  by  a  fine-pointed  electric 
cautery. 

(7)  The  Application  of  Caustics  and  other  Chemicals.  This  is  decidedly 
inferior  to  the  methods  already  described.  'J'hey  are  apt  to  destroy 
portions  of  healthy  tissue,  and,  at  the  same  time,  to  leave  behind  many 
small  lupoid  nodules.  The  application  is  painful,  the  wounds  heal 
slowly,  and  the  resulting  scars  are  thick  and  conspicuous.  Silver  nitrate 
in  fine-pointed  sticks,  or  acid  nitrate  of  mercury  applied  on  fine  glass 
rods  are  best.  Salicylic  acid  mixed  with  glycerine  to  form  a  paste,  an 
ointment  containing  10  per  cent,  pyrogallic  acid,  or  a  paint  composed  of 
hydra rg.  })erchlor.  5j,  collodion  ad  §j,  are  also  recommended. 

General  Treatment.  This  is  also  of  importance.  It  must  be  remem- 
bered that  lupus  is  a  tuberculous  lesion,  and  though  no  drug  has  a  specific 
action,  the  general  health  must  be  attended  to.  Injections  of  tuberculin 
have  proved  rather  disappointing  ;  they  may,  however,  be  used  in  con- 
junction with  other  modes  of  treatment. 

The  following  hints  will  be  found  usefid  in  the  treatment  and  after- 
treatment  of  a  disease  which  is  second  to  none  in  its  frequency,  its  in- 
veteracy, its  power  of  disfigurement,  and  for  the  care  and  watchfulness 
required  in  its  eradication. 

(1)  Unsparing  thoroughness  is  to  be  employed,  especially  at  the  first 
time  of  operation  ;  there  should  be  no  hurrying  ;  haemorrhage  should 
be  completely  arrested,  and  the  minute  foci  spoken  of  above,  deep-lying 
as  well  as  superficial,  searched  for  in  a  good  light  and  energetically 
destroyed.  (2)  An  ansesthetic  should  be  given  each  time.  (3)  The 
very  great  probabihty  of  relapses  and  the  need  of  repetition  of  operations 
should  be  explained  to  the  patient  and  friends,  and  their  co-operation 
secured  from  the  first.  (4)  The  patients  are  to  be  kept  under  obser- 
vation for  a  long  time.  The  points  in  the  scars  which  at  once  call  for 
operative  steps  are  the  appearance  of  reddish  specks  or  nodules,  one  or 
more  scars  remaining  obstinately  dark  bluish-red  or  purple,  and  the  per- 
sistent appearance  of  scales  or  scabs.  (5)  As  in  all  tuberculous  af!ections, 
while  local  treatment  is  of  the  chief  importance,  the  general  health  must 
be  looked  to  and  every  possible  step  taken  to  improve  it,  more  especially 
by  nutritious  food  and  the  best  air  obtainable.  In  brief,  routine  after- 
treatment  should  be  as  carefully  carried  out  as  the  minutise  of  the 
technique  at  the  time  of  the  operation. 

OPERATIVE  TREATMENT  OF  RODENT  ULCER 

Rodent  ulcer  is  a  form  of  carcinoma  commencing  either  in  the  sebaceous 
glands  or  in  the  deepest  layer  of  epithelial  cells  of  the  skin.  It  may  be 
considered  here  on  account  of  the  frequency  with  which  it  occurs  on  the 
face.  Commencing  usually  as  a  small,  flat-topped  warty  growth,  its 
progress  is  very  slow.  Though  it  does  not  disseminate  or  involve  the 
lymphatic  glands,  it  eventuall}''  extends  deeply  beneath  the  skin  and 
causes  extensive  destruction  of  soft  parts,  and  even  of  bone.  Needless 
to  say,  it  is  desirable  that  cases  should  be  treated  and  cured  before  this 
deep  ulceration  has  taken  place.  The  disease  occurs  in  middle-aged  or 
elderly  people,  and  as  it  is  not  accompanied  by  pain  or  other  inconvenience 
it  is  often  allowed  to  make  considerable  progress  before  advice  is  sought. 

It  is  now  known  that  non-operative  treatment  by  X-rays  or  radium 
will  in  many  cases  effect  a  cure.     In  deciding  whether  to  recommend  this, 


394  OPERATIONS  ON  THE  HEAD  AND  NECK 

or  operative  treatment,  the  following  points  have  to  be  considered  : 
(a)  The  age  and  general  condition  of  the  patient,  (b)  The  position  of  the 
growth.  Treatment  is  often  complicated  by  its  proximity  to  the  eye- 
ball or  the  nose,  (c)  The  presence  or  absence  of  ulceration,  (d)  The 
involvement  of  deep  parts,  such  as  cartilage,  bone,   &c. 

The  various  modes  of  treatment  will  first  be  considered,  and  then  the 
indications  for  selecting  each  particular  form. 

(1)  Excision.  In  many  cases,  especially  where  the  disease  is  not  very 
extensive,  this  is  the  best  mode  of  treatment.  In  such  cases,  provided 
that  the  growth  is  widely  removed,  there  will  be  no  recurrence.  In  this 
form  of  mahgnant  disease,  owing  to  its  extremely  slow  progress,  its  long 
connection  with  some  flat-topped  wart,  patients  sometimes  keep  on  de- 
ferring the  operation  till  their  age  and  the  extent  or  situation  of  the  ulcer 
cause  some  difficulty  in  ad\"ising  or  urging  an  operation.  In  some  of 
these  cases  X-ray  or  radium  treatment  may  be  tried,  while  in  others  dia- 
thermy will  offer  the  best  prospect  of  a  cure. 

The  Operation  Itself.  In  the  case  of  small  wart-hke  growths  with  but 
little  ulceration  and  no  extension  to  the  deep  tissues,  the  operation  is 
simple.  An  oval  incision  is  made,  care  being  taken  that  this  is  at  least 
a  quarter  of  an  inch  from  the  growth.  *  It  must  extend  deeply  down  to 
the  deep  fascia  or  into  the  muscle.  The  isolated  area  of  skin  containing 
the  disease  is  now  seized  "uith  toothed  dissecting  forceps  and  is  removed, 
together  with  the  underlying  subcutaneous  tissue.  The  margins  of  the 
incision  are  then  brought  together  with  a  few  salmon-gut  sutures.  If  this 
is  impracticable  the  wound  must  be  allowed  to  heal  by  granulation. 

The  following  hints  may  be  fomid  useful  in  a  more  extensive  opera- 
tion : 

(Ij  To  diminish  the  risk  of  suppuration  or  of  erysipelas  the  parts 
should  be  carefully  cleaned  and  kept  as  aseptic  as  possible. 

(2)  Steps  of  the  operation  itself.  The  surgeon  first  makes  a  groove- 
like incision  around  the  whole,  or,  in  a  very  extensive  case,  around  part 
of  the  growth^  and  well  wide  of  it.  and  arrests  the  bleeding  by  ligature, 
by  Spencer- Wells  forceps,  or  by  sponge  pressure.  The  next  step — that  of 
removing  the  affected  soft  parts — is  often  difficult,  owing  to  their  prone- 
ness  to  break  away,  and  thus  gi^^ng  no  firm  hold  to  forceps.  Scraping 
alone  is  not  to  be  trusted,  the  base  of  the  ulcer  must  be  everywhere 
excised.  When  the  growth  has  extended  to  bone,  the  worm-eaten  surface 
must  be  freely  removed  with  the  gouge  or  chisel.  In  one  region  especially 
these  must  be  used  with  the  greatest  caution,  i.e.  where  the  paper-fike 
bones  on  the  inner  wall  of  the  orbit  are  involved  ;  in  this  place,  if  the 
surgeon  is  not  satisfied  with  the  limited  use  of  the  gouge  or  chisel,  which  is 
alone  permissible  here,  he  must  be  content  with  finally  applying  Paquelin's 
thermo-cautery.-  In  other  places  zinc  chloride  paste  may  be  fearlessly 
employed,  as  long  as  precautions  be  taken  to  apply  it  in  a  thick  paste  and 
as  little  of  it  as  possible,  so  that  the  discharges  from  the  wound  shall  not 
allow  it  to  liquefy  and  run  either  towards  the  eye  or  nose  or  throat. 

(3)  Question  of  Removing  the  Eye  in  cases  where  the  Conjunctiva  is 
involved.  As  a  rule  consent  should  be  obtained  when  it  is  thought  that 
this  step  may  be  needful.     Cases  clearly  requiring  it  will  be  those  where, 

^  In  .such  cases  complete  excision  will  probably  not  be  possible.  Diathermy  (q.v.) 
is  likely  to  be  aseful. 

^  In  this  situation  there  is  a  possibility  of  damage  to  the  eyeball  if  the  high  frequency 
current  is  emploj-ed. 


OPERATIVE  TREATMENT  OF  RODENT  ULCER    395 

{(i)  the  eye  is  already  useless  or  so  distinctly  deteriorated  that  it  cannot 
improve  ;  (b)  where  the  lids  have  shrunk  away  from  it,  and  left  it  irrit- 
able and  painful  from  exposure  ;  (c)  where  the  disease  cannot  otherwise 
be  removed  or  eradicated. 

The  After-Treatment.  ( I )  The  chief  object  here  is  to  keep  the  wound 
scrupulously  aseptic.  Should  suppuration  threaten,  the  wound  should  be 
gently  packed  with  aseptic  gauze,  and  over  this  a  boracic  fomentation 
applied  and  renewed  at  frequent  intervals.  If  caustics  or  the  high 
frequency  electric  current  have  been  employed,  morphia  may  be  required 
for  the  first  day  or  two.     The  bowels  must  be  kept  acting  regularly. 

(2)  Secondary  Hcemorrhage.  This  is  rare,  but  it  may  occur  when  the 
sloughs  separate  if  caustics  or  any  form  of  cautery  have  been  used. 

(3)  Reappearance.  The  patient  must  always  be  most  carefully  watched, 
and,  in  the  case  of  extensive  and  deep  disease,  any  suspicious  granulations, 
or,  at  a  later  date,  induration  of  the  scar,  that  appear,  must  be  attacked 
at  once.  (4)  After  a  severe  operation,  when  there  is  much  deformity,  a 
plastic  operation — e.g.  the  bringing  down  of  a  flap  from  the  forehead, 
where  this  is  possible — should  be  performed  ;  and,  this  faiUng,  much  may 
be  done  by  a  well-made  vulcanite  or  other  artificial  mask  or  obturator. 

(2)  X-Ray  Treatment  of  Rodent  Ulcer.  Much  of  what  has  been  said 
about  the  light  treatment  of  lupus  is  also  applicable  here.  In  many  cases 
the  disease  healsfairly  rapidly  with  X-ray  treatment  but  recurrences  are, 
very  frequent.  The  patient  will  therefore  have  to  be  kept  under  observa- 
tion, and  any  suspicious  induration  or  recurrent  ulceration  again  receive 
attention.  The  most  suitable  cases  are  the  superficial  ulcers,  even 
when  these  are  of  considerable  extent.  Where  there  is  much  deposit 
about  the  edge  and  base,  the  outlook  is  less  favourable,  and  the  time 
required  will  certainly  be  much  longer.  In  the  later  stages  of  the  disease, 
when  the  deep  tissues  are  involved,  X-rays  are  often  ineffective.  In 
any  case  if  no  benefit  results,  the  treatment  should  not  be  persisted 
w^th,  but  some  other  method  should  be  employed.  It  is  always  advis- 
able to  continue  the  X-ray  treatment  for  some  little  time  after  the  ulcer 
has  apparently  healed  in  order  to  guard  against  recurrence.  Cases  in 
which  X-ray  treatment  should  be  employed  may  be  grouped  as  follows  : 
(a)  Cases  of  superficial  ulceration  or  of  the  warty  growth  which  precedes 
ulceration,  especially  when  the  growth  is  situated  near  the  eyehds  or  in 
some  other  situation  which  renders  excision  midesirable.  (6)  Cases 
where  Steno's  duct  or  the  facial  nerve  are  involved,  (c)  In  old  people  in 
whom  operation  is  not  considered  ad\'isable.  {d)  In  some  advanced  cases, 
as  a  palliative  measure,  and  in  the  hope  of  relieving  the  pain. 

The  resulting  scar  is  usually  supple  and  inconspicuous,  but  the 
resulting  deformity  will,  of  course,  depend  upon  the  extent  of  the  disease. 
Finsen  light  is  much  less  effective  than  the  X-rays  and  is  but  seldom 
employed. 

(3)  Curetting.  This  form  of  treatment  should  not  be  employed  except 
in  conjunction  ^^'ith  other  methods,  especially  with  excision,  and  when  it 
is  intended  to  destroy  the  growth  with  the  help  of  the  high-frequency 
current  (vide  infra).  The  use  of  caustics,  too,  has  been  practically 
superseded  by  more  modern  methods  of  treatment,  though  chloride  of 
zinc  paste  is  a  valuable  local  application. 

(4)  Freezing  by  the  application  of  solid  COj  is  sometimes  used  as  an  aid 
to  other  methods  of  treatment. 

lonisation  is  sometimes  employed  in  the  early  stages.     Zinc  sulphate 


396  OPERATIONS  ON  THE  HEAD  AND  NECK 

or  chloride  are  the  salts  usually  employed.     For  full  information  about  this 
method  a  special  work  should  be  consulted. 

(5)  Radium  Treatment  of  Rodent  Ulcer.  This,  on  the  whole,  is  more 
satisfactory  than  X-ray  treatment.  In  the  early  cases  there  is  less  likeli- 
hood of  recurrence,  and  when  there  is  deep  ulceration  radium  is  more 
likely  to  be  successful  in  arresting  the  progress  of  the  disease.  The  two 
modes  of  treatment  may  be  combined  in  the  same  patient.  In  some 
cases,  usually  far  advanced,  neither  X-rays  nor  radium  has  much  effect, 
and  the  disease  steadily  progresses  in  spite  of  all  treatment.  It  is  in 
these  cases  that  diathermy  (q.v.)  is  especially  indicated. 

(6)  Fulguration  and  Diathermy.^  It  -vvill  be  convenient  to  mention  here  the 
attempts  which  have  been  made  to  destroy  and  eradicate  new  growths  by  the  use 
of  the  liigh  frequency  electric  current,  especially  in  cases  where  the  situation,  the 
extent,  or  the  relations  of  the  growth  render  its  complete  removal  by  ordinary 
surgical  means  impossible.  Fulguration  was  introduced  by  Keating-Hart,  of 
Marseilles,  in  1906.  The  growth  is  first  removed  as  completely  as  possible  by  the 
knife,  scissors,  and  curette,  and  then  the  electrode  is  applied  to  the  surroimding 
tissues  which  are  suspected  to  still  be  infiltrated  by  the  growth. 

In  fulguration  the  ordinary  high-frequency  apj^aratus  is  used  and  is  so  timed 
that  a  spark  three  inches  in  length  is  given  off  from  the  electrode  connected  with 
the  top  of  the  resonator.  This  electrode  is  merely  a  -vvire  fixed  in  an  insulated 
handle,  and  the  spark  from  it  is  directed  over  the  surface  of  the  wound,  from  which 
all  haemorrhage  should  be  stopped  as  it  is  impossible  to  spark  on  to  a  fluid.  This 
operation  lasts  for  ten  to  twenty  minutes  and  no  change  visible  to  the  eye  is  pro- 
duced. Every  portion  of  the  wound  must  be  systematically  treated,  and  it  is 
essential  that  the  length  of  the  spark  should  not  be  less  than  three  inches.  If  the 
operation  can  be  repeated  once  or  twice  at  intervals  of  two  or  three  days  the  result 
is  more  likely  to  be  successful  and  there  is  no  likelihood  of  caasing  harm  by  over- 
doing the  treatment. 

In  diathermy  the  same  apparatus  is  employed,  but  instead  of  taking  the  current 
from  the  top  of  the  resonator  two  electrodes  are  connected  with  the  outer  coats  of 
the  condensers.  The  resonator  is  timed  so  that  a  short  dense  hot  spark  is  produced. 
If  the  two  electrodes  are  placed  in  contact  with  the  patient  a  continuous  line  of 
heat  is  produced  between  them,  and  if  one  is  small  and  the  other  large  the  high 
temperature  is  at  the  former.  Hence  the  large  electrode  represented  by  a  large 
sheet  of  metal  is  placed  in  contact  with  the  patient's  back  and  the  small  one  is 
applied  to  the  wound.  This  effect  is  produced  much  more  conveniently  and  easily 
by  the  various  diathermy  machines  now  made.  If  the  temperature  is  raised 
sufficiently  a  zone  of  coagulation  is  produced  around  the  smaller  electrode. 

The  surgical  measures  should,  if  possible,  be  the  same  as  those  used  before 
fulguration,  but  the  need  for  complete  removal  is  less  as  the  extent  of  destruction  of 
tissue  that  can  be  produced  is  unlimited.  The  whole  diseased  surface  is  systemati- 
cally treated,  care  being  taken  that  the  electrode  does  not  remain  in  contact  Tvath 
any  one  spot  for  an  midue  length  of  time.  As  a  general  rule  it  is  better  to  stop 
short  of  actual  coagulation,  especially  whtn  important  structures  are  in  close 
proximity.  This  treatment,  like  fulguration,  immediately  follows  the  surgical 
treatment,  and,  as  a  rule,  takes  about  five  minutes. 

The  effect  of  diathermy  is  to  produce  a  cauterisation  and  coagulation  of  the 
tissues.  It  differs  from  the  ordinary  cautery  in  that  the  superficial  action  is  far  less  but 
thatthe  penetration  of  the  coagulation  is  remarkably  deep.  Morbid  cells  and  structures 
seem  to  be  much  more  readily  destroyed  than  normal  tissues.  The  mode  of  action  of 
fulguration  is  more  micertain,  especially  as,  with  this  method,  there  is  no  cauterisation 
or  coagulation.  Dr.  C.  E.  Iredell  and  Mr.  Turner  have  tried  fulguration  and  dia- 
thermy in  a  number  of  cases  of  malignant  disease  (epithelioma,  carcinoma,  and 
sarcoma),  mostly  in  a  very  advanced  condition,  rodent  uleer,  especially  in  advanced 
cases  where  other  modes  of  treatment  have  failed,  and  in  one  case  of  very  advanced 
tuberculous  glands  in  the  neck  with  many  sinuses.  Though  not  obtaining  the 
results  obtained  by  Keating-Hart,  Juge,  and  others,  it  would  certainly  seem  from 
the  results  obtained  in  these  cases  that  the  high-frequency  current  does  have  a  very 
considerable  local  action  in  destroying  the  growiih.  Diathermy  is  certainly  much 
more  effective,  especially  where  obvious  masses  of  growth  remain  after  the  pre- 
^  These  notes  have  been  supplied  by  Dr.  C.  E.  Iredell. 


REMOVAL  OF  PAROTID  GROWTHS  897 

li miliary  surgical  treatment.  In  many  cases  of  malignant  disease  where  the  treat- 
ment of  the  local  condition  was  attended  with  success,  a  fatal  result  followed  from 
secondary  deposits  in  glands  or  viscera.  Hence  these  methods  of  treatment  arc 
only  likely  to  be  attended  with  complete  success  in  the  case  of  extensive  localised 
new  growths  without  any  secondary  d -posits.  This  is  unlikely  to  be  the  case  with 
epithelioma  and  carcinoma,  but  this  is  the  condition  met  with  in  advanced  cases  of 
rodent  ulcer.  Diathermy  can  be  strongly  recommended  here  as  shown  by  the 
following  case  :  * 

Walter  M.,  aged  aG,  was  admitted  to  hospital  in  1910  under  Mr.  Turner  for  a 
large  rodent  ulcer  which  had  perforated  the  right  cheek  from  the  angle  of  the  mouth 
to  the  anterior  border  of  the  mas.seter,  and  liad  also  invaded  the  muco-periosteum 
of  both  the  superior  and  the  inferior  maxilla".  The  disease  appeared  nineteen  years 
before  in  the  form  of  a  pimple  ;  ulceration  had  been  present  for  five  years.  In 
1907,  as  the  result  of  X-ray  treatment,  the  ulcer  cicatrised.  About  a  year  before 
admission  the  scar  broke  down  and  ulceration  rapidly  extended.  Radium  and 
X-ray  treatment  were  tried  for  six  months  without  benefit.  At  the  operation  the 
surface  of  the  ulcer  was  curetted  wht-n  a  backward  extension  in  the  soft  parts  of  the 
check  beneath  the  masseter  w'as  found.  The  curetting  was  followed  by  an  applica- 
tion of  diathermy  by  Dr.  Iredell.  After  ten  days  a  number  of  superficial  sloughs 
separated,  leaving  a  healthy  granulating  surface.  A  sequestrum  also  separated 
from  the  superior  maxilla,  leaving  a  large  opening  into  the  antrum.  The  ulcer 
completely  healed  in  about  three  months,  the  gap  in  the  cheek  being  closed  by  an 
obturator  suggested  by  Mr.  F.  J.  Pearce.  A  year  later  a  small  recurrence  about 
the  size  of  a  pea  was  excised,  and  the  patient  has  since  remained  well. 

The  case  of  tuberculous  glands  treated  by  diathermy  was  remarkably  successful, 
all  the  sinuses  healing  firmly  and  remaining  somid  after  three  years.  The  resulting 
scar  after  both  fulguration  and  diathermy  is  surprisingly  supple,  and  the  deformity 
is  much  less  than  after  application  of  the  actual  cautery. 

REMOVAL  OF  PAROTID  GROWTHS 

The  question  of  operation  arises  here  under  three  somewhat  different 
conditions,  viz.  : 

(i)  In  the  case  of  ordinary  parotid  growth. 

(ii)  In  that  of  a  sarcoma  of  the  parotid,  which  has  often  started  in  the 
growth  just  mentioned. 

(iii)  In  carcinoma  of  the  parotid. 

(i)  Removal  of  an  Ordinary  Parotid  Growth.  These  well-known 
growths,  containing  a  mixture  usually  of  fibro-cartilaginous,  myoxoma- 
tous,  and  imperfect  glandular  tissue,  require  no  special  allusion  here, 
beyond  the  need  of  :  (1)  Exposing  them  sufficiently  ;  (2)  paying  strict 
attention  to  the  facial  nerve  ;  and  (3)  removing  the  capsule  itself,  after 
the  growth  has  been  shelled  out,  in  any  case  of  doubt — \\z.  soft  consis- 
tency, or  rapid  growth. ^  (4)  Watching  the  After-Result.  This  must  be 
insisted  upon,  owing  to  the  view  recently  held  that  these  growths  often 
originate  in  endothelial,  not  connective,  tissue  elements  :  in  other  words, 
that  they  are  endotheliomata.     If  so,  recurrence  is  always  possible. 

(ii)  Operation  in  Sarcoma  of  the  Parotid.  This  disease  usually  begins 
in  one  of  the  growths  just  mentioned  ;    and  here  the  malignant  change 

1  Proc.  Roi/.  Soc.  Med.,  Clin.  Sec.  vol.  v,  1912,  p.  95. 

^  On  the  Enchondromata  of  the  Salivary  Glands  by  W.  H.  A.  Jacobson  (Guy's  Hospital 
Reports,  vol.  xxvi)  :  "  If  the  wound  be  made  too  small  in  the  first  case  for  fear  of  a 
scar,  the  edges  will  only  be  bruised,  and  primary  union  prevented.  It  is  not  uncommon  for 
branches  of  the  facial  nerve  to  be  in  relation  with  the  capsule  of  the  growi;h,  and  if  this 
has  been  much  handled,  or  treated  bj'  counter  irritation,  they  may  very  likely  be  firmly 
adherent.  In  either  case  injury  to  the  nerve  may  be  best  avoided  by  slitting  up  the 
capsule  and  shelling  out  the  enchondroma  first.  The  capsule  should  then  be  examined 
to  see  if  any  nerve  branches  are  adherent  to  it ;  after  these  have  been  separated,  the 
capsule  itself  should  be  removed.  This  should  always  be  done  to  prevent  any  recurrence, 
as  the  peripheral  part  of  these  enchondromata  is  often  adherent  to  the  capsule  itself." 


.398  OPERATIONS  ON  THE  HEAD  AND  NECK 

is  often  sudden  and  rapid,  after  a  long  benign  period.  This  and  the  next 
group  may,  as  far  as  operation  is  concerned,  be  considered  together. 

(iii)  Operation  in  Carcinoma  of  the  Parotid.  The  question  of  the 
advisabihty  of  interfering  at  all  with  really  malignant  growths  of  the 
parotid,  especially  carcinomata,  has  been  much  disputed,  but  as  each 
case  must  be  decided  by  itself,  and  as  no  hard-and-fast  hue  can  be  laid 
down  here,  some  useful  practical  points  may  be  mentioned.  Attention 
must  be  strongly  drawn  to  the  fact  that  reports  of  operations  are  often 
brief,  and  that  too  often  they  are  published  as  soon  as  the  patient  leaves 
his  surgeon,  and  thus  two-thirds  of  their  value  are  lost.  There  is  scarcely 
any  part  of  the  body  in  which  a  malignant  growth  so  quickly  obtains  a 
firm  hold  on  the  surrounding  structures — a  fact  which  has  even  a  graver 
bearing  on  the  operation  than  the  importance  of  these  structures  them- 
selves. 

A  case  of  carcinoma  of  the  parotid,  successfully  removed,  in  a  woman 
of  72,  is  recorded.^ 

At  one  spot  the  skin  was  adherent  and  ulcerated.  The  entire  gland  was 
extirpated,  together  with  the  affected  skin,  extending  up  as  far  as  the  temporal 
region.  It  was  found  needful  to  tie  the  external  carotid,  and  the  facial  nerve  was 
also  necessarily  sacrificed.  The  upper  part  of  the  sterno-mastoid,  being  infiltrated, 
was  removed.     The  patient  was  well  eight  months  later. 

PRACTICAL  POINTS  IN  THE  REMOVAL  OF  PAROTID  GROWTHS 

Characters  of  the  Growth.     Amongst  the  most  notable  of  these  are  : 

(1)  Mobility,  viz.  how  far  it  can  or  cannot  be  hfted  up  by  the  fingers 
from  the  subjacent  parts. 

(2)  Rapidity  of  groivth. 

(3)  Density.  Thus  a  great  hardness  or  softness  will  be  alike  un- 
favourable, the  latter  from  the  fact  that  such  soft  growths  will  break 
down  during  attempts  at  removal,  and  leave  a  part  behind. 

(4)  Symptoms  of  pressure,  especially  of  deep  pressure  upon  the 
pharynx.  Of  these,  dyspnoea,  dysphagia,  presence  of  outlying  masses  in 
the  fauces,  alterations  in  speech  and  in  hearing,  and  to  a  somewhat  less 
degree  facial  paralysis,^  are  of  evil  omen. 

(5)  Conditions  of  the  overlying  skin.^ 

(6)  Involvement  of  the  upper  part  of  the  sterno-mastoid,  sometimes 
giving  the  appearance  of  torticolhs. 

(7)  The  presence  of  infiltrated  glands,  especially  if  these  involve  the 
large  vessels  and  nerves  of  the  neck. 

Points  in  the  Operation  Itself.  To  begin  ^^•ith,  the  growth  must  be 
sufficiently  exposed  by  adequate  incisions.  Probably  none  will  be  more 
generally  suitable  than  a  |-  -shaped  incision,  the  vertical  portion  lying 
over  the  larger  vessels,  and  the  transverse  one  lying  parallel  ^^'ith  the 
zygoma  and  exposing  the  facial  part  of  the  growth  and  its  accessory 
portion. 

If  the  skin  is  adherent  at  any  spot  this  should  be  included.  The 
flaps  are  freely  dissected  back,  covered  with  sterile  gauze,  and  the  haemor- 

^  Amer.  Journ.  Med.  Sci.,  189.3,  vol.  cv,  p.  144. 

2  Prof.  Billroth,  quoted  by  Mr.  Butlin  {loc.  infra  cH.,  p.  118),  considers  that  facial 
paralysis  from  the  pressure  of  a  parotid  growth  is  a  sign  that  this  is  probably  a  carcinoma, 
for  the  sarcomata  and  other  tumours  rarely  produce  paralysis  by  pressure,  although 
paralysis  frequently  follows  operation  for  their  removal. 

*  The  more  adherent,  discoloured — viz.  reddish-purple — are  the  integuments,  the 
more  unfavourable  is  the  prognosis. 


KEIMOVAL  OF  PAROTID  (illOWTIIS  399 

rhage,  which  is  often  free,  even  at  this  early  stage,  entirely  arrested.  The 
surface  of  the  growth,  in  its  capsule,  if  one  be  present,  having  been  com- 
pletely exposed,  extirpation  is  begun  below  and  behind,  not  from  above 
downwards.  This  course  allows  of  securing  the  external  carotid  or  of  put- 
ting a  temporary  ligature  on  the  common  carotul (vide infra),  and  further, 
as  pointed  out  by  M.  Jierard :  ^  (1)  The  blood  flows  away  from  the  wound, 
and  not  over  the  instruments  of  the  surgeon.  (2)  The  same  vessels  do  not 
need  to  be  tied  more  than  once.  Next,  the  growth  is  freed  at  the  sides 
and  above.  This  step  is  comparatively  easy  over  the  parotid,  but 
adhesions  to  or  infiltration  of  the  sterno-mastoid  will  be  difficult  to  deal 
with.  There  should  be  no  hesitation  in  removing  the  upper  part  of 
the  nuiscle.  Every  vessel  is  carefully  secured,  and  oozing  is  checked  by 
firm  pressure  while  the  surgeon  is  engaged  with  some  other  part  of  the 
growth.  Gradually,  as  the  growth  is  pulled  in  different  directions  and 
freed  by  blunt  dissection — a  strong  pair  of  blunt-pointed  curved  scissors, 
used  both  closed  and  opened,  will  be  found  very  useful — the  growth 
comes  forward  more  and  more,  and  is  finally  only  attached  above  the 
styloid  process  and  pharynx.  Here  any  bands  of  fascia,  or  what  looks 
like  fascia,  must  be  carefully  examined  and  ligatured  if  needful  ;  the 
upper  part  of  the  external  carotid  or  its  terminal  branches  must  be  found 
and  ligatured  if  possible,  before  they  are  divided.  There  must  be  no 
hurrying  at  this  stage,  and  the  wound  must  be  bloodless  while  any  deep 
dissection  is  going  on. 

In  addition  to  the  free  oozing,  and  the  presence  of  important  vessels. 
other  difficulties  which  may  present  themselves  are  the  breaking  down 
of  a  soft  growth,  thus  baffling  attempts  at  complete  extirpation,  and  the 
strong  processes  of  fibrous  tissue  which,  passing  normally  from  the  parotid 
to  some  important  adjacent  structures — viz.  the  digastric,  the  internal 
pterygoid,  and  the  carotid  sheath^ — are  now  liable  to  be  either  increased 
in  density,  or  softened  by  extension  of  the  growth.  Where  the  surgeon 
is  uncertain  as  to  complete  extirpation,  diathermy  (q.v.)  is  especially 
likely  to  be  useful,  and  in  these  and  similar  cases  where  the  complete 
extirpation  of  the  deeper  parts  of  the  growth  is  doubtful,  arrangements 
should  be  made  beforehand  to  have  the  necessary  apparatus  and  assistance 
at  hand,  in  case  the  need  of  employing  them  should  arise.  Should  the 
apparatus  not  be  available  the  actual  cautery,  zinc  chloride  paste,  or 
sulphur  may  be  tried.  If  any  bleeding  persist  low  down,  Spencer-Wells 
forceps  should  be  left  on  for  thirty-six  hours.  Drainage  from  the  deepest 
part  of  the  wound  is  always  to  be  employed.  Two  points  require  special 
attention  here — viz.  the  amount  of  facial  paralysis  which  may  be  ex- 
pected,^ and  the  haemorrhage. 

Facial  Paralysis.  While  in  the  case  of  a  smaller  growth,  if  the  nerve 
has  only  been  bruised,  or,  when  divided,  if  the  ends  have  been  placed  in 
contiguity,  union  may  take  place,  and  the  paralysis  gradually  disappear,^ 
in  the  case  of  really  malignant  growths  the  question  of  future  deformity 
must  be  set  aside,  and  the  nerve  divided  as  soon  as  seen. 

1  Maladies  de  la  Glande  Parotide,  p.  240. 

^  If  the  surgeon,  especially  in  less  serious  cases,  when  making  any  deep  incision  that 
is  needful,  can  manage  not  to  go  above  the  level  of  a  line  drawn  horizontally  three- 
quarters  of  an  inch  below  the  lobule  of  the  ear,  he  will  avoid  any  serious  interference 
with  the  trunk  of  the  facial  nerve,  and  thus  escape  the  risk  of  permanent  paralysis. 

*  This  gradual  improvement  is  alluded  to,  with  a  case  in  point,  in  Mr.  Jacobson's  article, 
loc.  supra  cit.  Mr.  Butlin  (Operative  Treatment  of  Malignant  Disease,  p.  120)  suggests 
nerve  suture. 


400  OPERATIONS  ON  THE  HEAD  AND  NECK 

Best  Modes  of  meeting  Haemorrhage.  The  chief  vessels  which  will  be 
met  with  are  the  superficial  temporal,  transverse  facial,  occipital,  posterior 
auricular,  internal  maxillary,  and  external  carotid.  The  external  jugular 
vein  and  the  large  communicating  branches  between  it  and  the  internal 
jugular  are  sure  to  be  cut,  while  the  internal  jugular  vein  is  almost  certain 
to  be  seen  in  the  bottom  of  the  wound. 

It  must  be  remembered  that  not  only  will  all  the  above  vessels  be 
liable  to  be  much  enlarged,  but  numerous  other  unnamed  anastomoses 
will  be  present. 

The  common  carotid  has  several  times  been  tied  prior  to  this  opera- 
tion. Ligature  of  the  external  carotid,  with  all  the  accessible  branches, 
is  greatly  to  be  preferred  {q.v.).  If  hgature  of  the  common  carotid 
is  to  be  made  use  of  here,  it  should  be  reserved  for  those  cases  in  which 
the  surgeon  decides  to  attack  a  very  soft  and  vascular  growth,  as  here 
the  vessels  may  be  very  numerous  and  difficult  to  isolate,  and  hgatures 
may  not  hold.  In  such  a  case,  instead  of  tying  the  common  carotid 
and  thus  exposing  the  patient  to  the  risks  of  brain  mischief,  it  would 
be  better  to  pass  a  loop  of  chromic  catgut  ligature  around  the  vessel, 
loosely  tied,  and  to  ask  an  assistant  to  keep  up  tension  on  this  whenever 
bleeding  takes  place.  This  method  seems  to  have  been  first  used  by 
M.  Roux,  and  later  by  Mr.  Rivington  ^  and  Sir  F.  Treves. ^  [See  section 
on  "  Ligature  of  the  Common  Carotid.") 

In  dealing  with  any  large  veins,  the  risk  of  the  entrance  of  air  should 
be  prevented  by  malcing  finger-pressure  on  the  cardiac  side,  or  by  securing 
them  with  double  ligatm*es  before  they  are  cut. 

If  the  wound  has  become  infected — and  sometimes  in  these  operations 
near  the  mouth  and  nose  it  is  impossible  to  keep  the  bandages  from 
shifting — the  surgeon  must  always  be  prepared  for  the  accident  of  secon- 
dary haemorrhage.  And  on  account  of  the  same  risk  the  actual  cautery 
should  never  be  used  at  the  bottom  of  a  very  deep  wound  near  to  any  sus- 
picious tissues,  if  it  can  possibly  be  avoided. 

OPERATIVE  TREATMENT  OF  N^VI  ^ 

The  first  question  which  usually  arises  is  whether  these  growths 
should  be  operated  on  at  all,  or  whether  they  may  be  safely  left  to  them- 
selves. While  there  is  a  distinct  tendency  for  nsevi,  after  a  longer  or 
shorter  time,  to  undergo  a  fibroid  change,  sj)ontaneous  disappearance  is 
too  rare  to  be  confidently  reckoned  upon.  In  private  practice,  where  a 
nsevus  is  not  extending,^  where  it  is  in  neither  a  dangerous  nor  a  conspicu- 
ous place,  it  is  justifiable  to  watch  the  nsevus,  remembering  that  the  times 
of  teething  and  of  puberty  may  bring  about  atrophy  or  increase,  and  that 
the  former,  while  often  spontaneous,  is  most  hkely  to  follow  one  of  the 
exanthemata.     But  where  a  nsevus  has  any  of  the  cavernous  element 

1  Med.-Chir.  Trans.,  vol.  Ixix,  \).  72. 

2  Lancet,  January  21,  1888. 

*  This  is  a  convenient  place  to  consider  this  subject  on  account  of  their  frequency  and 
great  importance  on  the  face. 

*  "  In  certain  cases  the  surgeon  can,  with  some  degree  of  certainty,  foretell  the  pro- 
gress of  the  naevus.  If  it  is  uniformly  compressible,  soft,  and  highly  vascular,  approach- 
iuCT  to  a  bright  red  colour,  especially  at  the  margins,  it  is  fairly  safe  to  predict  that  it  will 
increase  in  size  "  (Mr.  Waterhouse,  Clin.  Journ.,  August  25,  1897).  Mr.  Waterhouse 
also  advises  that  the  surgeon  should  hold  his  hand  in  all  nsevi  which  are  not 
increasing,  in  infants.  Most  of  such  cases,  however,  are  suitable  for  non-operative 
methods  of  treatment. 


OPERATIVE  TREATMENT  OE  N.EVI  401 

ubout  it,  when  it  ()('cii])ies  a  dangerous  site,  one  where  irritation  of  any- 
kind  is  Hkely  to  bi'ing  al)()ut  hannorrhage — e.g.  scalp,  lips,  tongue,  palate, 
genitals,  rectum,  lingers,  or  toes — or  where  the  site  is  a  conspicuous  one, 
no  time  should  be  lost  in  ejecting  a  cure.  While  admitting  that,  after  a 
year,  there  is  a  distinct  tendency  for  a  nsevus  to  become  stationary,  and 
often  to  degenerate  ultimately,  treatment,  operative  or  non-operative, 
should  be  advised  in  lu^arly  all  cases,  for  the  following  reasons  :  (1)  During 
its  growing  and  stationary  stage  the  navus  is  always  a  source  of  anxiety, 
and  often  of  disfigurement.  (2)  This  growing  stage  commonly  lasts  for 
the  first  year.  When  a  nsevus  appears  to  be  stationary,  or  even  cica- 
trising at  its  centre,  it  may  be  spreading  at  its  periphery.  (3)  There  is 
often  great  difficulty  in  persuading  a  mother  to  put  up  with  any  deformity 
that  is  remediable  in  her  child.  (4)  In  early  life  naevi  are  usually  small, 
and  easily  and  safely  cured.  (5)  The  spontaneous  cure  of  a  large  na)vus 
may  leave,  by  puckering  or  redundant  folds  of  the  Fkai  more  deformity 
than  that  of  an  operation.  Before  describing  the  various  modes  of 
treatment  it  may  be  pointed  out  :  (a)  that  there  is  no  method  suited  to 
all  cases  ;  (6)  that  it  is  very  easy,  by  using  heroic  means  and  doing  too 
much,  to  cause  needless  scarring  ;  (c)  that  during  the  cure  of  large  nsevi 
in  early  life  the  patients  are  liable  to  pyrexial  attacks  and  grave  malaise. 
These  are  not  at  all  uncommon  during  the  cure  of  large  nsevi,  even  though 
asepsis  be  maintained. 

Non-Operative  Methods  of  Treatment.  These,  especially  radium  and  the  appli- 
cation of  solid  CO2,  have  in  recent  years  been  most  extensively  and  successfully 
employed. 

(1)  Solid  CO2.  This  is  especially  useful  in  the  treatment  of  the  very  common 
small  capillary  ngevi,  which  occur  on  the  head  or  face.  It  may  safely  be  employed 
when  the  eyelids  are  involved.  The  COg  "  snow  "  is  compressed  in  a  tube  to  form 
a  rod-like  pencil.  This  is  firmly  pressed  against  the  nawus  for  about  fifteen  to 
twenty  seconds.  A  boracic-acid  ointment  dressing  is  then  applied.  The  treatment 
will  probably  have  to  be  repeated  on  two  or  three  occasions.  The  application  is 
practically  painless. 

(2)  Radium.  This  may  also  be  employed  for  capillary  nsevi,  especially  when 
they  are  extensive.  Its  action  is  more  penetrating  than  that  of  COg,  and  hence  it 
may  be  used  for  cavernous  nawi.  It  is  also  more  effective  than  COg  in  the  treatment 
of  extensive  "  port-wine  stains."  It  gives  an  excellent  scar,  but  the  treatment  is 
more  prolonged  than  with  CO2,  and  it  is  of  course  more  expensive. 

(3)  Application  of  Caustics,  e.g.  sodium  ethylate  and  nitric  acid.  These  may 
be  used  for  cutaneous  n;i:>vi.  Ethylate  of  sodium,  introduced  by  the  late  Sir  B.  W. 
Richardson,  is  the  one  generally  used  as  being  least  painful.  It  should  be  applied 
daily  for  two  or  three  days  ;  a  crust  then  forms  :  when  this  drops  off,  the  nfevus 
will  be  fomid  to  be  cured  if  the  application  has  been  sufficient.  Nitric  acid  is  much 
more  powerful ;  careless  use  of  it  may  produce  most  odious  scars.  Whatever 
caustic  is  used,  it  is  well  to  smear  the  skin  aroimd  with  vaseline,  and  the  pointed 
wood  or  glass  rod  used  should  carry  only  just  enough  of  the  acid,  and  none  to  drop 
about. 

(4)  Collodion.  This  may  be  tried  in  tiny  cutaneous  nsevi  in  infants.  These 
can,  however,  be  better  treated  otherwise.  In  nearly  all  other  nsevi  it  is  a  placebo, 
but  not  always  a  harmless  one,  as  it  wastes  time. 

(5)  Vaccination.  This  is  not  to  be  recommended.  It  often  fails  to  cure  the 
nsevus,  and  the  resulting  scar  may  be  very  disfiguring. 

OPERATIVE  METHODS  OF  TREATMENT 

(1)  Excision.  This  method  may  be  employed  for  nearly  all  subcu- 
taneous and  mixed  neevi,  save  those  on  the  face,  and  for  many  large 
cutaneous  ones  where  the  scar  will  be  hidden.  It  is  a  rapid  method  ; 
healing  by  primary  union  may  be  expected,  and  there  is  no  slough  to 
separate,  as  is  the  case  with  the  cautery  or  ligature,  and  no  repetition  is 

SURGERY  I  26 


402  OPERATIONS  OX  THE  HEAD  AND  NECK 

required,  as  with  electrolysis.  Two  points  require  notice  :  one  is  the 
risk  of  haemorrhage.  This  is  met  by  working  rapidly,  by  judiciously 
applied  finger-pressure,  by  keeping  vdde  of  the  nsevus  (if  the  incisions 
are  made  outside  the  n8e\-us  the  haemorrhage  is  not  serious,  save  in  large 
naevi  in  infants).  The  late  Mr.  J.  X.  Davies-Colley  recommended,  in 
cases  where  severe  bleeding  might  be  expected,  that  two  needles  be  passed, 
beneath  the  base  of  the  n8e\'Tis.  at  right  angles  to  each  other,  and  tA^isted 
aromid  and  below  them  a  fine  drainage  tube  clamped  and  thus  kept  tight 
by  Spencer- Wells  forceps  ;  below  all,  two  or  three  silver  sutm-es  are  passed 
deeply.  After  the  n8e^^ls  has  been  removed,  the  needles  and  drainage 
tube  are  withdrawn,  and,  before  bleeding  can  occur,  the  sutures  are 
quickly  twisted  up.  The  other  point  is  the  ad\'isabihty  of  lea\ang  any 
nsevoid  skin  in  the  excision  of  a  large  mixed  nse^^is.  While  the  greater 
part  of  the  diseased  skin  should  always  be  removed,  narrow  strips  left  on 
either  side  will,  usually,  slowly  take  on  a  natm-al  colom\  The  womid  is 
carefully  united  with  sutures  of  fine  silkworm  gut  or  horsehair.  Usually  no 
drainage  is  required.  Where,  after  excision  of  large  naevi  on  parts  con- 
cealed, such  as  the  trunk  and  limbs,  it  is  impossible  to  bring  the  edges  of 
the  womid  together,  skin-grafting  by  Thiersch's  method  {q.v.)  may  be 
employed.  Caution  must  be  exercised  in  the  excision  of  subcutaneous 
naevi  over  the  abdomen  in  infants  or  httle  children.  In  these  cases  there 
will  be  an  additional  need  for  strict  asepsis,  for,  at  this  age.  the  abdominal 
wall  is  extremely  thin,  and,  if  suppuration  occur,  a  fatal  peritonitis  may 
result.  In  some  instances  of  deep-seated  extensive  naevi  of  the  side  of 
the  face,  excision  can  only  be  used  in  conjimction  with  other  methods,  such 
as  electrolysis.  In  such  cases  excision  should,  whenever  possible,  be  em- 
ployed first,  before  the  parts  are  altered  by  the  electrolysis.  One  more 
occasion  when  excision  will,  sometimes,  be  fomid  usefid,  is  when  a  nae^^ls 
has  been  cm-ed  by  some  other  means  and  an  ugly  scar  left.  e.g.  at  the 
root  of  the  nose.  If  it  be  possible  to  get  the  edges  together  and  to  secure 
primary  union,  excision  will,  here,  greatly  improve  matters. 

(2)  Electrolysis.  This  method  is  less  employed  than  formerly  owing 
to  the  improved  results  obtained  by  other  methods  of  treatment  such  as 
radium  and  solid  CO.2.  It  has,  however,  the  great  advantage  of  lea^^ng 
a  minimum  of  scar,  and  what  scar  there  is,  is  of  good  colour  and  does  not 
tend  to  contract.  Other  advantages  are  that  there  is  no  bleeding,  no 
danger,  and  httle  or  no  pain  after  the  operation.  The  chief  disadvantage 
is  that  it  requires  several  sittings — on  an  average,  four  or  five — and,  as  an 
interval  of  six  weeks  should  elapse  between  the  sittings,  the  treatment  is 
spread  over  a  considerable  time.  For  this  reason  the  method  is  not  suited 
to  hospital  patients.  With  patients  in  a  better  rank  of  life,  the  following 
should  be  insisted  upon  :  (1)  That,  while  electrolysis  is  not  expeditious, 
it  is  the  slow,  gradual  fading  of  the  nsevus  which  gives  the  best  after- 
result.  (2)  That  the  chief  object  of  the  operator  is  to  stop  the  growth,  and 
then  to  wait  patiently,  unless  the  nae\iis  redevelops,  or  its  subsidence  is 
much  delayed.  Electrolysis  is  best  suited  to  those  naevi  which  are  un- 
siiited  to  excision,  and  where  the  cautery  will  leave  a  conspicuous  scar, 
e.g.  upon  the  face,  and  especially  upon  the  eyehds  and  nose. 

Dr.  H.  LeT^^s  Jones,  who  has  had  large  experience  at  St.  Bartholo- 
mew's Hospital,  thus  describes  his  methods  in  the  St.  Bartlwhmeiv' s 
Hospital  Reports,  vol.  xxx,  p.  206.  He  considers  the  imipolar  method  the 
most  useful. 

"  Needles  of  platinum  having  been  coimeoted  with  the  negative  ix>lc.  the  circuit 


OPERATIVE  TREATMENT  OF  N^VI  403 

is  completed  tlirough  the  patient's  body  by  means  of  a  well- moistened  pad  attached 
to  the  positive  ])ole  and  placed  underneath  the  ]mtient's  back  or  hips.  Small 
currents  are  emjjloyed  and  tlie  nii3vus  is  treated  gradually.i^  The  reason  why  this 
plan  is  preferred  is  because  it  gives  the  operator  one  set  of  needles  only  to  manage  ; 
the  density  of  the  current  in  the  nsevns  is  more  easily  distributed  ;  the  changes 
produced  at  each  of  the  needles  is  alike,  and  there  is  little  or  no  bleeding  when  they 
are  withdrawii.  Further,  the  systematic  use  of  the  same  pole  makes  it  easier  to 
recognise  the  a])pearances  which  indicate  that  enough  has  been  done  so  as  to  stop 
the  electrolytic  action  before  the  stage  of  complete  destruction  and  sloughing.  The 
objections  to  the  unipolar  arrangement  of  needles  are  that  the  current  traverses 
the  body  of  the  child,  who  may  therefore  be  affected  by  electric  shocks,  and  the 
positive  pad,  if  not  carefully  managed,  may  produce  an  undesired  electrolysis  in 
the  wrong  place.  The  first  of  these  objections  is  not  serious  unless  the  nsevus 
be  situated  on  the  head,  and  even  then  with  proper  care  it  becomes  slight,  if  one 
remembers  that  the  needles  should  be  inserted  and  removed  singly  and  gradually, 
and  the  full  strength  of  the  current  turned  on  after  the  insertion  of  the  needles,  and 
turned  off  before  they  are  all  removed.  The  other  danger — that  of  electrolysis  at 
the  seat  of  the  positive  pad — can  be  guarded  against  by  strict  attention  to  the  pad 
and  conducting  wire;  both  must  be  completely  covered  by  moist  material,  as  the 
smallest  portion  of  uncovered  metal  will  produce  destructive  effects  at  the  place 
where  it  touches  the  skin." 

The  bipolar  method,  in  which  both  poles  are  inserted  into  the  naevus, 
is  carried  out  by  Dr.  Jones  by  means  of  his  fork  electrodes,  in  which 
two  to  five  needles  can  be  arranged,  firmly,  parallel  to  one  another,  thus 
easily  controlled  and  evenly  distributing  their  action  on  the  tissues.  If 
the  needles  are  used  in  the  ordinary  way,  care  must  be  taken  to  keep  them 
parallel,  not  to  allow  their  points  to  come  in  contact,  thus  producing  need- 
less shock,  and  to  keep  them  at  regrdar  distances  from  each  other,  from 
the  centre  to  the  periphery  of  the  naevus,  so  that  the  whole  of  the  navus, 
centre  and  periphery  ahke,  may  be  acted  upon.  If  the  needle-points 
converge  to,  and  thus  the  current  is  concentrated  in,  the  centre  of  the 
nsevus,  sloughing  is  likely  here,  while  the  periphery  will  escape.  As  to 
the  strength  of  current  used,  Dr.  Lewis  Jones  advises  as  follows  :  "  The 
best  way  of  specifying  the  current  is  to  take  into  consideration  the  number 
of  needles  used,  and  to  say  that  for  every  inch  of  needle  in  the  nsevus, 
twenty  to  thirty  milliamperes  is  sufficient.  Thus,  if  four  negative  needles 
are  inserted  to  a  quarter  of  an  inch  apiece,  the  total  current  may  be 
twenty  or  thirty  milliamperes."  The  needles  used  may  be  of  platinum, 
one  advantage  of  which  is  that  they  may  be  attached  to  either  pole.  The 
only  objection  to  them  is  the  difficulty  of  rendering  them  really  sharp.  If 
steel  or  copper  needles  are  used  they  must  be  attached  to  the  positive 
pole.  The  needles  should  be  isolated  with  vulcanite  for  a  full  half  of  their 
length,  otherwise  sloughing  will  occur  at  the  point  of  their  puncture. 
Before  use  the  needles  should  be  boiled.  When  introduced  their  points 
must  not  be  allowed  to  approach  the  surface  of  the  naevus  too  closely,  or 
sloughing,  and.  later  on,  sepsis,  vriW  occur.  The  progress  of  electrolysis 
is  best  judged  b}'  the  induration  which  takes  place,  also  by  any  discolora- 
tion at  the  points  of  entrance  of  the  needles.  A  greyish  spreading  zone 
here  indicates  that  it  is  time  to  withdraw  and  re-insert  the  needle. 
Blackening  at  any  part  denotes  that  sloughing  will  ensue  there.  Before 
the  needles  are  \\-ithdrawn  the  current  should  be  shut  off,  but  not  abruptly. 

^  It  may  be  taken  as  a  principle  of  the  electrolji;ic  treatment  that  the  current  should 
not  be  pushed  to  such  an  extent  as  to  caase  the  naivus  to  slough.  It  follows  as  a  rider 
to  this  that  electrolysis  can  very  seldom  be  used  so  as  to  get  rid  of  a  ntevus  at  one  opera- 
tion, unless  it  is  quite  a  small  one,  for  where  this  is  attempted  the  result  is  almost  certain 
to  be  a  slough,  and  should  be  regarded  as  an  unfavourable  termination.  If  the  najvus  is 
very  small,  say  under  a  fifth  of  an  inch  in  diameter,  it  may  be  completely  destroyed  in  one 
sitting. 


404  OPERATIONS  ON  THE  HEAD  AND  NECK 

The  only  dressing  needed  is  a  little  antiseptic  wool  or  gauze,  kept  on 
with  collodion  till  the  punctures  are  healed. 

(.'5)  The  Cautery.  Paquelin's  cautery  is  usually  employed,  the  large 
blade  at  a  cherry-red  heat  being  carefully  wiped  over  a  cutaneous  nsevus, 
and  the  fine  point  used  for  the  subcutaneous  ones.  This  is  made  to 
penetrate  the  skin  at  one  spot,  and  then  made  to  traverse  the  naevus  in 
several  directions  from  the  one  puncture.  It  is  an  efJectual  method,  but 
has  the  disadvantage  of  leaving  large  and  unsightly  scars.  Thus  the 
black  sinus  or  sinuses  left  after  the  operation  with  a  red  margin  of  scorched 
skin  suppurate  and  heal  tediously,  with  much  disfigurement  in  exposed 
places.  Furthermore,  while  the  slough  is  being  detached,  the  health  of 
the  infant  or  httle  child  often  suffers  considerably.  A  small-sized 
Paquelin's  cautery  is  greatly  to  be  preferred,  but  best  of  all  is  an  electric 
cautery  with  fine  platinum  points.  If,  in  hospital  practice  the  surgeon 
arranges  for  his  nsevus  cases  to  attend  on  one  day,  there  should  be  no 
difficulty  about  the  apparatus  being  in  working  order.  The  amount  of 
scarring  is  far  less  than  with  the  Paquelin's  cautery.  No  anaesthetic  is 
required  with  either  apparatus  in  infants,  the  pain  being  momentary. 
Attention  may  here  be  drawn  to  a  most  useful  warning  by  Mr.  Waterhouse. 
"  In  mixed  naevi  it  is  necessary  to  procure  destruction  of  the  subcutaneous 
portion  of  the  growth,  and  the  cure  of  the  cutaneous  part  as  a  rule 
follows.  Times  without  number  have  I  seen  cases  in  which  the  treatment 
adopted  has  been  destruction  of  the  skin  portion  with  caustics.  This 
has  resulted  in  ugly  scarring,  and  the  subcutaneous  portion  of  the  growth 
has  not  been  in  any  way  influenced  for  good."  A  very  simple  form  of 
cautery  for  those  stellate  patches  which  appear  on  girls'  faces  long  after 
infancy,  "  spider  nsevi,"  is  supplied  by  a  needle  heated  or  dipped  in 
nitric  acid.  An  anassthetic  should  be  given.  Another  excellent  means 
of  treating  small  nscvi  is  to  make  a  puncture  with  a  tenotome,  and 
apply  for  a  few  seconds  a  fine-pointed  stick  of  silver  nitrate. 

(4)  Subcutaneous  Discission.  This  method  of  obliterating  a  nsevus 
without  scarring  was  introduced  by  Dr.  Marshall  Hall.  A  cataract 
needle  or  fine  tenotome  is  passed  from  a  point  about  a  Hne  from  the 
margin  of  the  nsevus  to  the  opposite  extreme  edge  of  the  growth.  The 
needle  is  then  withdrawn  almost  to  its  point  of  entrance  and  pushed  again 
through  the  nsevus  at  about  one-sixteenth  of  an  inch  from  the  line  of  the 
first  puncture,  and  so  on  till  the  lines  of  puncture  take  a  fan-like  shape. 
The  number  of  times  which  the  needle  is  passed  will  vary,  according  to 
the  size  of  the  nsevus,  from  ten  to  forty.  Each  passage  must  be  just 
removed  from  the  last.  Should  the  needle  penetrate  the  skin,  pressure 
must  be  applied.  This  method  is  best  adapted  to  subcutaneous  or 
mixed  nsevi  of  moderate  size. 

(5)  Ligature.  This  method,  though  formerly  often  employed,  has  been 
practically  given  up,  owing  to  its  painfulness,  its  production  of  a  slough 
and  large  scar,  and  the  great  chance  that  part  of  the  strangled  mass  may 
escape  obliteration. 

(())  Injection.  This  again  is  practically  an  obsolete  method  of  treat- 
ment. Several  cases  suddenly  and  instantaneously  fatal  from  throm- 
bosis have  occurred.  It  should  certainly  never  be  employed  unless  the 
nsevus  is  secured  with  ring-forceps  or  by  means  of  temporary  ligatures. 
A  preparation  of  iron,  iodine,  or  pure  carbolic  acid  has  been  used. 

Port- Wine  Stain.  This  troublesome  form  of  cutaneous  nsevus  is  best 
treated  bv  radium.     Should  this  be  impracticable,  the  careful  use  of 


OPERATIVE  TREATMENT  OF  X.EVI  405 

caustics,  linear  scarification,  or  the  platimiiii  cautery  at  a  white  heat, 
may  be  tried.  Tlie  hitter  sliouhl  barely  touch  tlie  surface  of  the  stain. 
Whichever  method  is  used  care  nuist  be  taken  not  to  destroy  too  nuich — 
e.g.  no  more  than  the  epidermis  and  superficial  layer  of  the  rete  mucosum 
— in  the  cases  where  the  stain  is  thinnest  and  most  diffuse.  Cicatrisa- 
tion will  do  the  rest.  The  maintenance  of  asepsis  is  of  great  importance. 
Large  Hairy  and  Pigmented  Moles.  The  methods  at  hand  in  these 
very  troublesome  cases  are  excision  followed  by  grafting,  electrolvsis, 
and  the  use  of  caustics  or  solid  COg.  Where  they  descend  from  the 
forehead  and  encircle  the  eye,  every  precaution  must  be  taken  not  to 
destroy  the  tarsal  plates.  Where  a  large  isolated  patch  occupies  one 
cheek,  excision  and  grafting,  either  by  Thiersch's  or  Wolfe's  method,  may 
be  tried. 


CHAPTER  XVIII 

EXCISION  OF   THE   EYEBALL 

The  general  surgeon  may  at  any  time  be  called  upon  to  perform  this 
operation.  It  should  always  be  practised  upon  the  dead  subject,  and  for 
these  reasons  is  described  here.     Indications  : 

(i)  New  growths,  e.g.  glioma  of  the  retina,  melanotic  sarcoma  of  the 
uveal  tract. 

(ii)  In  the  following  cases  of  injury  and  its  results  : 

(a)  The  eyeball  ruptured  and  collapsed  after  a  blow. 

(6)  If,  though  the  wound  be  small,  it  lie  in  the  dangerous  region,  and 
have  already  set  up  irido-cyclitis. 

(c)  When  lens,  iris,  and  vitreous  have  been  extruded,  the  eyeball  is 
filled  with  blood,  and  there  is  no  perception  of  light.  In  cases  where  the 
lens  is  extruded  beneath  the  conjunctiva,  which  is  intact,  an  attempt 
should  be  mad<>.  to  save  the  eye. 

(d)  A  large  jagged,  foreign  body  in  tlie  eye,  e.g.  a  bit  of  metal,  not 
removable  without  inevitable  disorganisation. 

(e)  If  the  wound,  lying  wholly  or  partly  in  the  dangerous  region,  be  so 
large  and  so  complicated  with  injury  to  deeper  parts  that  no  hope  of  useful 
sight  remains. 

(/)  Where  there  is  a  wound  in  the  dangerous  region  comphcated  with 
traumatic  cataract. 

{g)  Where  a  small  foreign  body,  e.g.  a  shot  glancing  in  cover-shooting 
not  removable  by  an  electro-magnet,  gradually  sets  up  inflammation 
and  shrinking  of  the  eye. 

(h)  Where  traumatic  cataract  has  been  caused  by  a  wound  which  is 
wholly  corneal,  and  therefore  out  of  the  dangerous  area,  and  yet  severe 
iritis  and  pan-ophthalmitis  come  on  in  spite  of  treatment. 

(iii)  As  part  of  an  operation  for  rodent  ulcer  which  has  extensively 
involved  the  conjunctiva 

(iv)  Occasionally  in  the  course  of  excision  of  the  superior  maxilla 
where  the  growth  has  invaded  the  orbit. 

(v)  As  part  of  an  operation  for  the  removal  of  orbital  tumours,  e.g.  a 
glioma  or  sarcoma. 

Operation.  The  chief  object  is  to  remove  the  globe  alone,  whenever 
this  is  possible,  leaving  the  muscles  to  coalesce  and  form  a  stump  on 
which  the  artificial  eye  may  rest  and  be  movable.  As  much  conjunctiva 
as  possible  should  be  left.  The  surgeon,  standing  in  front,  having  in- 
serted a  spring  speculum  between  the  hds,  snips  with  blunt-pointed 
scissors  through  the  ocular  conjunctiva  close  to  the  cornea  and  all  round 
it,  using  small  toothed  forceps  to  lift  the  conjunctiva,  and  leaving  enough 
at  one  side  to  hold  on  by  the  forceps  during  the  next  step.  This  is  to 
open  freely  Tenon's  capsule,  and  catching  up  each  rectus  tendon  (beginning 

406 


EXCISION  OF  THE  EYEBALL  407 

u.sually  witli  the  external  rectus)  with  a  strabismus  hook,  to  divide  them 
close  to  the  sclerotic,  leaving  the  cut  end  of  the  external  rectus  long,  in 
order  to  draw  the  eyeball  forcibly  inwards.  The  superior  and  inferior 
rectus  are  then  cut,  and  the  speculum  pressed  back  into  tlu;  cavity  of  the 
orbit  so  as  to  make  the  eyeball  start  forwards.  'J'he  scissors,  blunt- 
pointed  and  slightly  curved,  are  now  passed  back  to  feel  for  the  optic 
nerve,  which  may  be  known  by  its  toughness  and  thickness,  and  which  is 
now  severed  with  one  clean  cut.  The  eyeball  being  drawn  forwards 
with  a  finger,  the  oblique  muscles  and  any  remaining  soft  parts  are  to  be 
cut  close  to  the  globe.  The  ha^moirhage,  though  temporary,  may  be 
troublesome  and  should  be  controlled  by  irrigation  with  hot  saline  solu- 
tion and  by  firm  pressure  for  a  few  minutes.  The  socket  should  not  be 
plugged,  but  sterilised  gauze  is  applied  outside  the  lids,  and  firm  pressure 
secured  by  bandaging  over  a  pad  of  absorbent  wool. 

If  the  eyeball  is  collapsed  the  operation  may  be  rendered  much  more 
difficult  owing  to  the  trouble  that  may  be  experienced  in  securing  the 
tendons  of  the  muscles  with  the  strabismus  hook. 

In  the  case  of  a  new  growth,  e.g.  glioma,  the  optic  nerve  must  be 
divided  as  far  back  as  possible.  The  scissors,  slightly  curved  and  long 
enough  to  reach  to  the  back  of  the  orbit,  are  introduced  on  the  inner  side, 
and  the  nerve  either  cut  as  far  back  as  is  possible  before  the  globe  is 
removed,  or,  after  this  is  done,  the  nerve  is  dissected  out  and  a  fresh 
section  made. 

Owing  to  the  early  stage  at  which  dissemination  of  intra-ocular 
sarcomata  takes  place,  and  to  the  tendency  of  these  growths  to  creep 
backwards  along  the  optic  nerve  towards  the  interior  of  the  cranium,  the 
prognosis  very  largely  depends  upon  the  earliness  of  the  extirpation.  On 
this  account  it  should  be  remembered  that  the  earliest  symptoms  of 
these  growths,  viz.  impairment  of  sight  from  partial  detachment  of  the 
retina  by  the  pressure  of  the  growth  behind  it,  should  be  most  carefully 
tested  in  suspicious  cases,  this  impairment  of  sight  being  not  usually 
noticed  by  the  patient,  save  accidentally  on  closing  the  sound  eye,  unless 
the  growth  originates  near  the  yellow  spot.  If  later  evidence  is  waited 
for,  such  as  evidence  of  tension  and  pain,  dissemination  or  recurrence  is 
most  probable,  while  the  growth  will  very  likely  have  perforated  the  eye. 
and  the  more  severe  operation  of  clearing  out  the  orbit  will  be  required. 
The  following  questions  will  very  likely  arise  :  If  there  is  evidence  of 
general  dissemination  of  the  disease,  is  it  expedient  to  remove  the  eye,  or, 
if  this  be  insufficient,  to  clear  out  the  orbit  as  well  ?  In  most  cases  the 
answer  will  be  in  the  affirmative,  in  order  to  save  the  patient  pain  and  the 
misery  of  the  protruding  and  ulcerating  mass. 

If  the  disease  has  recurred,  is  it  any  use  again  to  attack  it  ?  The 
answer  will  mainly  depend  on  the  amount  and  depth  of  the  recurrence, 
and  on  the  completeness  of  the  first  operation.  Thus,  if  the  eye  only  was 
removed  at  first,  it  may  be  wise  to  clear  the  orbit  out  thoroughly. 

In  a  few  most  distressing  cases  in  children  it  is  well  known  that  both 
eyes  are  attacked.  The  question  of  operating  on  the  second  eye  must 
now  be  faced.  Mr.  Treacher  Collins  ^  has  recorded  four  cases,  in  each  of 
which  three  years  had  passed  since  the  enucleation  of  the  second  eye  and 
the  patients  were  alive,  with  no  sign  of  recurrence.  Mr.  Lawson  held  that 
if  both  eyes  are  affected,  both  should  be  excised,  providing  that  the  sight 
has  already  been  destroyed.     He  had,  on  many  occasions,  removed  the 

^  Trans.  Ophth.  Soc,  vol.  xvi,  p.  142. 


408  OPERATIONS  ON  THE  HEAD  AND  NECK 

second  eye  to  procure  temporary  relief  from  the  excessive  pain  induced 
by  the  over-distended  globe,  and  when  there  had  not  been  the  slightest 
prospect  of  curing  the  disease.  In  each  case  the  operation  gave  immediate 
and  perfect  relief. 

Evisceration  :  Mules'  Operation.  In  this  operation  the  entire  con- 
tents of  the  eyeball  are  removed  from  the  interior  of  the  sclerotic,  which 
is  left,  and  into  which  a  ball  of  glass,  celluloid,  or  ivory  is  inserted  in 
the  latter  operation.  This  operation  is  said  to  provide  a  better  socket  for 
an  artificial  eye,  and,  owing  to  the  attachments  of  the  muscles  not 
having  been  divided,  much  more  movement  is  possible.  A  possible 
disadvantage  is  the  occurrence  of  sympathetic  inflammation.  The 
indications  will  be  similar  to  those  for  excision  (excluding  growths), 
but  it  is  said  to  be  specially  desirable  in  cases  of  suppuration  of  the 
eyeball  where  excision  may  lead  to  infection  of  the  sheath  of  the  optic 
nerve  and  thus  to  meningitis. 

The  Operation.  The  patient  having  been  anaesthetised,  the  ball  is 
transfixed  by  a  Beer's  knife,  the  points  of  entrance  and  exit  being  just 
without  the  corneo-sclerotic  junction.  By  cutting  upwards  a  flap  of 
cornea  and  sclerotic  is  obtained.  The  free  edge  of  the  flap  is  then  seized, 
and  the  cornea  is  entirely  removed  by  means  of  sharp  scissors.  The 
contents  are  then  eviscerated  by  a  sharp  spoon.  Care  must  be  taken  to 
remove  the  entire  uveal  tract  so  that  the  inside  of  the  cavity  should  be 
quite  white.     It  is  then  irrigated  with  dilute  perchloride  of  mercury  lotion. 

In  Mules'  operation  the  globe  must  be  aseptic.  Evisceration  is  first 
performed  as  directed  above,  and  then  a  loosely  fitting  celluloid  ball  is 
introduced  into  the  sclerotic.  The  cavity  is  then  closed  by  a  few  catgut 
stitches  inserted  into  the  sclerotic  and  the  conjunctiva  is  then  drawn  across 
by  a  few  sutures  of  gossamer  gut  or  silk. 

Clearing  out  the  Contents,  or  Exenteration  of  the  Orbit. 

In  November  1903  a  man,  aged  38,  wlio  had  the  eyeball  removed  for  sarcoma 
elsewhere,  was  admitted  under  Mr.  Jacobson  for  persistence  of  the  disease.  The 
left  orbit  was  occupied  by  a  fungating,  bleeding,  sloughy  mass ;  the  eyelids  were 
not  involved,  and  no  infiltration  of  the  glands  could  be  made  out.  An  incision 
having  been  made  all  round  the  orbital  margin  down  to  the  bone,  the  periosteum 
was  carefully  stripped  up  by  means  of  an  elevator  from  the  entire  interior  of  the 
cavity  back  to  its  apex.  The  optic  foramen  was  enlarged  with  a  small  gouge,  and 
then  with  fine,  blunt-pointed  scissors  pushed  in  as  far  as  possible,  the  optic  nerve 
was  divided.  The  entire  mass  then  came  away  with  its  coat  of  2)eriosteum.  The 
section  of  the  nerve  appeared  quite  healthy.  The  bones  did  not  appear  to  be 
involved.  The  frontal  sinus  was  explored  and  found  to  be  free  from  disease.  The 
cavity  was  packed  with  strips  of  sterilised  gauze  wrung  out  from  pure  formalin. 
These  were  removed  in  thirty-six  hours,  leaving  the  dry,  black,  odoiu'less  sloughs 
so  characteristic  after  the  use  of  formalin.  The  recovery  was  without  interruption 
save  for  severe  pain  during  the  first  forty-eight  hours.  The  patient  was  kept 
under  observation  for  nearly  two  years,  and  there  was  no  reappearance  of  the 
disease  and  the  patient  was  able  to  continue  his  work  as  a  shepherd.  In  September 
1905  the  opposite  eye  was  attacked,  the  patient  becoming  blind  and  dying  in  two 
months  with  paraplegia  and  convulsive  attacks.  There  was  no  reapjiearance  of 
disease  on  the  left  side.  The  deformity  was,  of  course,  considerable  ;  but  when  the 
malignity  of  sarcoma  of  the  eyeball,  its  speedy  reappearance  after  the  first  operation, 
and  the  interval  of  nearly  two  years  in  which  the  patient  remained  well  are  con- 
sidered, the  result  may  be  considered  satisfactory. 

Intradural  Growths  of  the  Optic  Nerve  Itself. 

Mr.  H.  P.  Bennett,  Surgeon  to  the  Newcastle-on-Tyne  Eye  Infirmary,  reports 
one  of  these  rare  cases.i     The  patient  was  a  boy,  aged  2.     From  the  perfect  mobility 

1  Brit.  Med.  Journ.,  190.5,  vol.  i,  p.  1041. 


KXe  LSION  OF  THE  EYEBALL  409 

of  tlio  cyo  and  its  projection  directly  forwards,  Mr.  Bennett  had  no  doubt  that  he 
had  to  deal  with  a  tumour  situated  within  the  muscular  cone,  and  from  the  early 
loss  of  sight,  with  prohal)ly  a  growth  of  the  optic  nerve.  The  eye  was  removed 
with  about  l',i  cm.  of  ap])arently  normal  nerve  attached  to  it.  On  inserting  a 
linger  into  the  orbit,  a  large  growth  could  be  felt  extending  right  down  into  the 
o])tic  foramen.  In  order  to  remove  the  whole  of  this  mass  a  small  gouge  wa.s 
in.serted  into  the  ajjcx  of  the  orbit,  and  the  whole  of  the  growth  was  removed  with 
1  cm.  of  healthy  nerve  at  the  posterior  end  ;  in  fact,  the  nerve  was  partly  torn  away 
at  or  very  near  the  chiasma.  The  growth  was  a  fibroma.  The  patient  was  well 
about  six  months  later. 

Temporary  Resection  of  the  External  Orbital  Wall.  Kroiilein,  in 
order  to  avoid  the  sacrifice  of  healthy  eyes,  and  to  enlarge  the  very  limited 
field  between  the  eyeball  and  the  outer  wall  of  the  orbit,  was  the  first  to 
propose  the  above  method  as  a  means  of  obtaining  access  to  the  structures 
behind  the  eyeball.  Domella  has  collected  ^  forty-five  cases  in  which  this 
operation  was  performed  and  has  analysed  the  results.  The  conditions 
calling  for  it  were  sarcoma,  angioma,  cysts,  endothelioma,  neuroma, 
adenoma,  osteoma,  growths  of  the  optic  nerve  and  sheath,  injtiry  pulsating 
exophthalmos,  and  retro-bulbar  suppuration. 

The  Operation.  A  curved  incision  is  made  with  its  convexity  forwards  in  the 
temporal  region,  commencing  at  the  anterior  part  of  the  temporal  crest,  1  cm.  above 
the  upper  margin  of  the  orbit,  extending  along  the  outer  orbital  margin  almost  as  far 
as  the  outer  canthus  and  ending  on  the  zygomatic  arch  midway  between  the  outer 
can  thus  and  the  auditory  meatus.  It  is  carried  down  through  the  skin,  aponeurosis 
and  muscles,  but,  along  the  orbital  margin,  only  divides  the  periosteum.  The 
periosteum  is  next  separated  with  a  rugine  from  the  outer  orbital  wall  as  far  back  as 
the  spheno-maxillary  fissure  below  and  a  few  mm.  behind  the  spheno-malar  suture 
above,  and  it  is  partly  retracted  along  with  the  orbital  contents.  The  exposed  outer 
wall  is  now  divided  along  the  three  following  lines  :  (1)  Above,  from  the  external 
angular  process  of  the  frontal  bone  liorizontally  backwards.  (2)  Posteriorly,  from  the 
posterior  end  of  this  incision  obliquely  into  the  spheno-maxillary  fissure.  (3)  Below, 
from  the  base  of  the  orbital  process  of  the  malar  bone  horizontally  backwards  to 
the  anterior  end  of  the  spheno-maxillary  fissure.  The  bony  fragment  with  all  its 
adherent  soft  parts  is  displaced  outwards  and  backwards,  the  orbital  periosteum  is 
incised  horizontally,  the  external  rectus  easily  distinguished  and  the  retro-ocular 
space  well  exposed.  At  the  conclusion  of  the  operation  the  orbital  periosteum  is 
sutured,  the  bone  replaced,  and  the  wound  sutured.  Of  the  forty-five  cases 
collected  by  Domella,  one  patient  died  from  an  invasion  of  the  cranial  cavity  soon 
after  the  operation.  In  six  others  it  was  necessary  completely  to  remove  the 
contents  of  the  orbit.  In  the  remaining  thirty-eight  no  atrophy  of  the  eyeball 
followed,  even  when  it  was  necessary  to  divide  the  optic  nerve.  In  many  cases 
vision  was  much  improved.  The  only  inconvenient  effects  are  said  to  be  temporary 
ansesthesia  of  the  cornea,  diminution  of  the  mobility  of  the  eyeball,  and  external 
strabismus. 

^  Revue  Med.  dc  la  (S'm/ssc  Romande,  1902,  vol.  xxii,  p.  833. 


CHAPTER  XIX 
OPERATIONS   ON   THE  FRONTAL   SINUSES^ 

Chief  Points  in  the  Surgical  Anatomy.  These  are  of  great  importance,  for 
it  must  never  be  forgotten  that  while  operative  interference  with  the 
maxillary  antrum  is  a  safe  proceeding,  a  similar  step  in  the  case  of  the 
frontal  sinus  is  a  very  different  matter  ;  owing  to  the  close  proximity  of 
the  meninges  and  the  communication  of  these  sinuses  with  the  ethmoid 
and  nose,  the  risk  of  fatal  infection,  especially  osteitis  and  meningitis,  is 
always  present. 

Extent.  The  variable  extent  of  these  sinuses  in  the  upward,  outward, 
and  backward  direction  is  well  known.  The  last  mentioned,  or  the  depth, 
is  the  most  important  from  the  surgeon's  point  of  view.  Logan  Turner 
gives  the  following  as  averages.  Height,  an  inch  and  a  quarter ; 
breadth,  one  inch  ;  depth,  three-quarters  of  an  inch.  When  the  sinuses 
are  asymmetrical,  one  may  extend  across  the  middle  line,  reducing  its 
fellow  to  a  mere  slit.  The  septum,  complete  in  health,  is  often  perforated 
in  disease  of  any  standing.  Thus,  where  both  sinuses  are  diseased  and 
communicating,  discharge  may  appear  in  the  nose  on  one  side  only 
(Tilley).  While  the  posterior  wall,  thin  and  brittle,  and  marked  pos- 
teriorly by  the  frontal  convolutions,  contains  no  diploe,  in  the  anterior 
wall  this  tissue,  though  slight  in  amount,  is  sufficiently  present  to  be  the 
seat  of  infective  osteitis.  The  floor  of  the  sinus  at  its  inner  and  posterior 
part  is  formed  by  the  anterior  ethmoidal  cells.  The  bone  here  is  delicate, 
readily  giving  way.  From  this  fact  and  the  close  contiguity  of  the 
openings  of  other  sinuses,  i.e.  the  anterior  ethmoidal  and  the  antrum,  to 
that  of  the  frontal  in  the  middle  meatus,  infection  readily  spreads  from  one 
to  the  other.  The  upper  opening  of  the  naso-frontal  duct  lies  at  the  back 
and  inner  part  of  the  inferior  wall  of  the  sinus.  It  is  on  this  part  of  the 
sinus,  i.e.  that  just  above  the  internal  angular  process,  that  the  surgeon 
should  especially  direct  his  attention.  The  duct  passes  through  the 
anterior  ethmoidal  cells.  Its  direction  is  downwards  and  backwards. 
Slightly  curved  backwards,  it  may  be  tortuous  ;  sometimes  a  mere  slit 
represents  the  upper  opening.  Apart  from  the  results  of  disease,  diflS.- 
culties  may  arise  in  the  passage  of  a  probe  along  the  duct  owing  to  the 
way  it  may  be  encroached  upon  by  the  anterior  ethmoidal  cells,  and  its 
varying  length  according  as  it  opens  directly  into  the  upper  part  of  the 
middle  meatus,  or  farther  down,  in  the  groove  known  as  the  hiatus  semi- 
lunaris, in  common  with  the  openings  of  the  anterior  ethmoidal  cells  and 
the  antrum.     The  latter  is  the  more  common  of  the  two,  and  may  account 

1  Operations  on  the  frontal  sinuses  are  described  here  as  the  incision  rec^uired  is 
situated  on  the  face.  The  frontal  sinuses  are,  however,  accessory  nasal  air  sinuses,  as 
are  also  the  antrum  of  Highmore  and  the  ethmoidal  air-cells.  Operations  on  these 
latter  are  described  at  pp.  431  and  461. 

410 


OPKKATIONS  ON  TIIK  FRONTAL  SINUSES         411 

foi'  the  I'lcMjuoncy  with  which  the  antiuiu  is  also  involved.  The  site  of  the 
opening  into  the  middle  meatus  is  denoted  on  the  surface  by  the  level 
of  the  inner  cant  liiis  ((lodlt'e). 

Chief  Indications  for  Operation.'  Fn  acute  cases  these  will  be  chiefly 
pain  and  severe  constitutional  disturbance  which  are  not  relieved  by 
intranasal  treatment.-  In  some  cases,  in  addition  to  very  severe  pain, 
there  will  be  osdema  and  redness  of  the  soft  tissues,  suggesting  that  the 
pus  is  making  its  way  forwards  through  the  anterior  wall  of  the  sinus. 

In  chronic  cases  the  indications  will  be  pain,  evidence  of  retained 
infective  material,  and  alteivd  health,  bodily  and  mental,  from  the 
constant  swallowing  and  breathing  of  such  material  and  the  resulting 
toxaemia.  It  will  be  assumed  that  intranasal  methods  have  been  tried 
and  have  failed.  In  chronic  cases,^pain,  so  long  as  the  duct  is  patent,  is 
not  usually  a  prominent  symptom.  Dr.  Milligan  ■*  goes  so  far  as  to  say 
of  these  cases  :  "  Localised  pain,  which  is  such  a  valuable  symptom  in  the 
diagnosis  of  deep-seated  suppuration,  is  usually  conspicuous  by  its  absence. 
It  is  true  that  pressure  over  the  floor  of  the  sinus,  whichjs  its  thinnest 
wall,  does  at  times  produce  marked  pain,  but  an  almost  equal  amount  of 
discomfort  is  not  uncommon  when  similar  pressure  is  made  on  the  floor 
of  the  opposite  sinus.  The  finger  must  be  introduced  well  under  the  supra- 
orbital arch,  and  pressure  made  upwards  and  inwards."  When  the 
surgeon  is  in  doubt  as  to  the  need  of  an  operation,  the  chief  point  for 
him  to  weigh  is  whether  adequate  drainage  exists.  Where  the  fronto- 
nasal duct  remains  patent,  and  operation  is  deferred,  patients  must  be 
made  clearly  to  understand  the  need  for  attending  regularly  to  report  their 
condition  and  to  allow  of  the  removal  of  polypi  or  granulation  masses  which 
arise  here,  as  elsewhere,  in  the  course  of  long-continued  suppuration.  In 
such  cases,  the  patients  must  also  be  warned  of  the  risks  of  fresh  attacks, 
e.(j.  of  influenza,  in  interfering  with  the  escape  of  discharge,  and  of  resulting 
cerebral  complications,  as  in  the  more  familiar  instance  of  imperfect 
drainage  through  an  ulcerated  membrana  tympani  in  otitis  media. 

Operation  is  strongly  indicated  where  the  discharge  is  profuse,  where 
the  sinus  is  distended  without  escape  of  discharge  from  the  nose,  and 
especially  when  there  has  been  any  threatening  of  cerebral  trouble,  and 
where  the  antrum  is  involved  as  well.  Two  other  indications  are  the 
presence  of  an  external  fistula  due  to  the  pus  having  made  its  way  through 
the  anterior  wall  and  burst  externally,  and  the  possibility  that  the  patient 
may  later  on  be  remote  from  surgical  assistance.     Another  point  that 

^  For  further  information  on  this  subject  reference  should  bo  made  to  a  discussion 
on  "  The  present  position  of  the  treatment  of  purulent  discharge  from  the  frontal 
sinuses  "  before  the  Larvngological  Section  of  the  Royal  Society  of  Medicine,  opened  by 
Dr.  Watson- ^Villiams  (Proc.  Rotj.  Soc.  Med.,  Lanjng.  Sec,  June  1911,  p.  127).  The 
indications  for  operation  and  the  relative  value  of  the  different  methods  are  here  fully 
discussed.  In  his  opening  remarks  Dr.  Watson- \Mlliams  gives  the  following  indications 
for  a  radical  operation  :  (1)  The  continuance  of  a  purulent  discharge,  despite  intranasal 
and  other  treatment,  sufficient  to  cause  grave  inconvenience  or  markedly  impaired 
health.  (2)  Persistence  of  headache,  or  of  mental  depression,  or  other  nervous  pheno- 
mena due  to  frontal  sinus  disease,  especially  in  neurasthenic  patients.  (3)  Recurrent 
facial  erysipelas,  orbital  or  external  cellulitis,  caries  of  the  sinus  walls,  the  formation  of 
a  fistulous  opening,  and  any  symptoms  of  intracranial  complications  secondary  to  the 
sinus. 

"  For  particulars  of  this  the  reader  is  referred  to  a  special  work  on  diseases  of  the  nose. 

^  Skiagraphy  is  often  of  very  great  assistance  in  confirming  the  diagnosis  of  chronic 
suppuration  in  the  frontal  sinus  as  well  as  in  the  other  accessory  nasal  sinuses.  Dr.  Tilley 
jjoints  out  that  an  X-ray  examination  may  also  show  certain  important  anatomical 
details  which  maj^  be  of  great  service  during  the  operation. 

*  Loc.  infra  cit. 


WI  OPERATIONS  OX  THE  HEAD  AND  NECK 

should  have  weight  is  that  the  longer  operation  is  deferred  the  more  pro- 
longed will  be  the  after-treatment,  and  the  greater  the  risk  of  deformity. 

Operation.  (Figs.  162,  163.)  This  will  vary  according  as  the  case  is 
acute  or  chronic,  and  whether  comphcated  with  disease  elsewhere. 

Owing  to  the  risk  of  infective  troubles  alluded  to  below,  every  care 
should  be  taken  in  the  preliminary  sterilisation.  Xot  only  are  the  eye- 
brows to  be  shaved  and  skin  thoroughly  cleansed,  but  all  the  parts  adjacent 
to  the  field  of  operation  are  to  be  rendered  as  sterile  as  possible.  Before 
opening  the  sinus,  any  polvpi  should  be  removed  from  the  nose,  and  to 
facihtate  drainage  the  anterior  end  of  the  middle  turbinated  bone  should 
be  removed  (see  p.  4:55). 

The  mouth  and  teeth  (more  particularly  if  the  antrum  is  also  infected) 
will  require  attention. 

(a)  In  Acute  Cases.  Ether  ^  having  been  given  and  the  posterior 
nares  blocked  by  a  plug  of  sterihsed  lint  secured  with  tape,  an  incision  is 
made  cur^'ing  from  ^"ithin  outwards,  commencing  above  the  site  of  the 
internal  palpebral  Ugament,  i.e.  a  little  below  the  inner  end  of  the  eyebrow 
(Figs.  162,  163).  The  incision  should  be  immediately  below  the  hne  of 
the  eyebrow  and  extend  to  the  jmiction  of  its  middle  and  outer  thirds. 
At  its  inner  parts  it  should  pass  down  to  the  bone  at  once,  the  outer  part 
being  made  more  superficially  at  first,  especially  in  shghter  cases,  so  as  to 
spare  the  supra-orbital  nerve  if  possible. 

The  incision  is  on  no  account  to  pass  below  the  supra-orbital  ridge, 
which  is  always  to  be  preserved.  The  periosteum  ha^'ing  been  cleanly 
di^^ded,2  the  soft  parts  are  raised  ^  with  an  elevator.  The  bone  is  then 
removed  with  gouge  or  chisel  and  mallet,  commencing  on  the  supra- 
orbital margin  vertically  above  the  inner  canthus.  Xo  undue  force  is  to 
be  used  with  the  mallet ;  the  eye  may  be  protected  with  a  sterihsed  pad. 
The  sinus  having  been  opened,  its  extent  is  ascertained  with  a  probe,  and 
the  opening  enlarged  chiefly  in  an  upward  and  outward  direction.  The 
amount  of  bleeding  during  this  stage  varies  ;  if  considerable,  it  is  best 
met  by  remo%"ing  the  bone  as  rapidly  as  is  consistent  with  safety,  and  then 
by  firm  plugging.  Suitable  dossils  of  sterihsed  gauze  and  adrenahn  solution 
(i  in  1000)  should  be  at  hand  for  this  purpose,  with  smaller  ones  for 
cleansing  the  recesses  of  the  sinus.  As  the  bone  is  removed,  the  mucous 
membrane,  normally  thin  and  bluish  in  colour,  now  more  li^-id  red, 
thickened  and  friable,  vryW  protrude  into  the  opening.  "When  opened, 
muco-pus,  pus.*  granulation-pol^-pi,  or  exposed  bone  will  be  met  '^ith 
according  to  the  duration  of  the  case.     On  this  depend  the  further  steps 

^  This  operation  is  one  which  it  is  probably  .safer  to  rely  upon  ether  throughout. 
G.  Fetterolf,  of  PhUatlelphia,  has  drawn  attention  (Aimr.  Med..  March  19.  1904)  to  a  case 
in  which  cardiac  inhibition  took  place  reflexly  from  irritation  of  the  peripheral  fibres  of  the 
fifth  nerve  during  an  operation  for  chronic  empyema  of  the  frontal  sinus.  Each  time  that 
the  curette  was  applied  there  was  a  marked  diminution  in  the  force  and  frequency  of  the 
pulse,  together  with  distinct  cyanosis.  The  path  of  the  impulse  is  through  the  sensory 
branches  of  the  fifth  to  the  fourth  ventricle,  and  so  to  the  vagus. 

2  Dr.  H.  TUley  has  found  from  an  examination  of  120  skulls  that  a  quarter-inch  trephine 
applied  to  the  lower  margin  of  the  frontal  bone  between  the  middle  line,  and  one  drawn 
vertically  upwards  from  the  internal  angular  process,  will  in  all  cases  open  the  sinus,  if  one 
exist. 

3  Especial  care  must  be  taken  to  deal  gently  with  the  periosteum  in  cases  where  it 
will  be  needful  to  obliterate  the  sinus.  In  such  cases  this  membrane  plays  an  important 
part. 

*  The  amount  of  this  in  a  sinus  which  has  been  discharging  freely  by  the  nose  may  be 
small.  While  there  is  no  specific  organism,  the  following  have  from  time  to  time  been 
demonstrated  in  pus  from  infected  sinases — streptococci,  meningococci,  pneumococci, 
and  the  bacUli  of  Pfeiffer  and  Friedlander  (Milligan). 


OPERATIONS  OX  THE  FRONTAL  SINUSES         413 


^^. 


Fig    102      Kilians  operation  for  chronic  suppuration  in  the  fronto-cthmoidal 
cells.     (Tilley.)  ^ 


Fig    ir33      Cavity  of  sinus  after  removal  of  the  anterior  wall  and  of  diseased 
mucous  membrane.     The  dotted  line  indicates  upward  extension  of  the  sinus. 

(Tillev.) 


1  These  figures  are  taken  from  a  paper  by  Dr.  H.  Tilley  {Lancet  M^y  21,  1904.  p.  1414) 
Reference  may  be  made  to  this  and  another  practical  paper  by  the  sanae  authority  (/^nf. 
^ffr^  Tnnrii  Aucrust  30  1002.  p.  582).  and  one  by  Dr.  R.  Milhsan  (Brtt.  Med.  Jorrn. 
jamiary  28,']905rp  171).  as  wdl  as  to  the  discussion  opened  by  Dr.  Milligan  mentioned 
on  p.  411. 


414  OPERATIONS  ON  THE  HEAD  AND  NECK 

of  the  operation.  It  if  be  a  recent  one  dating  to  an  acute  infection  from 
the  nose,  e.g.  influenza,  and  if  the  sinus  is  a  small  one,  it  will  be  sufficient 
to  remove  the  anterior  wall  sufficiently  to  admit  of  ck>,ansing  the  siims 
completely  and  finding  the  orifice  of  the  fronto-nasal  duct.  A  drainage 
tube  is  passed  along  this  into  the  nose,  the  upper  end  being  brought  out 
through  the  lower  and  inner  margin  of  the  incision,  which  is  never  to  be 
closely  sutured.  These  points  will  now  be  taken  in  detail.  The  anterior 
wall  having  been  cut  away,  pus  is  washed  away  by  syringing  with  sterile 
saline  solution,  and  the  mucous  membrane  is  gently  wiped  with  dossils  of 
gauze. 

The  orifice  of  the  fronto-nasal  duct  is  found  with  the  help  of  a  blunt 
probe  and  a  small  drainage  tube  with  lateral  windows  is  passed  through 
it  to  the  nasal  fossa.  The  wound  is  sutured  except  where  the  end  of  the 
drainage  tube  projects. 

(6)  In  chronic  cases.  The  sinus  is  opened  in  a  similar  way  and  the 
cavity  thoroughly  exposed  by  removal  of  its  anterior  wall.  All  polypi 
and  the  swollen  infected  membrane  must  be  removed  with  a  small  spoon 
or  curette.  If  the  case  be  of  any  duration,  it  will  be  needful  to  scrutinise 
the  cavity  for  any  loculi  or  recesses  in  which  infective  material  may  lurk. 

In  exploring  these  with  a  small  spoon,  especial  care  is  needed  in  dealing 
with  the  inferior  and  posterior  walls,  the  former  on  account  of  the  meninges, 
the  latter  chiefly  on  account  of  the  pulley  of  the  superior  oblique  (p.  417). 
If,  accidentally,  any  opening  be  made  in  the  posterior  wall,  this  must  be 
at  once  plugged  with  sterile  gauze  until  the  operation  is  completed. 
According  to  Dr.  Tilley,  diverticula  of  the  main  sinus  may  exist, 
especially  below.  Their  openings  are  easily  missed.  The  next  step 
will  be  to  find  the  fronto-nasal  duct  at  the  junction  of  the  posterior  and 
inner  walls  with  a  curved  probe  or  small  bougie. 

The  patency  of  the  duct  must  be  restored  to  ensure  a  medium-sized 
drainage  tube  being  passed  as  above.  To  enable  this  to  be  done,  and  at 
the  same  time  to  remove  parts  which  are  certain  now  to  be  involved 
(p.  410),  the  anterior  ethmoidal  cells  which  lie  in  front  of  the  probe,  acting 
as  a  guide  in  the  duct,  must  be  broken  through  and  removed  with  a  small 
gouge,  curette  and  burrs.  To  allow  this  to  be  done  efficiently,  it  will 
be  well  in  severe  cases  to  prolong  the  skin  incision  carefully  downwards,  and 
to  detach  the  periosteum  downwards  and  backwards.  Attention  must 
be  paid  at  this  stage  to  the  pulley  of  the  superior  oblique.  If  this  be 
detached  cleanly  and  without  damage,  any  after-trouble  {vide  infra)  will  be 
slight  and  temporary.  Any  interference  wdth  vision  which  may  show  itself 
for  a  few  days,  is  more  likely  to  be  caused  by  inflammatory  exudation. 

In  difficult  cases  passage  of  the  tube  and  breaking  down  of  the  an- 
terior ethmoidal  cells  will  be  facilitated  by  the  introduction  of  the  little 
finger  through  the  nostril,  and  the  introduction  by  this  route  of  small, 
ring-shaped  curettes.  But  it  will  be  safer  to  do  most  of  the  work  from 
above,  the  probe  in  the  sinus  being  a  guide  as  to  the  amount  of  bone 
which  lies  in  front  of  it  and  which  may  be  safely  removed. 

When  the  essential  point  of  free  drainage  has  been  secured  the 
operator  must  decide,  in  chronic  and  advaiiced  cases,  as  to  the  advisa- 
bility of  removing  freely  the  anterior  and  the  inferior  walls  of  the  sinus. 
He  will  have  explained  to  the  patient  that  such  obliteration  is  more  likely 
to  lead  to  a  certain  and  less  delayed  cure,  but  at  the  cost  of  an  evident 
depression.  The  size  of  the  sinus,  as. manifested  by  a  probe  (the  larger 
the  cavity  the  greater  the  disfigurement  resulting),  the  age  and  sex  of 


OPERATIONS  ON  TIIK  FHONTAL  SINUSES  nr, 

the  patient,  the  extent  of  tlie  disease,  and  especially  the  piesenc(>  of 
caries  will  iruide  the  surfj^eon  in  coming'  to  a  decision.  One  other  indica- 
tion may  be  given.  In  some  cases  no  duct  can  be  found  by  the  ))robe  ; 
in  a  few,  after  most  careful  attempts,  tlie  surgeon  may  fail  in  securing  a 
new  aiid  achMpuite  track  for  drainage  :  in  these  cases  the  cavity  shouhl 
be  obhterated,  otherwise  caries,  reopening  of  the  wound  and  a  persistent 
sinus  are  bound  to  foHow.  It  need  scarcely  be  added  that  in  advanced 
cases  there  is  additional  urgency  for  attention  to  the  details  alieady 
given  as  to  the  need  of  removing  all  diseased  tissues,  fiiuling  any  diverti- 
cula, and  taking  every  piecaution  to  leave  the  cavity  in  as  sterile  a  con- 
dition as  possible.  Before  the  dressings  are  applied  all  recesses  of  the 
wound  should  be  again  washed  out  and  dried,  and  any  small  plug  which 
has   been  inserted  in  a  possible  opening  in  the  posterior  wall  removed. 


Fig.  164.     Symonds'  frontal  sinus  cannula. 

A  drainage-tube  should  be  passed  along  the  fronto-nasal  duct  into  the 
nasal  fossa  as  advised  in  the  operation  for  acute  trouble.  One  or  two 
lateral  openings  should  be  cut  in  its  upper  part  and  this  end  should  just 
project  through  the  external  wound.  It  is  now  syringed  through,  and 
the  cavity  lightly  packed  with  sterile  ribbon  gauze,  one  end  of  which  is 
brought  out  at  the  lower  angle  of  the  incision  by  the  side  of  the 
tube.  The  outer  part  of  the  wound  is  then  carefully  sutured  with 
gossamer  salmon-gut.  Boracic  fomentations  are  usually  to  be  pre- 
ferred to  dry  dressings.  Finally  the  plug  in  the  posterior  nares  is 
removed. 

It  is  always  easier  to  insist  on  adequate  and  prolonged  drainage 
than  to  ensure  its  attainment  in  all  cases.  In  some,  the  tube  causes 
irritation,  in  others  it  soon  becomes  blocked,  and  we  are  all  aware  that 
drainage-tubes  may  be  sources  of  infection.  On  the  other  hand,  the 
importance  of  securing  patency  of  the  fronto-nasal  duct,  to  make  certain 
of  the  cure  remaining  thorough,  is  paramount.  Irritation  and  blocking 
of  the  tube  are  best  avoided  by  making  a  free  passage  for  the  tube  to  lie  in  ; 
infection  by  the  tube  by  remembering  that  keeping  the  skin  about  the 
wound  and  the  nose  as  sterile  as  possible  is  important  after  as  well  as 
before  the  operation. 

Where  the  disease  is  bilateral,  the  scarring  will  be  less  if  the  sinuses  are 
treated  by  separate  incisions.  Where  this  method  is  employed  at  one 
time,  the  operator  must  not  be  hurried  when  he  deals  with  the  second 
sinus,  or  the  result  is  certain  to  be  imperfect.  A  median  inverted  T- 
shaped  incision  may  be  made  use  of  in  men  ;  the  scar  tends  to  become 
much  less  noticeable  with  time,  but  this  method  gives  less  room. 
For  this  reason  especially  the  other  method  is  preferable,  but  the 
patient  should  always  be  warned  of  the  possible  necessity  of  the 
operations. 


416  OPERATIONS  ON  THE  HEAD  AND  NECK 

Of  the  other  sinuses,  disease  of  the  ethmoid  and  antrum  most  fre- 
quently complicates  that  of  the  frontal  sinus. ^ 

Transillumination,  radiographic  examination, ^  the  amount  of  sup- 
puration, the  number  and  extent  of  polypoid  masses,  and  evidence  of,  or  a 
history  of  previous  dental  trouble  may  all  help  to  elucidate  this  point. 
When  the  surgeon  feels  assured  as  to  the  co-existence  of  frontal  and  antral 
suppuration,  he  may  be  in  doubt  as  to  which  sinus  he  will  deal  with 
first.  Dr.  Tilley  ^  is  strongly  of  opinion  that  the  upper  sinuses  should 
be  dealt  with  first,  as  the  pus  may  be  formed  above,  the  antrum  merely 
acting  as  a  reservoir.  The  surgeon  will  have  an  additional  reason  for 
following  this  advice  in  the  fact  that  by  waiting  to  see  if  operation  on  the 
upper  sinuses  suffices,  he  will  be  better  able  to  deal  with  other  mischief  if 
this  prove  necessary,  than  if  he  had  attempted  to  cope  with  several 
sinuses  at  one  time. 

Operations  on  the  maxillary  antrum  are  described  below  (p.  431). 
Nothing  has  been  said  on  the  subject  of  the  sphenoidal  sinuses,  since 
disease  in  this  situation  is  not  a  common  complication  of  suppuration  in 
the  frontal  sinus.  For  detailed  information  on  the  diagnosis  and  treat- 
ment of  suppuration  in  this  inaccessible  situation,  where  the  mischief  is 
less  evident,  and  where  it  is  necessary  to  find  and  enlarge  the  orifice  and 
remove  polypi,  granulations  and  carious  bone,  the  reader  is  referred  to 
some  special  work  on  this  branch  of  surgery. 

When  frontal  sinus  suppuration  is  complicated  by  extensive  disease 
of  the  ethmoid,  some  more  radical  operation  is  required  to  eradicate  the 
whole  of  the  disease.  Under  these  circumstances  Kilian's  operation  is 
indicated.  The  incision  is  siniilar  to  that  described  above,  but  it  is  pro- 
longed downwards  in  front  of  the  inner  canthus  along  the  nasal  process  of 
the  superior  maxilla.  The  periosteum  is  displaced  by  a  rugine  and  the 
sinus  opened.  The  whole  of  its  anterior  wall  down  to  the  supra-orbital 
ridge  is  removed,  and  the  floor  is  then  completely  cut  away  by  bone 
forceps  so  as  to  allow  the  orbital  fat  to  bulge  upwards  and  aid  in  the 
obliteration  of  the  cavity.  Care  is  taken  to  preserve  the  margin  of  the 
orbit  entire.  All  diverticula  are  followed  up  and  all  diseased  mucous 
membrane  is  curetted  away  as  described  above.  A  second  opening  is 
now  made  by  removing  the  upper  part  of  the  nasal  process  of  the  superior 
maxilla.  This  gives  a  good  view  of  the  anterior  ethmoidal  cells,  which  are 
closed  in  by  this  process.  The  disease  can  then  be  efficiently  treated  by 
sharp  spoon   curette,  or  forceps. 

It  will  be  seen  that  in  this  method  a  bridge  of  bone  consisting  of  the 
supra-orbital  margin  is  preserved  between  the  two  openings,  and  thus 
excessive  deformity  is  prevented.  Drainage  will  take  place  into  the 
nasal  fossa,  and  hence  the  external  wound  can  be  completely  sutured. 
In  this  operation  attention  must  be  directed  to  avoidance  of  injury  to 
the  pulley  of  the  superior  obUque  muscle  or  diplopia  may  result.  If 
desired  the  floor  of  the  sinus  may  be  left,  but  this,  though  simplifying 
the  operation,  necessitates  longer  after-treatment. 

^  It  is  a  matter  of  comparative  rarity  to  find  only  one  .sinus  or  one  group  of  cells 
affected  ;  in  the  vast  majority  of  cases  two  or  more  sinuses  are  involved.  Zuckerkandl 
never  found  a  single  case  post-mortem  in  which  frontal  sinus  suppuration  was  uncom- 
plicated with  ethmoidal. 

^  Transillumination,  though  of  great  assistance  in  the  diagnosis  of  pus  in  the  antrum, 
is  of  doubtful  use  in  the  case  of  the  frontal  sinus.  The  lamp  should  be  placed  below  the 
inner  third  of  the  supra-orbital  arch. 

3  Lancet,  1904,  vol.  i..  p.  1416  ;    Brit.  Med.  Journ.,  1902,  vol.  ii.,  p.  585. 


OPERATIOXS  ON  THE  FRONTAL  SINUSES         417 

Aiter-treatment.  A  varying  amount  of  oedema  and  ecchymosis 
in  tho  loose  tissues  of  the  eyelid  is  certain.  In  acute  cases  the  dressings 
should  be  changed  on  the  following  day.  The  drainage-tube  should 
be  removed  on  the  second  or  tliird  day,  and  after  the  sinus  has  been 
irrigated  with  some  weak  antiseptic  lotion  such  as  boracic,  the  tube, 
which  has  been  resterilised,  is  replaced.  Gauze  dressings  may  be  used 
instead  of  fomentations  when  the  swelling  has  subsided.  The  treat- 
ment is  repeated  daily,  and  in  about  two  weeks  there  should  be  very  little 
pus,  so  that  the  tube  may  be  omitted  and  the  external  wound  allowed  to 
close. 

In  chronic  cases  the  after-treatment  is,  necessarily,  much  more  pro- 
longed. At  the  end  of  twenty-four  or  forty-eight  hours,  according  to 
the  state  of  the  parts  and  the  course  which  the  case  is  running,  the  gauze 
drain  should  be  removed.  If  the  condition  is  favourable,  it  need  not  be 
replaced,  a  strip  only  being  now  left  in  the  lower  angle  of  the  wound  to 
promote  free  drainage.  When  it  is  removed,  the  wound  must  be  carefully 
irrigated,  and  the  nose  and  mouth  must  also  h6  carefully  kept  clean.  The 
first  changing  of  the  drainage  tube  should  be  left,  if  possible,  until  the 
third  day,  and  is  much  facilitated  by  having  a  loop  of  silk  attached  to 
its  upper  end.  It  should  always  be  drawn  from  above  downwards 
through  the  nostril.  The  drainage  tube  must  be  replaced  and  cannot  be 
dispensed  with  until  the  discharge  is  scanty  and  serous  looking.  This 
often  requires  a  period  of  four  or  five  weeks.  In  one  case  of  chronic 
disease,  in  a  patient  of  sixty-five,  with  a  huge  right  sinus,  typical  egg- 
shell crackling,  and  downward  protrusion  of  the  eye-ball,  it  was  seven 
weeks  before  the  wound  was  closed,  the  drainage  tube  being  continued 
for  a  month.  A  feature  of  interest  in  this  case  was  the  fact  that  the 
sinuses  communicated  by  an  aperture  as  large  as  a  sixpence.  This 
allowed  of  the  left  sinus,  much  less  afiected,  being  dealt  with  with- 
out a  second  incision.  When  the  fomentations  are  omitted,  firm 
pressure  with  sterilised  gauze  or  pads  and  a  tight  bandage  will  be  found 
helpful. 

Possible  Sequelae  after  Operations  on  the  Frontal  Sinuses.  The  chief 
of  these  are  :  (1)  hifective  Truuhlc.  In  spite  of  all  care,  septic  osteo- 
myelitis, lighting  up  into  fresh  activity  of  quiescent  mischief  in  adjacent 
parts,  meningitis  and  cerebral  abscess,  are  all  grave  possibilities  to  be 
borne  in  mind.  To  avoid  these  serious  complications,  which  are  almost 
invariably  fatal,  it  is  necessary  to  have  removed  the  whole  of  the  disease 
and  to  provide  adequate  drainage  both  by  the  nose  and  through  the  ex- 
ternal wound.  Should  severe  pain,  swelling,  pyrexia,  or  other  symptoms 
suggesting  retained  pus  make  their  appearance  after  the  operation,  the 
stitches  should  be  removed  and  free  drainage  provided.  Should  symp- 
toms still  continue  the  wound  must  be  thoroughly  explored. 

(2)  Persistence  of  the  Disease.  This  may  be  due  to  an  incomplete 
operation,  or  to  mischief  in  the  opposite  sinus,  or  in  the  ethmoid,  an- 
trum. &c. 

(3)  Disfigurement.  This,  chiefly  marked  in  cases  where  the  disease 
is  extensive,  and  where  the  sinus  has  a  large  antero-posterior  extent, 
may,  if  persistent  in  young  subjects,  be  probably  remedied  by  the  injec- 
tion of  paraffin  {q.v.). 

(4)  Diplopia,  from  Injury  to  the  Pulley  of  the  Superior  Oblique.  This 
is  usually  temporary,  and  with  other  minor  sequelae,  such  as  ecchymosis 
and  altered  sensation  over  the  brow,  needs  no  further  mention. 

SURGERY    I  2y 


418  OPERATIONS  ON  THE  HEAD  AND  NECK 

(5)  Persistence  of  an  External  Sitivs.  This  is  due  to  some  focus  of 
disease  having  been  overlooked — very  possibly  in  the  ethmoid  cells. 
Further  operation  is  indicated. 

(6)  Dr.  Milhgan  has  noticed  in  several  cases  the  development  of  a 
keloid  scar  some  months  after  operation.  This  he  attributes  to  constant 
action  of  the  fibres  of  the  orbicularis  palpebrarum  preventing  local  rest 
to  the  tissues.  In  the  same  way  he  considers  the  movements  of  the  pla- 
tysma  as  responsible  for  the  keloid  appearance  of  the  scar  after  operations 
upon  the  neck.  The  ages  of  the  patients  and  the  time  occupied  in  healing 
are  not  mentioned,  but  there  is  no  doubt  that,  in  cases  where  primary 
union  has  been  secured,  scars  in  the  neck,  e.g.  after  partial  removal  of 
the  thyroid,  may  take  on  a  keloid  condition  some  time  after  an  operation 
in  those  no  longer  voung. 


CHAPTER  XX 

OPERATIONS  OF  THE  JAWS.  EXCISION  OF  THE  UPPER 
JAW,  PARTIAL  AND  COMPLETE.  OPERATIONS  ON  THE 
ANTRUM  OF  HIGHMORE.  EXCISION  OF  THE  LOWER 
JAW,  PARTIAL  AND  COMPLETE.  OPERATIONS  FOR 
FIXITY  OF  THE  LOWER  JAW 

OPERATIONS  OF  THE  UPPER  JAW 

These  will  include  : 

(i)  Removal,  partial  or  complete,  for  growths  (Figs.  1G5,  16G,  1G7). 
(ii)  Operations  for  naso-pharyngeal  fibroma  (Figs.  181,  182). 
(iii)  Operations  on  the  maxillary  antrum. 

REMOVAL  OF  THE  UPPER  JAW,  PARTIAL  OR  COMPLETE 

Indications.  These  include  the  diiierent  growths  to  which  the  upper  jaw 
is  liable,  and  opportunity  will  be  taken  here  to  give  briefly  the  chief 
practical  points  in  connection  with  these. 

(1)  Epulis.  One  of  the  new  growths  most  frequently  met  with  here. 
Etymologically  tumours  of  the  gum  these  growths  vary  a  good  deal.  At 
first,  and  most  frequently,  they  are  simply  fibrous,  tough,  and  firm, 
springing  from  the  periosteum,  the  peridental  membrane,  and  the 
endosteal  lining  of  an  alveolus. 

Myeloid  cells  and  small  spicules  of  bone  are  not  uncommon.  The 
longer  they  are  left,  the  more  they  are  irritated,  especially  wnth  imperfect 
attempts  at  removal,  the  more  cellular  and  vascular  do  they  become. 

Very  rarely  on  extracting  the  tooth,  to  the  alveolus  of  which  the  growth 
is  connected,  the  epulis  comes  away  completely.  Much  more  frequently 
it  is  firmly  connected  to  the  periosteum  and  subjacent  cancellous  tissue,  or 
to  the  endosteal  lining  of  one  or  more  alveoli.  Removal  should  be  early 
and  complete.  Shaving  off  the  growth  and  the  gum  beneath,  and  then 
cauterising  any  suspicious  granulations,  is  most  uncertain  and  unsatis- 
factory, especially  if  the  presence  of  teeth  be  allowed  to  interfere  with 
the  complete  removal  of  the  growth,  or  if  this  be  connected  with  stumps, 
and  thus  dips  deeply  into  an  alveolus.  By  far  the  best  treatment  is  to 
extract  a  tooth  in  front  and  another  behind  the  growth,  and  then  with  a 
narrow  saw  to  notch  the  bone  at  these  points  deeply  through  the  alveoli  : 
with  cutting-forceps,  or,  better,  a  chisel  and  mallet,  a  V-shaped  or 
rectangular  piece  of  the  bone  is  then  removed.  In  the  case  of  the  mandible 
this  bone  must  be  steadied.  The  extraction  of  teeth  not  only  enables  the 
surgeon  thoroughly  to  eradicate  the  growth,  but  their  removal  leads,  as 
pointed  out  by  Mr.  Salter,^  to  wasting  of  the  alveolus,  and  thus  to  non- 
recurrence  of  the  growth.  The  teeth,  if  sound,  and  if  the  patient  so  desire, 
should  be  preserved,  and  later  on,  when  all  is  firmly  healed,  fitted  to  a 
plate  by  a  dentist.     The  deformity  is  thus  rendered  imperceptible. 

1  System  of  Surgery,  vol.  ii,  p.  4.56.  Mr.  Salter  also  poiats  out  that  where  an  epulis 
forms  on  an  apparently  edentulous  part  of  the  jaw,  the  existence  of  s-tumps  should  always  be 
looked  for. 

41.9 


420  OPERATIONS  ON  THE  HEAD  AND  NECK 

If  a  patient  refuses  the  only  operation  which  is  safe,  the  siu'geon 
must  rest  satisfied  with  shaving  off  the  growth,  gouging  the  subjacent 
bone,  and,  if  needful,  cauterising  any  suspicious  patches  later  on.  This 
course  is  not  only  much  more  tedious  and  painful,  but  is  also  uncertain. 

(2)  Fibroma.  These  originate  either  in  the  periosteum  or  in  the 
endosteum  of  the  antrum,  the  connective  tissue  of  the  medulla.  Haversian 
canals,  vessels,  &c.  At  first  firm,  dense,  and  slow-gro^^^ng,  they  may, 
from  the  frequent  irritation  inseparable  from  their  site,  become  vascular, 
sloughy,  and.  taking  on  more  rapid  growth,  tend  to  invade  the  numerous 
fossae,  fissures,  and  foramina  in  the  neighbourhood  of  the  bone. 

They  should  be  attacked  early  ;  and  while  the  surgeon  may  need  at 
this  stage  to  remove  only  the  periosteum  and  bone  from  which  the 
tumour  springs,  especially  if  it  be  alveolar  in  origin,  or  after  opening  the 
antrum  to  shell  out  the  fibroma  completely,  he  must  also  be  prepared 
for  more  radical  measures,  e.g.  when  the  growth  is  of  long  standing,  of 
late  more  rapid,  if  the  patient  is  at  all  advanced  in  years,  and  especially 
if  the  growth  is  a  reappearing  one. 

(3)  Sarcoma.  These  include  the  spindle,  round  and  myeloid  varieties, 
the  fibro-,  chondro-,  and  osteo-sarcomata,  and  the  rarer  forms  of  alveolar 
sarcoma.  While  the  more  slowly  growing  ones  simulate  more  innocent 
growths  such  as  epuhs,  the  more  rapid  ones  will  tax  the  surgeon's  judgment 
as  to  whether  any  operation  is  justifiable,  and  all  his  sldll  if  removal  be 
attempted.     On  these  subjects  the  reader  is  referred  to  p.  423. 

(4)  Carcinomata.  These  are  usually  of  the  squamous  kind,  and 
commence  in  the  alveolar  border  in  the  form  of  ulceration,  beginning  in 
syphilitic  scars,  or  the  irritation  of  an  ill-fitting  tooth-plate.  They  tend 
to  creep  far  back,  and  to  invade  the  palate  and  tonsil  ;  on  this  account 
they  should  be  operated  on  early.  Whenever  a  sore  in  this  position  is 
suspicious  in  its  characters,  and  obstinate  to  treatment,  whatever  be  the 
age  of  the  patient,  the  parts  aft'ected  should  be  widely  and  freely  extir- 
pated. If  the  growth  has  eaten  into  the  antrum,  or  has  travelled  back 
so  as  to  invade  the  pterygoid  region,  removal  of  the  whole  bone  is  most 
likely  to  benefit  the  patient.  More  rarely  a  squamous  epithelioma 
attacks  the  jaw  from  the  lip  or  face.  This  happens  much  more  often  in 
the  case  of  the  lower  jaw. 

Another  epithelial  growth  met  ^\\t[\  here  is  a  carcinoma,  by  no  means 
infrecjuent,  and  it  is  often  a  difficult  matter  to  distinguish  it  clinically 
from  a  sarcoma.  Also  the  tubular  ^  variety  (cylindrical  or  adenoid 
carcinoma),  which  begins  in  the  mucous  membrane  of  the  antrum  or 
nose.  It  is  marked  by  rapidity  of  growth  and  invasion  of  the  surrounding 
parts,  and  is  thus  of  grave  prognosis. 

Acfordi ng  to  Prof.  Schlatter,-  carcinomata  as  compared  with  sarcomata 
possess  the  following  characteristics  :  They  usually  occur  in  older 
patients — the  average  age  in  the  case  of  sarcoma  is  about  35,  in  that  of 
carcinoma  about  55 — they  are  commoner  in  the  upper  than  the  lower 
jaw,  pain  is  greater  at  an  early  date,  growth  and  infiltration  are  more 
marked.  Involvement  of  the  lymphatic  glands  is  more  common  in 
carcinoma,  especially  in  the  case  of  the  mandible.  In  that  of  the 
maxilla  it  is  less  common,  but  it  is  to  be  remembered  that  it  is  the 
deep  glands  along  the  internal  maxillary  and  internal  carotid  which  are 
affected. 

I  Mr.  Heath  (Diet,  of  Surg.,  vol.  i.  p.  8.57)     quotes    Reclus    as    calling    this    form 
epithelioma  terebrant,  from  its  boring  or  burrowing  tenilency. 
*  Von  Bergmann's  Si/sf.  Prcicf.  Surg.,  supra  cif. 


REMOVAl.  OF  TTTK  Tl^PKl?   JAW  421 

(5)  Odontomes  and  Dentigerous  Cysts,  rndor  this  lu'.uliii^  the  coin- 
moiier  odontoincs  aiul  dental  cysts  will  he  alluded  to,  Of  odoiitouu's  or 
jirowtlis  ''eoinposed  ol'  dental  tissues  in  varvinj;  pro])oition  and  in  dilYerent 
de<;rees  of  development  aiisiji^  from  teeth  germs,  or  teeth  still  in  the  pro- 
cess of  growth"  (Bland  Sutton),  the  commonest  arc  the  epithelial  and 
the  follicular  odontomes.^ 

{a)  The  ei)ithelial  odontomes  (inultiloeular.  cystic  epithelial  growths 
of  Kve),  wiiile  occurring  as  a  rule  in  the  mandible,  have  been  observed  in 
the  maxilla.  They  are  most  frequent  about  the  twentieth  year.  The 
structure  is  that  of  a  fairly  firm  capsule,  containing  a  collection  of  various 
sized  cysts  separated  by  their  septa  and  containing  brownish  mucoid 
fluid.  Microscopically  they  consist  of  branching  columns  of  cells,  often 
columnar,  often  imperfect,  the  origin  of  which  is  as  yet  uncertain.  In 
some  cases  it  may  be  from  remains  of  the  enamel  organ,  in  others  from 
the  gum,  and  in  some  it  is  of  endothelial  origin.  While  in  many  cases, 
owing  to  the  bony  capsule  and  the  early  degeneration  of  the  epithelium, 
these  growths  have  little  tendency  to  spread,  where  they  are  of  endo- 
thelial origin,  or  where  sarcomatous  change  has  set  in  from  irritation,  the 
outlook  is  nuich  more  grave. 

{h)  FoUicular  Odontomes  or  Dentigerous  Cysts.  These  are  formed  by 
a  collection  of  viscid  or  serous  fluid  taking  place  during  the  development 
of  a  tooth,  nearly  always  a  permanent  one,  and  especially  a  molar,  which 
has  not  come  through  the  bone.^ 

There  are  two  varieties  of  these  cysts  ;  one,  the  commonest,  is  cystic 
only,  consisting  of  an  outer  bony  shell  of  varying  thickness,  and  an  inner 
membranous  one.  The  tooth  may  be  well  formed,  or  a  small,  shapeless, 
calcified  mass  ;  its  crown  usually  projects  into  the  sac,  vertically  or  hori- 
zontally. The  following  points  are  of  practical  importance.  These 
cystic  swellings  may  be  taken  for  solid  growths,  but  this  mistake  may  be 
avoided  by  remembering  that  when  such  a  swelling  exists  there  is  usually 
a  history  of  its  having  commenced  in  early  life,  and  that  though  all  the 
teeth  may  appear  to  be  present,  one  will  very  likely  be  found  to  be  a 
temporary  one.  Furthermore,  there  is  the  help  derived  from  puncture 
with  a  fine  trocar. 

In  the  other  variety,  usually  of  longer  duration  and  in  older  patients, 
solid  growth  of  a  sarcomatous  nature  is  present  in  addition  to  the  cyst. 

(6)  Dental  Cysts.  These  usually  occur  in  connection  with  carious 
teeth  or  the  stumps  of  teeth.  They  are  met  with  in  either  jaw.  Suppura- 
tion and  a  sinus,  very  rare  in  the  case  of  follicular  odontomes,  are  more 
common  here.  Occasionally  they  are  allowed  to  grow  until  clinically 
they  resemble  new  growths.  Their  painless  slow  growth  and  above-given 
origin  should  always  cause  their  presence  to  be  suspected. 

1  For  further  information  on  odontomes,  especially  the  rarer  forms.  Mr.  Bland 
Sutton's  Tumours  Innocent  and  Malignnnt.  p.  47.  should  be  referred  to,  with  its  excellent 
illustrations.  The  following  seven  varieties  are  recognised:  (1)  Epithelial  odontomes, 
or  libro-cystic  disease  of  the  jaw  ;  (2)  follicular  odontomes  ;  (3)  fibrous  odontomes  ; 
(4)  radicular  odontomes;  (5)  cementomes  ;  ((5)  composite  odontomes;  (7)  malignant 
odontomes.  The  excellent  and  comprehensive  Report  on  Odontomes,  published  by  the 
British  Dental  Association,  1914,  should  also  be  read  by  those  desiring  a  detailed  account 
of  these  tumours. 

2  Mr.  v^alter  [Syst.  of  Surg.,  vol.  ii,  p.  4(59)  gives  the  following  three  circumstances  as 
capable  of  pioducing  impaction  of  a  tooth  :  (1)  The  tooth  may  be  originally  developed 
too  deep  in  the  body  of  the  jaw — thus,  though  it  grow  in  the  right  direction,  it  will 
never  reach  the  alveolar  margin  ;  (2)  while  it  may  be  sufficiently  superficial,  it  takes  an 
oblique  direction  of  growth,  so  that  it  lies  covered  more  or  less  in  the  axis  of  the  bone  ; 
(3)  the  position  of  the  tooth  and  its  line  of  growth  may  be  originally  normal,  but  from 
arrest  of  the  development  of  the  fang  it  may  fail  to  reach  the  alveolar  edge. 


422  OPERATIONS  ON  THE  HEAD  AND  NECK 

Treatment.  In  the  case  of  the  epitheUal  odontomes  where  the  growth 
has  been  slow  and  the  cystic  element  is  the  chief  one,  the  operation 
performed  within  the  mouth  should  be  on  the  lines  of  that  given  for 
epulis  (p.  419),  aided  by  the  gouge,  gouge  forceps,  and  small,  really  sharp 
curettes.  All  diseased  tissue,  cystic  or  bony,  must  be  removed.  The 
basilar  border  can  always  be  left.  Where  the  growth  is  of  longer  duration, 
the  patient  older,  and  the  amount  of  solid  tissue  present  greater,  the 
whole  thickness  of  the  jaw  must  be  resected  ;  and  where  it  is  a  case  of 
reappearance  of  a  growth,  extensive  resection  is  indicated. 

In  the  case  of  the  follicular  odontome  or  dentigerous  cyst,  the  treat- 
ment consists  in  exposing  the  surface  of  the  cyst  by  turning  the  lip  up, 
incising  the  mucous  membrane  and  then  in  cutting  away  freely  (with 
gouge  and  chisel,  aided  by  a  three-quarter  inch  trephine  if  needful) 
the  walls  of  the  cyst,  so  as  to  examine  its  contents,  and  next  digging 
out  the  tooth- — often  the  most  difficult  part  of  the  operation.  The 
cavity  is  then  carefully  stuffed  with  strips  of  aseptic  gauze  to  encourage 
its  granulating  from  the  bo':tom.  If  any  swelling  persist,  keeping  up 
deformity,  pressure  must  be  trusted  to,  the  Hainsby's  truss  of  old  days 
being  here  found  useful. 

In  the  other  variety  of  dentigerous  cysts,  where  solid  growth  of  a 
sarcomatous  nature  is  present  in  addition  to  the  cystic,  the  surgeon  must 
use  his  discretion  as  to  opening  the  cyst,  freely  scraping  out  the  growth, 
and  then  applying  strong  formalin  solution  or  zinc-chloride  paste,  or 
removing  the  bone  itself.  If  the  case  is  of  any  duration,  if  the  growth 
is  soft  and  making  rapid  progress,  the  latter  course  will  be  the  wiser  one. 

In  the  case  of  the  dental  cyst,  treatment  is  usually  simple.  It  consists 
in  the  removal  of  any  teeth  or  fangs,  and  then  in  the  thorough  curetting 
of  the  cyst  walls.  Whenever  it  is  needful  to  do  this  thoroughly,  the 
anterior  aspect  of  the  bone  must  be  removed  with  gouge  and  chisel  to  give 
free  access.  The  cavity,  when  thoroughly  exposed  and  dealt  with,  is 
carefully  plugged  with  sterilised  gauze. 

(7)  Euchondromata.  These  are  rare.  They  seem  to  commence  in 
adolescence,  usually  starting  from  one  surface  of  the  bone,  e.g.  the  nasal, 
or  from  the  antrum.  They  should  be  removed  early  and  completely,  as 
they  grow  steadily,  involving  the  nose,  orbit,  frontal  sinuses,  and  thinning 
the  cranial  bones. ^ 

(8)  Osteomata.  These  are  rare  also.  Two  forms  occur  :  (1)  Of  the 
nature  of  an  ordinary  exostosis.  These  are  usually  cancellous,  but  ivory 
ones  arise  from  the  superior  maxilla  as  well  as  from  the  orbit  and  frontal 
sinuses.  Occasionally  they  are  symmetrical. ^  Their  growth  is  usually 
slow.  If  they  occur  in  young  subjects  they  should  be  attacked  while 
small.  The  ivory  exostoses  are  occasionally  found  loose  on  laying  open 
the  antrum,  as  is  sometimes  the  case  with  those  in  the  frontal  sinuses. 
(2)  Diffuse  osteomata.  These  are  intermediate  in  hardness  between 
cancellous  and  ivory  exostoses.  They  have  often  broad,  ill-defined  bases, 
and  ar".  not  infrequently  multiple  and  symmetrical.  As  they  tend  to 
produce  hideous  deformity,  and  though  slowly,  most  distressingly,  to 
destroy  life,  they  should  be  attacked  while  small.     Mr.  Pollock  ^  states 

^  rjood  instances  of  what  these  enchondromata  may  come  to  are  given  by  Mr.  Morgan's 
case,  (tuy's  Hospital  Reports,  1842  ;  Mr.  Heath's  Diseases  and  Injuries  oj  the  Jaws,  p.  237, 
with  an  excellent  illustration,  Fig.   10  7. 

-  In  Mr.  Hutchinson's  Clinical  Surgery,  vol.  i,  p.  11,  Figs.  3  and  4,  will  be  found 
admirable  illustrations  of  symmetrical  exostoses  from  the  u^iper  jaw. 

^  Syst.  of  Surg.,  vol.  ii,  p.  535. 


REMOVAL  OF  THE  UPPER  JAW  423 

that  in  cases  where  the  whole  mass  is  beyond  removal,  a  portion  may 
be  cut  away  with  present,  if  not  permanent,  benefit.  This  can  only  apply 
to  osteoniata  of  purely  hypertrophic  nature.  Where  the  bony  growth  is 
tipped  with  cartilage,  eyery  atom  must  be  removed  for  the  operation 
to  be  of  any  benefit.  Well-made  osteotomes  and  drills  worked  by  an 
electro-motor  may  be  of  much  service  here,  the  great  object  being  to  drill  a 
number  of  holes  in  different  directions  through  the  growth,  and  then  to 
cut  through  the  intervening  bone  with  osteotomes  and  a  mallet.  One  of 
the  chief  risks  is  that  of  intracranial  inflammation,  especially  if  the 
growth  has  involved  the  interior  of  the  skull. 

QUESTIONS  ARISING  BEFORE  ATTEMPTING  THE  REMOVAL 
OF  THE  UPPER  JAW 

(i)  Is  the  growth  cystic  or  solid  ?  (ii)  What  is  the  relation  of  the 
growth  to  the  jaw  ?  Did  it  begin  on  one  of  the  surfaces  of  the  jaw, 
within  the  antrum,  or  behind  the  jaw  ?  (iii)  Is  the  growth  one,  whether 
malignant  or  not,  that  it  is  wise  to  attempt  to  remove  ? 

(i)  Is  the  Growth  Cystic  or  Solid  ?  Mr.  Heath  gave  a  case  under 
his  o^^^l  care  in  which  caseous  pus,  after  suppuration  in  the  antrum, 
was  taken  for  a  solid  growth,  and  the  jaw  removed.  As  the  diagnosis  is 
evidently  most  difficult  in  some  cases,  the  surgeon  should,  in  all  cases  of 
doubt,  explore  first  with  a  trocar  and  cannula,  or  gouge  or  bradawl, 
removing  a  portion  for  histological  examination.  The  X-rays  may  be 
of  assistance  here. 

(ii)  What  is  the  Relation  o£  the  Growth  to  the  Jaw  ?  Did  it  begin 
on  one  of  the  surfaces  of  the  jaw,  within  the  antrum,  or  behind  the  jaw  ? 

In  some  cases  it  is  quite  impossible  to  be  sure  on  this  point  up  to  the 
time  when  the  flaps  are  reflected  or  till  the  jaw  itself  is  removed  ;  even  the 
use  of  a  finger  aided  by  an  anaesthetic  is  insufficient.^ 

The  following  points  may  be  useful  in  aiding  a  decision  as  to  the  rela- 
tion of  the  growth  to  the  jaw  : 

If  the  growth  began  on  the  surface  of  the  jaw,  e.g.  the  nasal  or  malar 
process,  there  will  probably  be  a  history  of  a  lump  noticed  here  first, 
very  likely  after  a  blow,  and  any  evidence  of  the  antrum,  nose  palate,  and 
orbit  being  involved,  will  be  deferred  till  late.  On  lifting  up  the  cheek, 
masses  of  growth  will  very  probably  be  found  creeping  down  between  the 
cheek  and  gums,  but  not  altering  the  line  or  affecting  the  structure  of  the 
alveolus,  unless  it  commenced  in  it  or  just  above  it. 

If  the  growth  began  in  the  antrum,  the  cheek  is  more  slowly  swollen, 
and  the  swelling  is  deeper  and  less  defined.  The  different  walls  and 
boundaries  of  tfie  cavities,  viz.  the  orbital,  nasal,  facial,  and  zygomatic, 
are  expanded  steadily  and  with  a  varying  rapidity,  while  the  palate  is 
depressed,  the  alveolar  border  displaced,  and  the  teeth  rendered  irregular. 

If  the  growth  began  behind  the  antrum,  e.g.  in  the  basilar  process  of 

the  sphenoid  or  the  spheno-  or  ptery go-maxillary  fossa,  in  many  cases  a 

history  will  be  given  of  polypi  removed  from  the  nose  or  pharynx  some 

time  before,  perhaps  reappearing  soon  ;  the  upper  jaw  is  pushed  forwards, 

and  in  some  cases  th.ere  is  but  little  alteration  in  its  outward  shape,  but 

this  is  by  no  means  constant.     Not  infrequently  the  upper  jaw  will  be  so 

altered  by  pressure,  its  processes,  e.g.  the  malar,  so  thinned,  flattened, 

^  Growths  originating  in  the  nasal  fossae  and  their  accessory  sinuses  often  extend 
most  widely  and  in  a  most  insidious  manner.  This  is  owing  to  the  large  number  of 
foramina  and  fissures  which  open  into  these  spaces.  Thus  even  the  cranial  cavity  may 
unexpectedly  be  found  to  have  been  invaded  through  the  sphenoidal  fissure. 


424 


OPERATIONS  ON  THE  HEAD  AND  NECK 


and  expanded,  that  it  may  well  be  thought  that  the  disease  began  in  the 
bone  itself.  And  this  mistake  is  the  more  excusable  when  it  is  remembered 
how  easily  a  growth  situated  behind  the  antrum  may  make  its  way  into 
this  cavity,  either  by  absorbing  its  walls,  or  by  entering  it  through  the 
opening  into  the  nose. 

Other  possible  evidence  of  the  existence  of  a  retro-maxillary  growth, 
whether  arising  in  the  roof  of  the  naso-pharynx  or  the  above-mentioned 
fossse,  will  be  symptoms  pointing  to  the  nose,  viz.  early  discomfort  and 
perhaps  increased  secretion,  pain  here,  or  in  the  orbit  and  brow  ; 
epiphora  from  blocking  of  the  nasal  duct  ;  interference  with  nasal  breath- 
ing, epistaxis  ;  possible  symptoms  of  interference  with  the  function  and 
movements  of  the  eyeball  ;  swelling  in  the  temporal  region  ;  yet  it  must 
be  remembered  that  many  of  these  symptoms 
will  be  brought  about  by  a  growth  within  the 
antrum  increasing  rapidly. 

It  is  only  when  the  surgeon  finds  no  evidence 
of  the  growth  beneath  the  skin,  or  of  its  origina- 
ting on  the  surface  of  the  bone,  no  depression  of 
the  palate,  and  no  irregularity  of  the  alveolar  mar- 
gin or  displacement  of  the  teeth,  that  he  can  say 
that  the  growth  is  probably  behind  the  antrum, 
(iii)  Is  the  Growth  one,  whether  Malignant 
or  not,  that  it  is  wise  to  attempt  to  remove  ? 
While  every  case  must  be  decided  upon  sepa- 
rately, and  while  it  would  be  most  misleading 
to  lay  down  hard-and-fast  rules,  the  following 
are  not  unworthy  of  attention  : 
Growths  with  a  duration  extending  over  many 
months,  hard,  well  defined,  limited  to  the  jaw,  with  the  skin  over  the 
growth  perhaps  thinned  from  pressure  and  altered  in  colour,  but  still 
movable  over  the  parts  beneath. 

Unfavourable  Cases.  History  of  a  few  months'  duration  ;  growth 
soft,  vascular,  ill  defined  ;  integuments  involved  and  fixed  ;  naso-pharynx 
invaded  ;  extension  into  orbit  or  temple,  e.g.  a  soft,  semi-elastic  swelling 
noticed  behind  the  malar  bone  in  the  temporal  region  ;  extension  to  the 
sub-maxillary  and  cervical  glands  ;  origin  of  the  growth  behind  the  jaw, 
rather  than  on  it. 

Occasionally,  a  growth  unfavourable  at  first  sight  from  its  large  size 
will  be  found  to  have  protruded  on  to  the  face  without  involving  the  parts 
around,  and  especially  those  behind.  The  history  must  be  carefully 
examined  into.  If  it  be  doubtful  where  the  growth  began,  whether  it 
has  invaded  or  only  crept  towards  the  nostril,  the  surgeon  will  inquire  as 
to  the  existence  of  deep-seated  pain,  stuffiness  in  the  back  of  the  nose,  loss 
of  smell,  interference  with  nasal  respiration,  epistaxis,  &c.  Again,  the 
existence  of  any  swelling  near  the  inner  canthus  will  point  to  extension 
towards  the  ethmoid  and  base  of  the  skull. 

Complete  Removal  of  Upper  Jaw  (Figs.  165,  167).  The  parts 
having  been  previously  rendered  as  sterile  as  possible,  the  patient  is 
brought  carefully  ^  under  an  anaesthetic,  and  duly  propped  up,  as  near 

1  As  in  excision  of  the  tongue,  the  assistant  to  whom  the  ansesthetic  is  entrusted 
is  second  only  in  importance  to  the  surgeon.  He  should  watch  most  carefully  for  the  first 
signs  of  flagging  of  the  puhe,  and  meet  this  by  injection  of  ether  or  brandy.  Any  evi- 
dence of  blood  going  down  the  throat,  dyspnoea  (as  shown  by  venous  stasis  of  the  cheeks), 
lividity  of  the  lips,  or  rcsjjiration  short  and  fi.xcd,  must  also  be  looked  out  for.     Intra- 


FlG.  165.    The  incision  for 
excision  of  the  upi^er  jaw. 

Favourable  Cases. 


ke:mov.\t.  of  thk  vvvvai  jaw  425 

to  tlu'  e(l<i('  of  tlio  tablo  as  possible,  witli  the  head  raised  and  turned  over 
towards  the  o])j)osite  si(h\  and  {h)\vn\vards  as  inueli  as  is  permissible  to 
faeilitate  the  readv  esca])e  of  blood  from  the  mouth.  The  sur<,'eon  now 
takes  the  oi>[)ortunity  of  examining  more  completely  tlu^  attachments 
and  limits  of  the  growth,  and  decides  whether,  owing  to  its  vascularity, 
it  may  be  advisable  to  tie  the  external  carotid  or  place  a  temporary 
ligature  on  the  common  trunk  (q.v.).  It  will  be  seen  later  (p.  4:51)  how 
unsuccessful  this  severe  operation  is  in  spite  of  the  advance  of  modern 
surgery,  tiiat  a  ])artial  factor  in  the  incomplete  removal  of  the  disease  is 
the  shock  and  ha'morriiage,  which  lead  to  the  close  of  the  operation  being 
hurried,  and  further  that  the  high  mortality  is  mainly  due  to  haemorrhage 
in  patients  whose  vitality  is  often  very  low,  and  to  aspiration-pieumonia. 

German  surgeons — and  this  operation  seems  to  continue  to  be  more 
common  with  tliem  than  it  is  with  us — and  Dr.  J.  D.  Bryant,  of  New 
York,  are  strongly  in  favour  of  preliminary  ligature  of  the  external 
carotid,  especially  in  patients  exhausted  by  haemorrhage  and  cachexia. 
Preliminary  exposure  of  the  bifurcation  of  the  carotid — for  ligature  of 
the  external  alone  does  not  always  suffice — to  admit  of  a  temporary 
ligature  ^  being  placed  around  the  common  trunk,  has  the  further  ad- 
vantage of  exposing  any  deep-seated  glands  that  might  otherwise  have 
escaped  notice.  8ir  F.  Treves  and  Mr.  Hutchinson  -  consider  that 
"  preliminary  ligature  of  a  large  artery  is  not  a  necessary  or  desirable 
proceeding.  Should,  however,  the  tumour  be  extremely  vascular,  a 
hgature  may  be  placed  round  the  external  carotid."  Efficient  plugging 
of  the  posterior  nares  is  recommended,  the  division  of  the  bony  palate 
being  taken  last. 

The  surroundings  of  the  surgeon  will  largely  aid  in  a  decision  on 
these  points.  If  the  apparatus  for  the  intratracheal  administration  of 
ether  be  not  available  and  if  it  be  thought  inadvisable  or  unnecessary  to 
make  use  of  a  prehminary  ligature  of  the  external  carotid  and  a  laryngo- 
tomy,  he  must  be  aided  by  efficient  assistants  ready  at  all  points  with 
sponge-pressure,  necessary  movement  of  the  patient's  head,  and  with  the 
anaesthetic.  He  must  plug  the  posterior  nares  efficiently,  removing  the 
plugs  before  the  bony  palate  is  divided,  and  he  must  not  forget  the 
possibility  of  infiltrated  deep  cervical  glands. 

One  more  preliminary  step  needs  reference.  It  has  been  advised 
that  the  operation  take  place  with  the  head  in  the  dependent  position 
after  the  external  carotid  has  been  tied.  This  is  an  extremely  incon- 
venient position  for  the  operator.  The  Trendelenberg  position,  as 
advised  by  Prof.  Keen  in  excision  of  the  larynx,  is  worth  a  trial,  but 
might  cause  much  venous  congestion  of  a  vascular  growth. 

The  incision  which  goes  by  the  name  of  Sir  W.  Fergusson  ^  is  then 

tracheal  insufflation  of  ether  is  the  most  desirable  an£esthetic  in  these  cases.  If  the 
necessary  apparatus  and  an  expert  anresthetist  are  not  available,  preliminary  laryngotomy 
and  plugging  the  pharynx  are  advisable.  With  regard  to  a  preliminary  laryngotomy— 
not  a  tracheotomy  be  it  noted — it  is  to  be  recommended  not  only  because  the  pharynx 
can  be  plugged  preventing  blood  being  drawn  down  to  the  lungs,  but  also  because  it  is 
on  this  account  an  important  safeguard  against  the  development  of  aspiration-pneumonia. 
The  laryngotomy  tube  is  removed  as  soon  as  the  operation  is  completed. 

^  C'rile's  clam])  may  also  be  employed. 

-  Manual  of  0 per.  Surg.,  vol.  i,  j).  (594. 

'  First  recommended  by  Dieft'cnbach.  Its  advantages  are  very  great,  viz.  (1)  only 
the  terminal  liranches  of  the  facial  nerve  are  divided  ;  (2)  only  branches  of  the  facial 
vessels,  not  their  trunks,  are  cut ;  (3)  the  scar  is  inconspicuous,  as  the  incision  is  placed 
in  natural  feature-folds. 


426 


OPERATIONS  ON  THE  HEAD  AND  NECK 


icCTio/^   Of  Bont 
re) 


made  through  the  centre  of  the  upper  hp  (an  assistant  controlhng  the 
opposite  coronary  while  the  one  in  the  flap  is  commanded  by  the  surgeon 
himself),  round  the  ala,  up  along  the  side  of  the  nose  to  the  inner  canthus, 
and  outwards  just  below  the  margin  of  the  orbit,  as  far  as  the  malar 
prominence.  Where  the  disease  is  extensive,  the  incision  may  have  to  go 
farther  out  ;  on  the  other  hand,  where  it  is  not  needful  to  remove  the 
orbital  plate,  this  part  of  the  incision  may  be  dispensed  with  more  or 
less.  The  angular  vessels  and  lateralis  nasi  will  give  the  most  trouble 
before  their  bleeding  is  entirely  checked.  The  flap  thus  marked  out  is 
then  reflected,  and  wrapped  in  steriHsed  gauze.  The  haemorrhage  is  often 
free,  especially  in  cases  of  rapidly  growing  tumours  which  have  thinned 

the  bone.  Spencer- Wells  forceps 
are  applied  to  the  larger  of  the 
vessels  ;  when  the  flap  has  been 
reflected,  care  being  taken  not 
to  cut  into  the  growth,  these  are 
secured,  and  an  assistant  makes 
pressure — plenty  of  sterilised  pads 
on  holders  must  be  at  hand — 
upon  the  flap  to  arrest  oozing, 
while  the  surgeon  divides  the 
bones  in  the  following  order,  the 
ala  of  the  nose  being  first  de- 
tached from  the  bony  surface, 
and  the  periosteum  of  the  floor 
of  the  orbit  detached  from  the 
bony  surface  and  pushed  back- 
wards as  far  as  the  spheno- 
maxillary fissure  if  the  whole 
bone  is  to  be  removed  ;  during  this 
step  the  origin  of  the  inferior 
oblique  is  raised  with  the  perios- 
teum, and  the  eyeball  and  fat  are 
protected  with  the  copper  spatula. 
(1 )  The  junction  of  the  superior 
maxilla  with  the  malar  bone  is 
divided.  The  line  for  the  saw  is  marked  out  with  the  knife  upon  the  bone  just 
in  front  of  the  origin  of  the  masseter.  With  a  narrow  strong-backed  saw 
(Gant's  or  Adams'  osteotomy  saw)  this  line  is  converted  into  a  deep 
groove  and  the  rest  of  the  bone  quickly  severed  with  forceps,  the  left 
forefinger  placed  upon  the  margin  of  the  orbit  steadying  the  instrument 
used  and  preventing  any  damage  to  the  eye.  This  bone  section  is  practi- 
cally in  a  line  with  the  spheno-maxillary  fissure  (at  the  lower  and  outer 
part  of  the  orbit),  and  should  fall  into  it.  This  will  preserve  the  pro- 
minence of  the  cheek.  If  the  malar  bone  be  involved  the  zygoma  must 
be  sawn  through.  Schlatter  advises  the  use  of  a  Giglis  saw  (Fig.  128). 
This  delicate  instrument  inflicts  very  little  damage  on  the  soft  parts,  and 
cutting  away  from  the  growth  is  not  hkely  to  injure  it.  It  is  carried  on  a 
half-curved  needle  through  the  spheno-maxillary  fossa  and  over  the 
exposed  surface  of  the  malar  bone. 

(2)  The  nasal  process  of  the  superior  maxilla  is  next  divided  at  the 
level  of  the  highest  part  of  the  bony  anterior  nares,  by  cutting  a  saw- 
groove  across  it  and  then  placing  one  blade  of  the  forceps  inside  the 


Fig.  106.  ^,Line  of  saw-cut  at  the  junction 
of  the  external  and  inferior  walls  Oi  the 
orbit.  This  is  continued  backwards  to  the 
spheno-maxillary  fissure.  B,  Line  of  saw- 
cut  through  the  palatal  process.  fVLine 
of  saw-cut  through  the  nasal  process.  This 
is  continued  back  to  the  spheno-maxillary 
fissure. 


REMOVAL  OF  THE  UPPER  JAW 


427 


nostril  and  the  othor  within  the  orbit  as  far  as  the  posterior  end  of 
the  spheno-niaxillary  fissure,  the  soft  parts  being  first  a  little  freed  and 
carefully  lvei)t  out  of  the  way  with  the  left  thumb-nail.  This  bone 
section  may  be  also  made  with  a  chisel  and  mallet.  In  either  case  there 
must  be  no  splintering. 

(3)  The  central  or  a  lateral  incisor  being  next  extracted — this  step  is 
always  to  be  left  till  now,  to  save  needless  bleeding — the  mouth  is  widely 
opened  with  a  gag,  an  incision  made  with  a  stout  scalpel  along  the  middle 
line  of  the  hard  palate  up  to  the  teeth  and  over  the  anterior  aspect  of  the 
alveolus  into  the  nostril,  and  another  transversely  outwards  at  the  junc- 
tion of  the  hard  and  soft  palace,  towards  the  molar  teeth  on  the  side 
affected.     The  soft  palate  is  then  detached  with  a  scalpel  or  blunt- 


A. 

Fig.  167.  A,  Removal  of  upper  jaw.  (Earlier  stage.)  Reflection  of  the  flap, 
and  section  of  the  bones.  The  extraction  of  an  incisor  was  not  needed  here. 
B,  Removal  of  u]>per  jaw.  ( Later  stage. )  The  flaps  arc  reflected  and  held  aside. 
The  bones  have  been  divided.  The  upper  jaw  is  being  disarticulated  with  the 
lion-forceps  while  a  pair  of  cutting  bone-forcejDS  completes  the  division  of  the 
palatine  attachments.     (Heath.) 


pointed  scissors,  and  thus  preserved  when  the  bone  and  growth  are 
wrenched  away.  The  hard  palate  is  next  deeply  notched  with  the  saw 
introduced  through  the  nose  opposite  to  the  tooth  which  has  been  drawn, 
and  severed  with  long  bone  forceps,  one  blade  of  which  is  introduced 
within  the  nose,  and  the  other  into  the  mouth.  If  a  Giglis  saw  is  used 
here,  it  is  passed  from  the  nose  into  the  mouth  with  a  curved  probe. 
If  a  chisel  or  osteotome  be  now  inserted  into  the  different  lines  of  bone 
section,  the  bone  is  loosened  with  a  series  of  quick  and  careful  levering 
movements,  while  finally,  lion-forceps  being  made  to  bite  firmly  into  the 
hard  palate  and  the  malar  aspect  of  the  bone,  in  the  manner  shown  in 
Fig.  167.  the  bone  is  detached  by  a  few  wrenching,  rocking  movements 
upwards  and  downwards  and  laterally,  the  left  forefinger  detaching  any 
soft  parts  which  retain  the  bone,  and  the  superior  maxillary  nerve  being 
cut  cleanly  with  scissors.     If  the  above  mentioned  sections  have  been 


428  OPERATIONS  OX  THE  HEAD  AND  NECK 

properly  made,  the  difficulty  in  detaching  the  bone  lies  in  the  pterygoid 
and  palatine  processes.  The  introduction  of  curved  cutting  bone-forceps 
behind  the  tuberosity  of  the  maxilla  will  help  now. 

When  the  bone  has  been  much  invaded  by  disease,  or  in  practising 
this  operation  on  the  dead  subject,  it  is  very  likely  to  come  away  in  frag- 
ments, being  unavoidably  crushed  down  by  the  forceps.  On  the  removal 
of  the  bone,  haemorrhage  is  often  free  from  the  palatine  and  other  arteries, 
especially  in  a  case  of  rapid  growth.  A  large  sterilised  pad  is  at  once 
thrust  into  the  cavity,  and  pressure  efficiently  made.  If  on  its  withdrawal 
any  vessel  still  spirts,  it  is  usually  easily  tied,  owing  to  the  large  size  of  the 
gap.  The  pterygoid  fossae,  the  cavity  of  the  nose,  and  the  palate  are 
next  examined,  the  sharp  spoon  or  gouge  being  applied  to  remove  any 
remaining  portions  of  disease,  or  Paquelin's  cautery  made  use  of  to 
destroy  what  cannot  be  otherwise  removed.' 

If  there  is  any  doubt  about  any  part  of  the  growth  having  been  left 
behind,  and  if  zinc  chloride  paste  or  strong  formalin  is  used  (p.  422), 
these  had  best  be  inserted  on  gauze,  the  strips  being  brought  out  of  the 
mouth  at  the  angle  and  tied  together  with  silk,  and  so  readily  removed 
after  a  few  days.  But  if  the  bone  has  come  away  with  all  the 
growth,  if  the  surface  of  this  is  smooth  and  encapsuled,  not  ragged  or 
lacerated,  and  the  bleeding  is  all  arrested,  the  surgeon  will  do  best  to 
insert  nothing  into  the  cavity.  If  oozing  is  going  on,  or  if  there  is  reason 
to  fear  intermediary  haemorrhage,  strips  of  sterilised  gauze  should  be  care- 
fully packed  in,  and  removed  later  on  by  the  mouth.  But  it  is  difficult  to 
keep  even  these  sweet,  and  the  surgeon  will  do  best  to  dispense  with  any 
plugging  if  possible,  and  to  content  himself  with  brushing  over  the  wound 
with  a  solution  of  zinc  chloride  (gr.  xl  to  §]),  or  Whitehead's  varnish  (p.  517) 
The  edges  of  the  wound  are  then  brought  together  with  salmon-gut 
and  horsehair  sutures.  Especial  care  should  be  paid  to  adjusting  two 
points — one,  the  muco-cutaneous  junction  of  the  lip,  the  other,  the  angle 
of  the  flap  near  the  inner  canthus.  If  suppuration  take  place  here, 
ectropion  will  follow.  When  the  edge  of  the  lip  is  united  the  suture 
should  be  left  long  and  the  lip  thus  everted,  while  its  mucous  surface  is 
carefully  stitched  with  sterilised  catgut  or  horsehair  sutures,  left  long  in 
the  latter  case.  A  few  strips  of  sterihsed  gauze  are  then  laid  along  the 
line  of  incision,  with  transverse  ones  across  the  divided  hp,  so  as  to  give 
additional  support  here  ;  they  are  kept  in  position  with  iodoform  and 
collodion. 

A  few  points  require  further  attention.  The  dropping  of  the  eye 
from  the  orbital  plate,  and  probably  also  all  the  attachments  of  the 
suspensory  part  of  Tenon's  capside  (Lockwood),  and  the  harmful  results 
which  may  follow,  are  alluded  to  below  (footnote,  p.  429). 

In  a  favourable  case,  the  surgeon,  having  divided  the  periosteum, 

may  be  able  with  saw  or  chisel  to  leave  the  greater  part  or  even  the  whole 

of  the  orbital  plate.     Where  all  this  bone  must  go,  the  suggestion  of 

Von  Konig  may  be  followed.     This  surgeon  takes  a  strip  of  the  temporal 

muscle,  half  a  finger's  breadth,  together  with  a  piece  of  the  anterior 

border  of  the  coronoid  process  chiselled  off  at  its  junction  with  the 

horizontal  ramus.     To  give  support  to  the  eyeball,  the  strip  is  carried 

below  and  around  it  towards  the  nasal  wall,  where  it  is  sutured  to  the 

remains  of  the  frontal  process  of  the  maxilla.     As  malignant  growths 

^  The  high  frequency  electric  current  as  recommended  on  p.  396  may  alno  be  employed 
for  this  purpose. 


REMOVAL  OF  THE  U1UM^:R  JAW  429 

may  pioliiVrate  into  tlie  oihit  without  any  disturbance  of  the  eyeball, 
Schlatter  ^  advises  that  in  extensive  cases  the  patient's  consent  be  obtained 
to  removal  of  the  eyeball. 

During  the  after-treatmiMit  the  patient  should  he  kept  well  pi()j)|)cd 
up  to  facilitate  the  escape  of  discharges,  which  must  be  prevented  from 
collecting  by  frequent  syringing,  or,  what  is  better,  by  the  patient  himself 
often  rinsing  and  gargling  his  mouth  and  wound  with  some  safe  antiseptic 
solution,  ('.(j.  chinosol,  boroglyceride,  potassium-permanganate  lotion, 
or  one  of  the  spirits  of  wine,  5ss  to  a  t\imbler  of  water.  The  wound 
inside  should  be,  if  needful,  occasionally  brushed  over  or  sponged  with 
hydrogen  peroxide  lotion.  The  patient  should  be  fed  with  nutrient 
enemata  and  a  soft  tube  for  the  first  few  days.  Especial  care  is  needed 
to  cleanse  the  mouth  after  food  is  taken.  If  possible,  patients  should  be 
got  out  of  bed  into  an  armchair  within  the  first  week. 

In  those  cases,  rare  nowadays,  where  the  growth  is  of  great  size, 
owing  to  the  operation  being  deferred,  the  mouth  may  remain  open  for 
some  days  after,  but  the  power  over  the  muscles  which  raise  the  lower  jaw  is 
rapidly  regained.  The  lost  sensation  is  usually  restored,  and  the  resulting 
deformity  is  often  very  slight.^  Later  on,  when  the  parts  are  soundly 
healed,  the  skill  of  a  dental  surgeon  is  called  upon  to  fit  on  a  tooth-plate 
and  obturator,  if  needfvd.  The  deformity  due  to  the  falling-in  of  the 
cheek  may  be  remedied  by  the  injection  of  paraffin  (p.  452). 

Partial  Extirpation  oJ  the  Upper  Jaw.  Operations  for  removal  of  an 
epulis  with  the  alveolar  border  have  been  described  at  p.  419,  and  one 
for  opening  up  and  exploring  the  antrum  is  given  at  p.  432. 

If  the  surgeon  find  that  the  lower  part  only  of  the  upper  jaw  need  be 
removed,  abundant  room  will  be  given  by  dividing  the  upper  lip  in  the 
middle  line,  prolonging  this  round  the  columella  into  the  nostril  on  the 
diseased  side.  By  detaching  the  nose  and  dissecting  up  the  flap  of 
cheek,  the  facial  surface  of  the  jaw  can  be  well  exposed. 

Again,  if,  after  exposing  the  w^hole  jaw  by  Sir  W.  Fergusson's  incision, 
the  surgeon  find  that  the  orbital  plate  can  be  spared,  a  horizontal  saw- 
cut  is  made  just  below  the  infra-orbital  foramen,  and  the  bone  cut  through 
with  a  chisel  and  a  few  taps  of  a  mallet.^ 

When  the  orbital  and  nasal  parts  of  the  upper  jaw  are  involved  and 
the  lower  alveolar  portions  are  sound,  these  latter  may  be  thus  preserved. 
A  cheek  flap  being  reflected  by  an  incision  through  the  lip  and  upwards  to 
the  inner  canthus  along  the  nose,  the  nasal  and  malar  processes  are 
divided  while  the  eye  is  duly  protected.  A  horizontal  saw-cut  is  then 
made  above  the  alveolar  process,  outwards  from  the  nose,  and  another 
carried  upwards  from  the  outer  end  of  this,  to  join  the  incision  through 
the  malar  process,  being  made  either  mth  the  saw  or  chisel.     The  piece 

^  Loc.  supra  cit. 

^  No  .skin  is,  of  course,  removed,  even  if  it  appears  to  be  very  redundant ;  it  rarely 
sloughs,  save  when  the  stretching  has  been  extreme,  or  when  it  has  been  needful  to  apply 
the  cautery  to  the  flap.  When  the  growth  has  invaded  the  skin  over  it,  a  hideous  fistula 
is  left,  which  must  be  closed  later  on,  if  the  patient  survives,  which  he  seldom  does  in 
these  cases  ;  or,  if  the  vitality  be  very  low,  a  flesh-tinted  artificial  cheek,  supported  by 
spectacles,  must  be  worn.  Sir  Watson  C'heyne  and  Mr.  Burghard  point  out  that  this  has 
the  great  advantage  of  allowing  the  inspection  of  the  cavity,  and  timely  application  of 
any  needful  cautery  or  caustics. 

*  The  orbital  plate  should  always  be  left,  if  possible.  As  Mr.  Butlin  (loc.  supra  cit., 
p.  12.5)  points  out,  when  the  floor  of  the  orbit  has  been  removed  there  often  residts  not 
only  serious  disfigurement,  but  much  oedema  of  the  lower  lid,  and  an  unhealthy  condition 
of  the  eye  itself,  which  may  be  destroyed.  Paralysis  of  the  lower  part  of  the  orbicularis 
and  epiphora  from  damage  to  the  lachrymal  duct  are,  also,  not  uncommon  sequelae. 


430  OPERATIONS  OX  THE  HEAD  AND  NECK 

of  bone  thus  mapped  out  is  loosened  with  a  chisel  or  elevator,  and  either 
prised  out  with  the  latter  instrument,  or  wrenched  downwards  and  out- 
wards with  the  lion-forceps. 

Several  other  operations  invohnng  partial  removal  of  the  upper  jaw 
are  given  under  the  treatment  of  naso-pharyngeal  fibroma  (p.  469). 

IDifficulties  and  Dangers  during  the  Operation.  These  have  been 
already  alluded  to.     The  chief  are  : 

{I )  Shock. 

(2)  HcBm/rrrlMfje. 

(3)  Breaking  dovjn  of  the  hone  in  the  lion- forceps. 

(4)  Oatlyiiifj  fjieces  of  growth  either  in  the  pterygoid  or  other  fossae, 
or  in  the  temporal  region,  or  far  back  in  the  roof  of  the  nose. 

Possible  Causes  of  Failure.  ( 1 )  Prolonged  Shock.  Inability  to  rally. 
All  the  usual  details,  before,  during,  and  after  the  operation,  should  be 
attended  to.  Feeding  with  a  tube  pa.ssed  by  the  mouth  or  by  the 
opposite  nostril  should  be  early  resorted  to,  especially  in  the  case  of 
elderly  patients,  or  in  those  much  run  down. 

(2)  Secondary  Hcernorrhage.  If  this  be  severe,  resisting  the  use  of 
ice,  &c.,  the  wound  must  be  opened  up,  and,  if  no  definite  bleeding-point 
be  found,  firm  plugging  must  be  resorted  to,  either  with  sterihsed 
gauze,  or  the  same,  with  the  ends  in  the  wound,  wrung  out  of  adrenahn 
chloride  (1  in  1(XX))  or  turpentine.  These  steps  faihng  to  arrest  the 
heemorrhage,  ligature  of  the  external  or  the  common  carotid  must  be 
employed. 

(.3)  Infection  of  the  Wound.  Different  forms  of  this  grave  complica- 
tion are  likely  to  set  in  when  the  patient  is  aged  or  much  broken  down  in 
health,  with  impaired  viscera,  or  when,  owing  to  extensive  removal  of 
bone,  e.g.  having  to  saw  through  the  zygoma  and  loosen  the  outer  wall 
of  the  orbit,  the  surgeon  opens  up  deep  planes  of  cellular  tissue,  which 
cannot,  from  the  surroundings,  be  kept  aseptic,  most  troublesome  burrow- 
ing in  the  neck  probably  following.  To  cut  cellulitis  short,  free  scarifica- 
tion with  small  incisions  should  be  made  use  of  early  so  as  to  unload  the 
parts,  and  abscesses  should  be  opened  at  once.  Boracic  acid  fomenta- 
tions should  be  early  employed. 

(4)  Inhalation- [rneumonia  is  here,  as  after  removal  of  the  tongue,  a 
decided  risk.  In  this  case,  also,  the  treatment  is  mainly  preventive, 
attention  being  as.siduously  paid  to  all  the  details  already  given,  before, 
during,  and  after  the  operation. 

(5)  Inpimmation  of  the  Brain  or  its  Membranes.  Sir  H.  Butlin  ^  has 
shown  that  the  mortality  after  removal  of  the  upper  jaw  is  nearly  30  per 
cent.  He  coes  on  to  remark  that,  if  we  are  to  reduce  this  mortality,  "  we 
must  adopt  two  courses  in  the  after-treatment — first,  such  means  as  will 
render  the  wounds  aseptic  ;  second,  regular  and  sufficient  administration 
of  food." 

The  experience  of  German  surgeons  bears  out  the  above.  Schlatter  ^ 
writes  :  "  How  little  the  antiseptic  era  influenced  the  prognosis  of 
this  operation  is  shown  by  a  comparison  of  Rabe's  and  Kronlein's 
compilations.  The  former  collated  606  cases  of  major  operations  upon 
the  upper  jaw  between  1827  and  1873,  and  found  a  mortality  of  18-4  per 
cent.  ;  while  Kronlein  calculated  a  mortality  of  21-5  per  cent,  from  158 
total  resec  ions  taken  from  the  antiseptic  period,  1870  to  1897.  Konig 
estimates  the  mortality  at  about  30  per  cent. 

^  Loc.  supra  cit. 


OPKHATIOXS  ON  TIIK  MAXILLARY  ANTRUM      431 

Kroiilehi  in  his  most  recent  communication  has  shown  the  cause  of 
failure  in  the  latter  cases  to  be  diseases  of  the  air  passages,  not  wound 
injuries.  More  than  half  the  deaths  after  this  operation  are  referable 
to  these  complications,  especially  aspiration  during  anesthesia. 

({))   Recurrence. 

With  regard  to  this  Sir  H.  Butlin  considers  the  prospects  are  very 
gloomy  in  cases  of  malignant  disease,  only  four  cases  out  of  sixty-four 
(in  wliich  the  result  is  recorded)  being  able  to  be  considered  relatively 
successful,  i.e.  having  remained  cured  for  three  years. 

This  opinion  is  again  fully  borne  out  by  the  results  of  German  surgeons. 
Thus  Schhittei-  writes,  at  Zurich,  he  "  observed  recurrences  after  an 
average  of  3-9  months  in  all  cases  of  malignant  tumour  involving  the 
entire  jaw."  Kuster  recorded  no  permanent  results.  In  the  Eilanger 
statistics  one  permanent  cure  was  recorded  in  seventeen  cases.  In  the 
Griefswald  statistics,  of  seventeen  cases  there  was  not  one  permanent 
cure.  Estlander  found  ten  reappearances  in  sixty-two  operations.  In 
the  Gottingen  clinic  of  seventy-four  total  resections,  with  twenty-three 
deaths.  Martens  found  ten  permanent  cures.  Stein  has  recently  reported, 
from  Von  Bergmann's  clinic,  that  of  thirteen  total  resections  for  car- 
cinoma, between  1890  and  1900,  not  one  of  those  whose  record  is  obtain- 
able is  living  at  the  present  time.  The  prognosis  in  sarcoma  is  more 
favourable  than  in  carcinoma.  Out  of  Mr.  Jacobson's  five  cases  of 
removal  of  the  upper  jaw  only  one  was  permanently  cured.  The  patient 
was  a  young  servant-girl  ;  "the  growth  was  proved  microscopically  to 
be  a  spheroidal-celled  carcinoma.  Seven  years  afterwards  the  deformity 
was  extremely  slight,  and  owing  to  the  skill  of  a  dentist,  mastication 
and  articulation  were  little  interfered  with. 


OPERATIONS  FOR  SUPPURATION  IN  THE  ANTRUM 
OF  HIGHMORE 

It  must  be  remembered  that  suppuration  in  the  maxillary  sinus,  or 
antrum  of  Highmore,  may  be  secondary  to  dental  trouble,  or  be  associated 
with  suppuration  in  the  other  accessory  sinuses  of  the  nose,  the  prognosis 
being  usually  better  when  the  former  is  the  cause.  The  condition 
of  these  cavities  therefore  must  be  investigated  in  all  cases  of  antral 
suppuration,  and  conversely  when  there  is  suppuration  in  the  frontal 
sinus  or  ethmoidal  cells  it  must  be  remembered  that  the  antrum  may 
have  become  secondarily  affected. 

The  following  operations  will  be  considered  :  (1)  Tapping  the  antrum 
through  the  alveolar  process.  (2)  The  radical  operation  in  which  the 
antrum  is  exposed  through  the  canine  fossa.  (3)  Drainage  through  the 
nose. 

(1)  Through  the  Alveolar  Process.  This  method  has  the  following 
advantages  :  (a)  It  drains  the  cavity  at  the  most  dependent  part. 
(6)  By  extraction  of  the  tooth  it  often  removes  the  cause  of  the  trouble, 
(c)  It  does  not  involve  any  cutting.  The  operation  is  a  slight  one  and 
rapidly  performed.  It  is  indicated  in  all  simple  uncomplicated  cases  of 
short  duration. 

The  disadvantage  connected  with  this  operation  is,  that  in  many 
cases,  especially  those  of  long  duration,  it  does  not  effect  a  cure,  as  it 
does  not  permit  of  the  removal  of  diseased  and  polypoid  mucous  mem- 


432  OPERATIONS  ON  THE  HEAD  AND  NECK 

brane  from  within  the  cavity.  In  other  cases  the  after-treatment  is  very 
prolonged,  and  daily  attention  to  the  tube  is  required. 

A  tooth  has  usually  to  be  first  extracted,  and,  as  long  ago  pointed 
out  by  Mr.  Salter,  "  the  tooth  whose  fangs  are  most  intimately  connected 
with  the  antrum  is  the  first  permanent  molar,^  and  its  removal  in  a  case  of 
antral  abscess  is  especially  indicated  from  this  circumstance,  and  from 
the  frail  and  perishable  nature  of  the  tooth  itself,  which  gives  it  less  often 
than  other  teeth  a  long  tenure  of  usefulness."  The  operation  may  be 
carried  out  under  nitrous  oxide,  which  may,  if  thought  desirable,  be 
followed  by  ether.  The  puncture  is  made  with  an  antrum  drill,  the  point 
of  which  is  introduced  into  the  inner  root  socket,  and  is  directed  up- 
wards and  slightly  inwards  towards  the  inner  canthus  of  the  corresponding 
eye.  The  antrum  can  also  be  opened  from  the  socket  of  the  second  molar 
or  the  second  bicuspid,  in  which  case  the  instrument  should  be  inclined 
slightly  more  forwards  or  backwards  respectively.  The  forefinger  should 
be  firmly  held  about  one  inch  from  the  point  of  the  instrument  to  prevent 
it  penetrating  too  deeply.  By  a  combined  thrusting  and  boring  movement 
the  antrum  is  then  quickly  opened.  The  drill  is  then  withdrawn,  and 
the  size  of  the  opening  may  be  increased  by  a  larger  'instrument,  or  by  a 
burr.  A  solid  vulcanite  plug,  with  a  flange  to  prevent  it  slipping,  is  fitted 
into  the  opening. 

The  chief  points  in  the  after-treatment  are  to  keep  the  opening  patent, 
to  prevent  the  entrance  of  food,  and  to  encourage  a  healthy  condition 
of  the  lining  membrane. 

To  ensure  these  ends  the  cavity  must  be  regularly  syringed,  the  plug 
being  removed  for  this  purpose,  and  subsequently  replaced.  By  the 
third  day  a  rubber  obturator  may  be  substituted  for  the  vulcanite 
plug,  and  later  a  plug  may  be  fitted  to  the  tooth-plate  by  a  dental  surgeon. 
The  cavity  should  at  first  be  syringed  twice  a  day  with  lotions  of  boracic 
or  dilute  carbolic  acid,  sterile  saline  solution,  or  potassium  permanganate 
— the  lotion  itself  not  being  of  so  much  importance  as  the  regularity  with 
which  it  is  used.  When  the  discharge  has  diminished,  syringing  once 
a  day  will  suffice,  and  when,  possibly  after  many  months,  no  discharge 
has  been  noticed  for  some  days,  it  may  be  altogether  omitted  and  the 
plug  removed.  The  opening  then  usually  closes  spontaneously,  but  if 
this  does  not  occur,  by  applying  caustics  such  as  silver  nitrate  2  or  pure 
carbolic  acid  to  the  fistulous  track. 

The  Radical  Operation.  In  cases  where  the  suppuration  is  of  long 
duration,  where  the  interior  of  the  antrum  is  the  seat  of  caries  or  where  the 
mucous  membrane  has  undergone  a  polypoid  change,  where  the  cavity 
acts  as  a  reservoir  for  pus  coming  from  other  sinuses,  or  where  there  is  a 
fistulous  opening  on  the  face,  the  above  treatment  will  not  be  sufficient. 

^  Any  other  tooth,  as  Mr.  Salter  advises,  molar,  bicuspid,  or  canine,  whose  disease  is 
possibly  the  cause  of  the  abscess,  will,  of  course,  be  extracted,  as  absorption  round  any 
carious  tooth  facilitates  perforation  of  the  alveolus.  Unless  the  drill  is  carefully  in- 
serted in  the  right  direction  the  antrum  may  be  missed  and  the  floor  of  the  nasal  fossae 
perforated . 

2  Dr.  H.  Tilley  {Brit.  Med.  Jonrn..  August  30,  1902,  p.  585)  found  as  the  result  of 
alveolar  drainage  in  thirty-four  cases,  that  sixteen  were  cured  of  their  discharge  in  from 
two  to  eighteen  months,  fourteen  were  so  relieved  of  their  symptoms  that  they  ^ireferred 
to  continue  wearing  their  tube  lest,  by  its  removal,  discharge  should  recur  and  necessitate 
further  treatment.  In  all  these  uncured  cases,  except  one,  the  headache  had  disappeared, 
the  discharge  had  diminished  almost  to  vanishing- i)oint,  and  the  patients  were  perfectly 
comfortable.  As  an  antral  discharge  is  so  cpiickly  diminished  by  alveolar  drainage  and 
irrigation.  Dr.  Tilley  considered  that  as  a  rule  the  patient  should  be  given  a  chance  of  cure 
or  great  improvement  by  this,  the  simplest  motle  of  treatment. 


OPERATIONS  ON  THE  ANTRUM  433 

Tho  radical  opi'iation  admits  of  free  exposure  of  the  interior  of  the  antrum 
and  removal  of  the  diseased  tissues,  while  a  free  connnunication  is  made 
with  the  nasal  fossa  to  allow  of  permanent  drainage.  The  patient 
having  been  anaesthetised,  the  naso-pharynx  is  plugged  with  a  sterilised 
sponge  {see  p.  412),  and  a  second  sponge  is  placed  between  the  cheek  and 
the  alveolar  process.  The  cheek  is  then  retracted,  and  a  horizontal  in- 
cision made  through  the  mucous  membrane  just  above  the  canine  fossa. 
Tiie  bone  is  now  exposed  by  displacing  the  soft  parts  upwards  and 
downwards  by  a  periosteal  elevator.  By  means  of  a  gouge  or  chisel  the 
antrum  is  next  opened  ;  by  means  of  a  burr,  or  forceps,  the  opening  is 
freely  enlarged  so  that  the  little  finger  can  be  introduced.  The  condition 
of  the  interior  of  the  cavity  is  then  investigated  with  the  help  of  a  good 
light  from  a  frontal  lamp.  All  diseased  mucous  membrane  is  removed 
by  forceps,  scissors,  or  curette.  Any  carious  patch  in  the  bone  also 
receives  attention.  Healthy  mucous  membrane  should  not  be  removed, 
for,  as  in  the  case  of  the  frontal  sinus,  owing  to  the  size  of  the  cavity,  the 
object  of  the  surgeon  must  be  to  leave  the  lining  membrane  in  as  healthy 
a  condition  as  possible,  not  to  remove  it  entirely.  Special  attention 
should  be  directed  to  the  crevices  between  the  projections  caused  by  the 
roots  of  the  teeth,  and  to  the  recesses  at  the  anterior  and  posterior  ex- 
tremities of  the  cavity.  The  operation  may  be  accompanied  by  extensive 
oozing,  but  this  may  be  kept  in  check  by  the  use  of  strips  of  sterilised 
gauze  ^vrung  out  of  hot  sterilised  sahne  solution  or  hydrogen  peroxide 
lotion.  When  all  diseased  tissues  have  been  cleared  away,  the  surgeon  must 
make  a  free  opening  into  the  nasal  fossa.  A  Krause's  cannula  should  be 
introduced  into  the  nose,  and  its  point  pushed  through  into  the  antrum 
just  below  the  anterior  end  of  the  middle  turbinal.^  This  gives  an 
excellent  guide  as  to  where  the  bone  should  be  removed.  The  opening 
is  enlarged  through  the  antrum  with  gouge  or  punch-forceps.  The 
communication  should  be  as  free  as  possible  and  should  certainly  admit 
of  the  surgeon's  little  finger  being  passed  through  the  antrum  into  the 
nasal  fossa.  The  sponge  in  the  naso-pharynx  is  then  withdrawn.  No 
stitches  are  necessary,  for  the  soft  parts  fall  naturally  into  position.  The 
subsequent  drainage  takes  place  through  the  opening  into  the  nasal 
fossa.  The  antrum  will  require  to  be  washed  out  daily  until  the  discharge 
ceases.  A  Eustachian  catheter,  connected  with  a  ball  syringe,  may 
be  introduced  into  the  cavity  through  the  nasal  opening,  and  it  is  thus 
syringed  out  with  hot  saline  solution  or  boracic  lotion.  All  discharge 
should  cease  in  the  course  of  a  few  weeks.- 

(3)  Puncture  of  the  Antrum  and  Drainage  through  the  Nose.  Simple 
puncture  of  the  antrum  may  be  readily  effected  for  diagnostic  purposes 
by  means  of  Lichtwitz's  hollow  needle  under  local  anaesthesia.  The 
needle  is  pushed  through  the  inner  wall  of  the  antrum  beneath  the  inferior 
turbinal.  Air  is  then  forced  through  the  needle,  and  if  the  antrum  con- 
tains pus  this  will  be  forced  through  the  natural  orifice  and  appear  in 
the  region  of  the  meatus. 

For  purposes  of  drainage  a  general  anaesthetic  should  be  given,  the 
anterior  end  of  the  inferior  turbinal  be  removed  if  necessary,  and  Krause's 

^  If  the  anterior  end  of  the  inferior  turbinal  has  not  been  previoasly  removed  this 
should  be  done,  as  described  on  p.  455,  at  the  beginning  of  the  operation. 

2  In  cases  of  chronic  empyema  of  the  maxillary  antrum  this  operation  is  very  successful. 
Failure  may  be  due  to  overlooking  stumps  of  teeth  within  the  cavity,  and  from  leaving 
detached  pieces  of  the  carious  wall  ipvithin  it.  If  the  pyogenic  polj'poid  mucous  membrane 
be  not  carefully  removed,  suppuration  may  persist. 

SURGERY  I  28 


434 


OPERATIONS  ON  THE  HEAD  AND  NECK 


Fig.  168.     Exploration  of   the  antrum    bv 
Krause's  cannula  after  removal  of  the  an- 
terior extremity  of  the  inferior  turbinate. 


cannula  thrust  through  into  the  antrum.  The  opening  thus  made  is 
enlarged,  through  the  nasal  fossa,  by  means  of  punch-forceps.  The  chief 
difficulty  is  to  enlarge  the  opening  in  a  forward  direction.  By  this  means 
free  drainage  can  be  secured,  more  so  than  by  puncture  through  the 
alveolar  process.  It  has,  however,  the  disadvantage  that  the  interior  of 
the  antrum  cannot  be  inspected,  and  diseased  mucous  membrane  cannot 
be  satisfactorily  and  certainly  removed.     Hence  it  cannot  be  described 

as  a  radical  cure,  and  if  the  dis- 
charge does  not  soon  cease,  the 
radical  operation  described  above 
will  have  to  be  performed. 

The  cavity  is  regularly  washed 
out  through  a  large  Eustachian 
catheter  as  described  in  the  after- 
treatment  of  the  radical  operation. ^ 
The  following  opinions  of  well- 
known  authorities  on  the  results  of 
operative  interference  will  be  useful 
to  the  general  surgeon  who  has  to 
decide  as  to  which  method  he  should 
adopt.  Dr.  Lambert  Lack,  writing 
of  the  simpler  methods  says  :  "In 
considering  the  question  of  a  cure 
by  these  means  it  is  safe  to  say, 
(1)  that  in  cases  of  dental  origin 
recent  or  chronic,  a  large  majority  are  cured  ;  (2)  that  in  recent  cases 
of  nasal  origin  a  majority  are  cured  ;  (3)  that  taking  all  cases  together, 
about  50  per  cent,  are  cured  and  every  case  is  greatly  relieved  ;  (4)  that 
the  cure  depends  to  a  large  extent  upon  the  care  with  which  the  patient 
conducts  the  after-treatment.  If  pus  reappears  in  the  nose  immediately 
after  washing  out  the  antrum,  there  are  such  strong  probabilities  of 
other  cavities  being  involved  that  they  should  at  once  be  explored  and 
treated  if  found  diseased." 

Dr.  Tilley  -  found  as  the  result  of  alveolar  drainage  in  thirty-four  cases 
that  sixteen  were  cured  of  their  discharge  in  from  two  to  eighteen  months, 
fourteen  were  so  relieved  of  their  symptoms  that  they  prfeerred  to  con- 
tinue wearing  the  tube  lest,  by  its  removal,  discharge  should  recur  and 
necessitate  further  treatment.  In  all  these  uncured  cases,  except  one, 
the  headache  had  disappeared,  the  discharge  had  diminished  almost  to 
vanishing-point,  and  the  patients  were  perfectly  comfortable.  As  an 
antral  discharge  is  so  quickly  diminished  by  alveolar  drainage  and 
irrigation,  Dr.  Tilley  considered  that  as  a  rule  the  patient  should  be 
given  a  chance  of  cure  or  great  improvement  by  this,  the  simplest  mode 
of  treatment. 

REMOVAL  OF  THE  LOWER  JAW,  PARTIAL  OR  COMPLETE 

Indications.  These  are  much  the  same  as  those  already  given  for 
removal  of  the  upper  jaw  (p.  419).     Sir  H.  Buthn^  has  discussed  these 

^  The  advantages  claimed  for  tliis  operation  are  that  it  is  simple,  quicker,  and  as 
effective  as  the  one  with  the  opening  from  the  canine  fossa.  But,  of  course,  it  does  not 
allow  any  inspection,  and  only  a  partial  removal,  of  the  diseased  contents  of  the  sinus. 
Still  the  results  obtained  are  so  satisfactory,  that  it  seems  atlvisable  to  try  it  in  the 
majority  of  cases  as  a  necessary  first  step,  even  if  the  radical  operation  has  to  be  com- 
pleted later. 

2  Brit.  Med.  Joum.,  1902,  vol.  ii,  p.  585.  »  Qper.  Treat,  of  Malig.  Dis.,  p.  137. 


REMOVAL  OF  THE  LOWER  JAW 


435 


growths,  and  has  pointed  out  that  here  important  differences  are  observ- 
able between  the  central  and  subperiosteal  sarcomata.  Thus  the  central 
(most  often  myeloid)  sarcomata  grow  slowly,  the  periosteal  c^uickly  ; 
the  former  aie  encapsulod,  and  even  when  they  make  their  way  into  the 
surrounding  structures  they  do  not  show  that  tendency  to  infiltration 
which  is  so  marked  in  the  periosteal  sarcomata.  The  central  ones 
are  rarely  associated  with  affection  of  the  lymphatic  glands,  or  with 
st>condary  growths. 

The  following  operations  will  be  considered  : 

A.  Partial  removal  of  the  lower  jaw. 

B.  Complete  removal  of  one  half  of  the  lower  jaw  (Fig.  170). 
C  Complete  removal  of  the  jaws,  upper  or  lower. 

A.  Partial  Removal  o£  the  Lower  Jaw.  This  is  frequently  required 
in  the  case  of  epulis.  The  steps  are  the  same  as  those  already  given  at 
p.  419.  The  alveolar  border  should  always  be  removed  ;  in  the  case  of  a 
growth  very  far  back  around  the  lower  molars  it  is  advisable  to  slit  the 
cheek,  especially  if  the  growth  is  becoming  doubtful  in  character,  and 
thus  requires  thorough  extirpation. 

The  above  remarks  still  more  hold  good  in  the  case  of  a  growth  about 
the  gums,  situated  far  back,  in  an  older  patient,  and  becoming  epithelio- 
matous. 

Cases  are  occasionally  met  with  where,  owing  to  an  epithelioma  of 
the  lip  not  having  been  treated,  or  to  its  recurrence,  the  symphysis  of  the 
jaw  is  infiltrated  and  requires  removal. 

The  soft  parts  being  reflected  by  incisions,  starting  on  either  side 
widely  of  the  diseased  parts,  converging  towards  the  hyoid  bone,  and  the 
vessels  secured,  the  bone  is  sawn  through  in  two  places,  well  beyond  the 
level  where  its  softened,  spongy  state,  and  the  loosened  teeth  show  that 
it  is  invaded.  The  sawn  surface  left  must  be  carefully  scrutinised.  The 
tongue,  prevented  from  falling  back  by  a 
loop  of  silk  passed  through  its  tip,  is  now 
detached  by  snipping  through  the  mucous 
membrane,  and  the  muscles  attached  to 
the  genial  tubercles.  Any  further  haemor- 
rhage being  looked  to,  the  sublingual  and 
submaxillary  glands  are  examined,  and, 
together  with  any  enlarged  lymphatic 
glands,  removed  if  needful ;  flaps  are  dis- 
sected up  from  the  neck  to  make  a  new  lip 
(p.  493,  Figs.  198-203),  and  drainage  pro- 
vided, the  tubes  being  brought  out  below 
at  the  lowest  level  of  the  region  from  which 
the  flaps  have  been  dissected  up.  The 
adjustment  of  these  to  form  the  new  lip 
will  be  the  more  easy  in  proportion  to  the 
amount  of  bone  removed. 

So,  too,  especially  in  epithelioma  in  the 
region  of  the  angle  of  the  jaw  directly  extending  from,  or  secondary  to 
that  of  the  tongue,  the  surgeon  may  be  led,  in  order  to  relieve  his 
patient's  condition,  if  he  cannot  cure  him,  to  operate  extensively  here. 
Thus,  after  turning  up  a  horseshoe-shaped  flap,  with  the  concavity 
upwards,  and  clearing  the  masseter  off  the  jaw,  this  bone  is  divided  above 
the   angle,  then  through  the  horizontal  ramus,  and  removed,  together 


Fig.  169.     Incision  for  excision 
of  lower  jaw. 


436 


OPERATIONS  OX  THE  HEAD  AND  NECK 


with  the  submaxillary,  subUngiial,  and  lymphatic  glands,  which  will 
probably  be  enlarged,  and  also  adherent.  The  haemorrhage  ^  will  be 
free,  from  the  facial  and  lingual  vessels,  and  veins  communicating  with 
the  external  jugidar.     Free  drainage  must  be  pro\dded. 

Removal  of  part  of  the  horizontal  ramus  or  of  the  angle  may  be 
called  for  in  cases  of  new  growths  limited  to  these  parts  ;  and  the  surgeon 
may,  especially  in  the  case  of  a  woman,  ask  how  far  it  is  worth  while  to 
try  and  remove  these  from  the  mouth,  detaching  the  softptarts  with  a 
raspatory,  and  sawing  the  bone  in  front  and  behind  the  growth,  as  in  the 

case  of  an  epuhs,  but  the 
section  here  passing  through 
the  whole  thickness  of  the 
jaw.  It  may  be  doubted  if 
the  extra  trouble  and  risk  of 
the  proceeding  are  balanced 
by  the  absence  of  a  scar, 
which,  in  the  majority  of 
cases,  need  not  involve  the 
lip.  and,  if  properly  placed, 
will  be  nearly  invisible 
afterwards. 

Question  of  Removing  a 
Portion  or  the  Whole  or  Half 
of  the  Lower  Jaw.  This 
matter  will  have  to  be  de- 
cided when  the  surgeon, 
having  a  case  of  growth 
before  him  which  involves 
the  horizontal  ramus  as  far 
back  as  the  angle,  is  in  doubt 
whether  to  saw  through  the 
vertical  ramus  or  to  dis- 
articulate. In  the  great 
majority  of  cases,  especially  where  the  patient  is  no  longer  young,  where 
the  gi'owth  is  not  a  central  one,  where  it  has  been  attacked  before,  the 
operator  had  much  best  place  his  patient  and  himself  on  the  safe  side 
and  disarticulate.  The  lower  jaw  being  '  a  floating  bone,"  this  radical 
step  often  gives  a  better  prognosis  for  operation  here  than  in  the  case  of 
the  upper  jaw.  On  the  other  hand,  the  lower  jaw  is  so  embedded  in  soft 
parts,  and  so  near  to  important  parts,  e.g.  pharvnx  and  pterygoid  fossae, 
that  delay  may  render  the  extirpation  of  the  growth  impossible. 

B.  Removal  of  Half  of  the  Lower  Jaw  (Figs.  169, 170).  The  patient's 
head  and  shoulders  are  raised,  his  body  brought  to  the  edge  of  the  table, 
and  the  head  moved  to  the  opposite  side.  The  operator  stands  on  the 
afiected  side,  or  operates  on  either  jaw  from  the  right.  The  parts 
are  again  rendered  as  sterile  as  possible.  A  prehminary  larpigotomy 
will  rarely  be  called  for,  and  only  when  the  growth  is  so  vascular 
as  to  make  plugging  of  the  fauces  a  ^vise  precaution.-  As  it  will  be 
well  in  most  cases  to  explore  the  submaxillary  region,  the  incision  which 

^  Dr.  Addenell  Hewson  advises  that  the  external  carotid  should  be  ligatured  before 
proceeding  to  removal  of  the  jaw.     (A  nn.  of  Surg.,  1909,  vol.  xlix,  p.  618.) 

-  The  advantages  of  the  intratracheal  insufflation  of  ether  in  these  cases  have  been 
alreadj-  indicated. 


\ 


¥iG.  ITT). 


REMOVAL  OF  TIIK   LOWKll   JAW  437 

bei^ins  just  below  the  lip  '  in  the  centre  oi  the  chin,  should  pass  clown  to 
the  hyoid  bone.  Hence  it  is  carried  laterally  well  below  the  mandi  ble  along 
the  subinaxillary  cervical  crease  (Kocher)  to  a  point  a  finf];er's  breadth 
beliind  and  below  the  angle.  The  authority  just  mentioned  advocates  this 
level  for  tlie  lateral  part  of  the  incision  as  sparijig  the  supraniaxillary 
branch  of  the  facial  nerve.  The  incision  is  carried  down  to  the  bone 
over  the  chin  ;  over  the  facial  artery  it  should  be  only  skin-deep.  This 
vessel  is  next  secured  between  two  ligatures.  In  raising  the  flap  thus 
marked  out,  the  nuiscles,  where  it  is  safe  to  do  so,  are  raised  with  it  by. 
a  periosteal  elevator  and  the  point  of  the  knife,  including  the  small  ones 
in  front  and  the  masseter  and  buccinator  behind.  Where  there  is  any 
risk  of  their  being  infiltrated  the  flap  must  consist  of  skin  and  fascia 
only.  Such  arteries  as  the  mental  and  masseteric  will  now  probably  need 
attention.  From  the  inner  aspect  of  the  mandible  the  muscles  are  next 
detached,  viz.  anteriorly  the  digastric,  mylohyoid,  genio-hyoid  and 
genio-hyoglossus,  and  posteriorly  the  internal  pterygoid,  until  the  mucous 
membrane  is  reached,  but  the  cavity  of  the  mouth  should  not  be  opened 
at  this  stage,  if  possible.  The  flap  that  has  been  raised  is  wrapped  in 
sterile  gauze. 

An  incisor  being  extracted  if  needful,  the  jaw  is  divided  to  one  side  of 
the  symphysis  well  in  front  of  the  growth,  by  deeply  notching  it  with  the 
saw  2  before  using  the  bone-forceps  or  chisel.  If  it  be  needful  to  remove 
the  bone  so  freely  that  the  symphysis  and  the  genial  tubercles  are 
removed  also,  the  tongue  must  be  prevented  from  falling  back  upon  the 
aperture  of  the  larynx  by  means  of  a  loop  of  stout  silk  passed  through 
the  lip.  The  bone  being  divided  and  pulled  outwards,  any  of  the  muscles 
which  remain  undivided  on  the  inner  aspect  of  the  law,  together  with 
the  buccal  mucous  membranes  at  its  junctioi^  with  the  alveolus,  are 
divided  with  blunt-pointed  scissors.  Care  must  again  be  taken  not  to 
leave  behind  any  infiltrated  tissues.  In  a  very  few  cases,  where  the  nature 
of  the  growth  admits  of  it,  the  submaxillary  and  sublingual  glands  may 
be  spared  by  keeping  the  knife  or  scissors  close  to  the  bone. 

The  anterior  half  of  the  jaw  being  now  freed,  the  surgeon,  taking 
it  in  his  left  hand,  everts  it  so  as  to  divide  the  internal  pterygoid  more 
freely,  and  also  the  inferior  dental  nerve  and  vessels.  The  jaw  is  next 
strongly  depressed  so  as  to  bring  down  the  coronoid  process,  and  the 
insertion  of  the  temporal  muscle.  This  strong  tendon  requires  complete 
division,  as  depression  of  the  bone  brings  fasciculus  after  fasciculus  into 
view.  If  the  coronoid  process  is  very  long  it  may  hitch  against  the  malar 
bone  or  be  jammed  against  it  by  the  bulk  of  the  tumour  :  in  such  cases  it 
had  better  be  cut  of?  with  bone-forceps,  and,  after  the  removal  of  the 
growth,  dragged  down  with  sequestrum-forceps  and  removed.  After 
the  temporal  tendon  is  thoroughly  detached  (when  this  is  effected  the  jaw 
comes  down  more  easily),  strong  depression  of  the  jaw  is  continued  so  as 
to  bring  the  condyle  within  reach,  no  eversion  or  rotation  outwards  of 
the  bone  being  permissible  at  this  stage  of  the  operation,  or  the  internal 

^  If  there  are  reasons  for  especial  speed,  such  as  the  condition  of  the  patient, 
or  if  the  growth  is  very  large,  the  red  border  should  be  divided,  as  this  facilitates  matters 
much,  and  the  additional  deformity  is  very  slight. 

^  \^"hen  the  condition  of  things  admits  of  it,  the  jaw  should  always  be  divided  as 
far  from  the  symphysis  as  possible,  in  order  to  preserve  the  anterior  belly  of  the  digastric 
and  its  insertion,  which  will  thus  counteract  the  tendency  of  the  muscles  on  the  opposite 
side  to  draw  the  chin  somewhat  over.  It  is  convenient  to  be  provided  with  a  Gant's  saw 
or  one  with  a  movable  back. 


438  OPERATIONS  ON  THE  HEAD  AND  NECK 

maxillary  artery  which  passes  between  the  neck  of  the  jaw  and  the  in 
ternal  lateral  ligament  will  be  brought  into  the  wound  and  very  likely 
cut.  causing  troublesome  hgemorrhage.  The  external  pterygoid  is  next 
partlv  torn  through  with  the  finger  or  the  director,  the  capsular  ligament 
is  opened  in  front  with  the  careful  use  of  the  knife  or  scissors,  which  next, 
kept  close  to  the  bone,  divides  the  lateral  ligaments,  when  the  jaw  comes 
awav,  the  final  separation  being  usually  effected  by  the  remaining  fibres 
of  the  external  pterygoid  being  torn  through,  together  with  the  stylo- 
maxillary  hgament  and  the  periosteum  to  which  it  is  attached.  The 
knife,  if  it  is  required  here,  should  be  kept  very  closely  in  contact  with  the 
posterior  border  of  the  ascending  ramus.  But  usually  after  division  of 
the  external  lateral  ligament  the  mandible  can  be  pulled  away. 

If  the  internal  maxillary  artery  has  been  divided,  which  is  sometimes 
excusable  in  cases  of  large  growths  extending  far  up,  it  can  be  readily 
secured  in  the  large  wound. 

If  the  operator  finds  the  vertical  part  of  his  incision  insufficient,  and 
yet  does  not  hke  to  prolong  it  for  fear  of  damaging  the  chief  part  of  the 
seventh  nerve,  the  soft  parts  should  be  well  raised  by  a  retractor,  after 
being  pushed  upwards  with  a  periosteal  elevator. 

In  cases  where  the  jaw  has  been  extensively  thinned  or  eroded  by 
growth,  it  is  very  hkely  to  fracture  under  the  depression  which  is  required 
to  bring  down  the  condyle.  If  this  accident  occur,  removal  of  the  condyle 
and  coronoid  process  is  rendered  difficult,  as  the  latter  is  drawn  upwards 
under  the  zygoma  by  the  temporal  muscle.  Their  removal  will  be  facili- 
tated by  dragging  them  down  with  lion-forceps  and  detaching  the  tem- 
poral tendon  with  blunt-pointed  scissors. 

All  haemorrhage  being  securely  arrested,  the  submaxillary  region  is 
investigated,  and  if  needful  is  thoroughly  cleared  out.  Careful  search 
is  made  for  any  remaining  infiltration  of  the  parts  severed,  or  for  any 
outlying  portions  of  growth.  The  flap  is  then  brought  down,  and 
adjusted  with  sutures  of  silkworm-gut  and  horsehair,  drainage  being 
first  pro\'ided  for  by  bringing  a  drainage-tube  from  the  neighbourhood 
of  the  condyle  through  the  wound  below. 

Especial  care  must  be  taken  in  exactly  uniting  the  red  line  of  the  lip 
and  suturing  the  mucous  membrane  with  horsehair  le£t  long  (p.  428) 
if  this  has  been  di^^ded. 

The  wound  is  then  dressed,  as  at  p.  428,  and  the  patient  here  also 
should  be  propped  up  to  facilitate  escape  of  the  discharges.  For  the 
first  few  days  it  may  be  necessary  to  feed  by  a  nasal  tube,  aided  by 
rectal  enemata  and  suppositories.  The  patient  should  wash  his  mouth 
out  as  frequently  as  possible  as  directed  at  p.  429.  The  drainage-tube 
should  be  shortened  so  that,  as  soon  as  is  safe,  it  ceases  to  communicate 
with  the  cavity  of  the  mouth.  ♦ 

From  time  to  time  attention  has  been  drawn  to  the  need  of  replacing 
artificially,  the  removed  portion  of  the  jaw,^  and  thus  restoring,  in  a 
measure,  the  power  of  mastication  and  removing  the  deformity.  C. 
Martin,  a  surgeon-dentist,  of  Lyons,  brought  forward  an  artificial  jaw 
made  of  gutta-percha,  in  1889.  It  is  fastened  to  the  remaining  portions 
of  the  jaw  with  nails  or  screws  at  the  close  of  the  operation.  A  series  of 
perforations  allows  of  the  passage  of  discharges  and  of  irrigating  fluids. 

It  remains  in  place  during  the  entire  period  of  wound  repair.  About 
the  third  week  it  is  replaced  by  a  permanent  artificial  jaw  provided  with 

^  Mc.Bumey,  Ann.  of  Surg.,  July  1894  ;  Pearce  Gould,  Lancet,  January  16,  1897, 
p.  179, 


REMOVAL  OF  THE  LOWEK  JAW  UV.) 

teeth.  This  ami  other  forms  of  artificial  jaws,  sonic  made  of  almiiiiiium, 
are  figured  by  Schlatter,^  An  admirable  result  of  what  Martin's  splint 
can  effect  is  shown  by  the  illustration  of  a  girl  aged  18,  in  whom,  eight 
years  before,  Schlatter  resected  JO  cm.  of  the  lower  jaw.  Here  neither 
speech  nor  mastication  were  impaired. 

Difficulties  and  Possible  Mistakes  during  the  Operation. 

(1)  S]i])ping  back  of  the  tongue,  if  the  symphysis  has  been  removed. 

(2)  Wound  of  the  pharynx  by  not  keeping  the  knife  close  to  the  bone  in 
separating  the  soft  parts  from  the  angle  of  the  jaw.  This  interferes  with 
the  patient's  being  able  to  swallow  from  the  very  first. 

(3)  Fracture  of  the  jaw. 

(■f )  Januning  of  the  coronoid  process. 

(5)  Rigidity  and  permanent  contraction  of  the  temporal,  masseter,&c. 

(G)  Wound  of  the  internal  maxillary  vessels. 

(7)  Outlying  growth  in  the  temporal  region,  or  near  to  the  tonsil 
and  large  vessels. 

C.  Operations  for  Complete  Removal  of  Both  Jaws.-  Before  leaving 
the  subject  of  removal  of  the  jaws,  a  few  words  may  be  said  of  those  rare 
cases  which  occasionally  call  for  removal  of  both,  the  upper  or  the  whole 
of  the  lower  jaw,  or  both  the  jaws  on  the  one  side.^  Space  does  not 
admit  of  giving  more  than  brief  references  to  a  few  cases. 

The  growths  which  call  for  removal  of  both  upper  jaws  simultaneously 
fall  mainly  under  the  two  heads  :  (a)  Epithelioma  of  the  palate  and  alveoli 
involving  one  or  both  of  the  antra  ;  ^  (b)  Growths,  usually  sarcomatous, 
spring  often  from  the  base  of  the  skull  or  some  part  of  the  naso-pharynx, 
and  projecting  forwards  the  jaws  with  hideous  deformity.^  These  cases 
are  much  less  favourable  than  the  epitheliomata. 

In  either  case  the  parts  are  exposed  by  slitting  the  centre  of  the 
upper  lip  and  then  carrying  the  incision  round  the  nose  on  either  side, 
Fergusson's  incision  being  made  use  of  as  far  as  needful.  In  a  few  cases, 
in  order  to  get  adequate  room,  it  may  be  needful  to  make  incisions  from 
the  angles  of  the  mouth  to  the  malar  bones,  and  raise  all  the  intermediate 
soft  parts  as  a  flap.  Wherever  it  is  feasible,  as  in  cases  where  the  growth 
has  begun  in  the  alveolar  processes,  the  infra-orbital  plates  should  be 
retained.  This  may  be  done  by  sawing  through  both  bones  from  the 
nose  outwards,  and  completing  the  separation  of  the  lower  part  of  the 
maxillge  from  tlie  upper  by  an  osteotome  or  chisel. 

After  the  full  account  already  given  of  removal  of  the  upper  jaw,  no 
description  need  be  given  of  these  operations  for  removal  of  both  halves 
simultaneously.  The  greater  risk  of  shock,  the  liability  to  more  profuse 
haemorrhage,  the  probabihty  of  finding  the  growth  extending  far  back 
into  the  different  fossae  and  along  the  base  of  the  skull,  are  obvious. 
Later  on,  if  the  patient  make  a  good  recovery,  the  help  of  a  dentist  will 
be  much  needed  in  fitting  some  form  of  obturator,  as  articulation  is  now 

^  Loc.  -supra  cit. 

2  It  is  not  always  easy  to  tell  the  limits  of  a  growth  of  the  jaw.  Thus  one  of  these 
may  extend  up  to  the  level  of  the  lower  part  of  the  ear,  bulge  forwards  close  up  to  the 
nose,  creep  low  down  in  the  neck,  and  yet  originate  in  the  lower  jaw.  In  deciding  to 
which  jaw  a  growth  belongs,  attention  should  be  paid  to  involvement  of  the  floor  or  roof 
of  the  mouth,  and  the  results  of  masticatory  movements. 

'  Mr.  Spanton  (Brit.  Med.  Journ.,  1885,  vol.  ii,  p.  64)  records  a  case  in  which  first 
the  upper,  and.  a  few  months  later,  the  lower  jaw  on  the  right  side,  became  the  seat  of 
malignant  disease.  The  jaws  were  removed  at  an  inteval  of  a  week.  The  patient, 
aged  55,  recovered  from  the  operations,  but  the  growth  quickly  reappeared. 

*  Godlee,  Clin.  Soc.  Trans.,  vol.  xx,  p.  260. 

5  J.  Lane,  January  25,  1862  ;   Dobson,  Brit.  Med.  Journ.,  October  H,  1873. 


440  OPERATIONS  OX  THE  HEAD  AND  NECK 

far  more  imperfect.  The  deformity  is  also  obviously  far  greater.  In 
fact  the  operation  is  only  justifiable  in  a  patient  of  good  vitality  and 
with  increasing  pain  from  pres.sure  on  the  nerve  foramina. 

That  such  extensive  operations  are  still,  occasionally,  required,  is 
shown  by  a  case  of  Dr.  Bernays,^  of  St.  Louis.  Here,  in  a  man,  aged  31,  a 
recurrent  sarcoma  required  the  removal  of  both  maxillae  and  most  of 
the  bones  of  the  nose.  A  preliminary  tracheotomy  was  performed,  and 
Trendelenberg's  apparatus  employed.  The  patient  made  a  good  recovery, 
but  the  disease  reappeared  ten  months  later.  Excellent  photographs 
illustrate  the  condition  before  and  after  the  operation.  In  two  other  cases 
Dr.  Bernays  had  removed  both  maxillae. 

OPERATIONS  TO  RELIEVE  FIXITY  OF  THE  LOWER  JAW, 
SUTURE  OF  DISPLACED  FIBRO-CARTILAGE  (Fig.  171) 

The  above  condition  may  be  due  either  to  changes  in  the  temporo- 
maxillary  articulation  resulting  in  ankylosis,  or  to  cicatricial  bands 
between  the  jaws,  or  to  both. 

Operations.     The  two  usually  performed  are  : 

(1)  Excision  of  the  condyle,  an  operation  indicated  when  the  mischief 
is  limited  to  the  joint  itself. 

(2)  Esmarch's  operation  of  removing  a  wedge  of  bone  from  the 
horizontal  ramus  in  front  of  the  cicatrices  and  masseter  ;  this  operation 
being  preferable  to  the  first  when  scars  are  present  which  interfere  with 
excision  of  the  condyle. 

Conditions  justifying  one  of  the  above  Operations.  Inabihty  to  open 
the  mouth,  resisting  use  of  wedges,  &c.2  Foetor  of  saliva  and  breath. 
Difficulty  of  speech.     Inability  to  eat  solid  food. 

The  above  are  brought  about  by  the  following  cau.ses,  which  will 
be  enumerated  together  here,  though  some  call  for  one  of  the  above 
operations  and  some  for  the  other,  viz.  : 

(1)  Inflammation  of  the  joint  set  up  by  a  punctured  wound,^  gonor- 
rhoeal  arthritis,  severe  contusion,  4  or  sprain,  osteo-arthritis,'^  or  suppura- 
tive arthritis,  from  abscesses  burrowing  into  the  joint,  e  g.  abscesses  con- 
nected with  otitis  media.  (2)  An  unreduced  dislocation  in  which  much 
stiftness  remains  after  attempts  at  reduction  have  failed,  in  a  patient 
healthy  and  not  advanced  in  life.  (3)  Cicatrices  after  sloughing  set  up 
by  scarlet  fever,  measles,  typhus,  cancrum  oris,  or  mercurial  stomatitis. 
(4)  Cicatrices  after  suppuration  due  to  necrosis  or  alveolar  abscess. 

The  most  difficult  cases  to  deal  with  are  those  where  there  has  been 
much  previous  suppuration,  and  where  the  mischief  is  bilateral. 

The  earlier  any  needed  operation  is  performed  in  young  patients  the 
better,  owing  to  the  interference  with  the  eruption  of  the  teeth,  and  the 
wasting  of  the  muscles,   which  is  sure  to  follow.     Probably  in  these 

1  Med.  Rec,  March  28,  1896. 

^  Mechanical  apparatus  must  be  used  early  to  do  any  good.  Daily  forcible  use  of 
levers  is  usually  unsatisfactory,  and  the  use  of  interdental  shields  do  little  more  than 
retard  scar-formatioa 

^  Cf.  Mr.  Hilton's  case  {Rest  and  Pain,  p.  114),  in  which  bony  ankylosis  of  this  joint 
and  of  the  upper  cervical  vertebrae  seemed  to  commence  after  a  punctured  wound  in  the 
neck. 

*  Mr.  Heath  {R.  C.  8.  Letts.,  1887,  vol.  ii,  p.  114)  mentions  a  ca-e  in  which  ankylosis 
of  the  temporo-maxillary  joint  followed  on  a  kick  from  a  hort-e  on  the  side  of  the  face.  In 
.such  cases  a  fracture  may  co-exist.  W.  J.  Roe  (Ann.  of  Surg.,  May  1903)  is  of  opinion 
that  bony  ankylosis  here  invariably  results  from  fracture. 

^  Good  illustrations  of  this  condition  are  given  })y  Mr.  Heath  (Brit.  Med.  Jovrn., 
1887,  vol.  ii,  p.  5.5).     The  fibro  and  articular  cartilages  will  probably  be  wanting. 


FIXITY  OF  TIIF  LOWER  JAW  441 

scviMc  rases  the  best  lesiilts  follow  on  bilateral  excision  of  the  condyle, 
with  riMnoval  of  the  coronoid  process  if  needful.  It  has  been  stated  by 
11.  Matas,^  that  if  Ksmarcirs  method  be  made  use  of  on  both  sides,  loss 
of  cont'ol  of  the  intervening  fraj^nients  will  follow.  Mr.  Swain's  case 
(p.  442)  proves  that  this  is  not  always  correct.  In  the  worst  cases, 
several  operations  and  the  most  persevering  after-treatment  will  be 
required,  if  a  satisfactory  result  is  to  follow. 

Excision  of  the  Condyle  (Fig.  171).  This  operation  is  indicated 
when  the  mischief  is  limited  to  the  joint  itself,  as  may  be  the  case  in  the 
first  two  conditions  given  above.     It  may  be  performed  as  follows  : 

An  incision  about  an  inch  and  a  half  long  is  made  on  a  level  with  the 
tragus  along  the  lower  border  of  the  zygoma.  The  parotid  and  branches 
of  the  facial  nerve  being  drawn  down,  the  masseter  fibres  are  cleared  away 
from  their  insertion  with  a  narrow  elevator  and  the  joint  exposed.  The 
neck  of  the  condyle  is  now  sawn  through  with  a  fine  saw,  or  divided  with 
an  osteotome,  and  the  condyle  turned  out  with  an  elevator,  the  external 
pterygoid  being  detached.  The  fibro-cartilage  is  left  behind.  The  peri- 
osteum should  not  be  preserved.  The  bone,  which  must  not  be  splintered, 
should  then  be  further  pared  down  ;  and  the  operation  will  very  likely 
need  repeating  on  the  opposite  side 
before  sufficiently  free  movement  is 
regained.  Care  must  be  taken  in 
prising  out  the  condyle,  in  the  use  of 
gouges,  &c.,  not  to  open  the  cranial 
cavity.  The  use  of  a  small  drain 
will  usually  be  advisable.  While  the 
patient  is  still  under  the  ansBsthetic, 
the  mouth  should  be  opened  with 
a   gag   to  a  full   inch  at  least,  more 

if  possible.  The  use  of  hard  wood  Yig.  171.  A,  Excision  of  condyle 
wedges  or  cones  grooved  transversely  B,  Excision  of  coronoid  and  con- 
to  give  resting-places  for  the  teeth,  clyloid  process,  c  E.sraarch'smodi- 
,  ^, , .  ,1  1-  11  1  1  mi  •  ncd  operation,  ihis  must  always 
should  be  methodically  employed.  This  be  in  front  of  all  cicatrix-tissue.    'it 

step     should     be     frequently     repeated       happens  to  correspond  here  to  an 

with  the  aid  of  nitrous  oxide  or  ether  edentulous  part  of  the  jaw. 

if  needful.     The  case  must  be  watched 

most  carefully  owing  to  the  frequency  with  which  relapses  take  place. 

Esmareh's  Operation  (Fig.  171).  This  operation,  which  is  suited 
to  those  cases  where  the  fixity  is  brought  about  by  cicatrices  within  the 
mouth  rather  than  by  mischief  limited  to  the  joint,  consisted  at  first  in 
simple  division  of  the  mandible.  Removal  of  a  wedge-like  piece  of  bone, 
in  other  words,  a  cuneiform  osteotomy,  in  front  of  all  scars,  is  to  be 
preferred. 

Division  of  the  bands  inside  the  mouth  is  absolutely  futile,  and 
attempts  to  cover  the  wounds  made  by  excision  of  scars  with  flaps  of 
mucous  membrane  or  skin  are  difficult,  bloody,  and  disappointing. 
The  most  recent  of  these  is  the  plan  of  Von  Mikulicz,  who  drew  forward  a 
flap  from  the  masseter,  and  fixed  it  to  the  edges  of  the  gap  between  the 
fragments  with  sutures. 

An  incision  two  or  two  and  a  quarter  inches  long  is  made  along  the 

lower  border  of  the  jaw  in  front  of  the  masseter  and  cicatrices.     This 

incision  should  go  down  to  the  bone  :  the  facial  artery  will  probably  need 

securing.     As  the  soft  parts  are  raised,  any  muscular  fibres  met  with  on 

^  Journ.  Amer.  Med.  Assoc,  November  28,  1903. 


442  OPERATIONS  ON  THE  HEAD  AND  NECK 

either  aspect  should  be  carefully  detached.  A  triangular  wedge  of  bone, 
of  sufficient  size,  is  then  removed  with  a  narrow  saw,  e.g.  Gigli's  or 
Gant's.  The  section  should  be  made  as  cleanly  as  possible,  to  avoid 
risk  of  necrosis,  and  the  periosteum  should  be  removed  with  the  bone. 
The  wedge  should  measure  at  the  very  least  an  inch  and  a  quarter  below 
and  three-quarters  of  an  inch  above,  and  it  must  be  taken  from  a  part 
entirely  in  front  of  any  cicatricial  tissue. 

If  possible,  its  apex  should  correspond  to  an  edentulous  gap  in  the 
alveolar  process.  If  the  dental  artery  bleed  freely,  the  foramen  should 
be  plugged  ^^dth  a  tiny  sterihsed  wooden  plug,  or  the  bone  crushed  in 
around  the  bleeding-point. 

Some  surgeons,  who  prefer  a  cuneiform  osteotomy  to  excision  of  the 
condyle,  advise  removal  of  the  bone  at  the  angle  of  the  jaw,  not  in  front 
of  it.  Here  an  angular  skin  incision  is  made.  Such  a  course  would 
only  be  permissible  where  no  cicatricial  tissue  is  present.  To  prevent 
a  return  of  the  ankylosis  some  Continental  surgeons  have  inserted  a 
flap  of  muscle,  e.g.  temporal  in  the  case  of  the  condyle,  and  masseter 
in  that  of  Esmarch's  operation,  securing  it  in  place  with  sterihsed  catgut. 
We  owe  this  step  to  the  ingenuity  of  French  surgeons,  who  first  made  use 
of  it  by  inserting  a  flap  from  the  triceps  after  excision  of  the  elbow.  It 
is  a  needless  complication  if  only  sufficient  bone  is  removed  in  every 
case. 

Owing  to  the  tendency  to  relapse,^  passive  and  active  movement  should 
be  made  use  of  early,  and  at  first,  if  needful,  with  the  aid  of  an  ansesthetic. 

The  operation  should  be  performed  early  in  cases  where  cicatrisation 
arfter  severe  ulceration  is  leading  to  increasing  fixity  of  the  jaw,  ulti- 
mately needing  operative  interference. 

Mr.  Swain,  of  Plymouth,  published  a  most  successful  case,^  in  which 
he  operated  on  both  sides  simultaneously,  by  a  modification  of  Esmarch's 
operation. 

The  subperiosteal  method  preserves  the  attachment  of  the  masseter 
and  internal  pterygoid  to  the  inner  surface  of  the  angle,  thus  keeping 
intact  the  two  elevator  muscles.  If  a  sufficiently  large  wedge  is  removed 
the  danger  of  relapse  is  very  remote. 

The  jaws  had  been  closed,  after  scarlet  fever,  for  thirteen  years.  An  incision 
about  an  inch  and  a  half  long  was  made  just  at  the  angle  of  one  jaw,  and  then  on 
the  other  side,  parallel  with  the  line  of  the  jaws,  the  jwint  of  the  angle  being  at 
the  centre  of  the  incision.  The  knife  was  carried  at  once  down  to  the  bone.  With 
a  raspatory  the  whole  of  the  periosteum  on  the  outer  and  inner  surface  of  the  angle 
of  the  jaw  was  lifted  from  the  bone,  together  with  the  insertions  of  the  masseter 
and  internal  pterygoid.  A  narrow  saw  was  then  applied,  and  a  triangular  piece  of 
bone  removed,  including  the  angle  of  the  jaw,  and  measuring  at  its  base  about 
one  inch. 

Dr.  Howard  Lilienthal,  of  New  York,  has  recorded  a  successful  case  of  bilateral 
temporo-maxillary  ankylosis  treated  by  excision  of  the  joints.  The  condyle  was 
exposed  by  making  an  incision  along  the  zygoma  and  a  second  vertical  incision 
1^  inches  long  from  the  posterior  end  of  the  first  downwards  towards  the  angle  of 
the  jaw.  The  zygoma  was  divided  in  two  places  by  a  Gigli  saw  and  an  osteoplastic 
flap  tm-ned  downwards.  The  joint  was  thus  exposed  and  the  condyle  excised.  The 
flap  was  then  replaced,  sutures  for  the  divided  zygoma  not  being  required. 

^  This  relapse  is  more  likely  if  the  wedge  is  not  removed  well  in  front  of  all  cicatrices. 
Thus,  Mr.  Heath  {Dis.  and  Inj.  of  the  Jaws,  p.  332)  found,  two  years  after  Esmarch's 
operation  for  complete  closure  of  the  jaws,  that  the  interval  between  the  left  molars  had 
diminished  from  i  to  ^  inch,  and  that  between  the  lateral  incisors  from  f  to  f  inch. 

2  Lancet,  1894.  vol.  ii,  p.  189.  Mr.  Swain  collected  in  this  paper  19  other  cases 
of  operation  for  closure  of  the  jaws,  of  which  12  were  cases  of  removal  of  the  condyle 
or  portions  of  the  neck.  In  few  of  the  former  was  the  result  comparable  with  that 
obtained  by  Mr.  Swain  in  his  case. 


CHAPTER  XXI 

PLASTIC  OPERATIONS  FOR  REPAIR  OF  THE  NOSE 

These  operations  will  be  considered  under  the  following  headings : 
(A)  Those  for  "  saddle-nose  "  where  the  bridge  is  lost ;  (B)  those  for 
complete,  and  ((')  those  for  partial  restoration.  The  injection  of  paraffin 
will  be  found  described  at  p.  452. 

Indications.  When  the  patient  is  healthy  and  of  good  vitality  ; 
when  the  cause  of  the  destruction,  viz.  lupus,  gunshot  or  other  injury, 
syphilitic  ulceration  congenital  or  acquired,  new  growth  {e.g.  epithelioma 
or  rodent  ulcer)  necessitating  removal,  is  not  only  checked  but  somidly 
healed.^ 

Thus,  when  lupus  has  been  cured,  and  still  more  in  the  case  of  syphilitic 
ulceration,  it  will  be  well  to  wait  six  months  at  least  after  the  disap- 
pearance of  the  disease. 

A.  Operation  Jor  Saddle-Nose. 2  This  partial  rhinoplasty  will  be 
taken  first  and  by  itself,  as  it  is  one  of  the  most  frequently  indicated,  and 
as  it  is  one  which  gives  the  best  results.  The  condition  presents  itself  in 
varying  degrees  of  deformity.  In  a  typical  case  the  entire  bridge  is 
deeply  depressed,  while  the  cartilaginous  portion  with  the  subjacent 
part  of  the  septum  is  tipped  upwards  and  forwards  by  cicatricial  con- 
traction, the  nostrils  looking  forwards  instead  of  downwards.  It  may 
follow  syphilis  acquired  or  congenital,  depressed  fracture,  or  suppuration 
and  necrosis  after  injury.  That  due  to  depressed  fracture  is  obviously 
likely  to  give  the  best  results.  Whatever  the  cause,  healing  must  be 
complete  before  any  operation  is  attempted.  Operative  steps  here 
will  probably  be  largely  replaced  by  the  use  of  paraffin.  The  operator 
has  two  indications  before  him  :  (1)  to  replace  and  to  retain  in  its  new 
position  the  cartilaginous  part  of  the  nose  ;  (2)  to  restore  the  bridge. ^ 
The  following  account  is  given  in  detail,  as  this  operation  will  be  found  to 
give  the  best  basis  of  the  methods  for  complete  rhinoplasty.  Most 
of  these  have  now  only  an  historical  value,  and  do  not  give  permanent 
results.  The  credit  of  the  success  of  the  operation  for  saddle-nose  must 
be  given  in  the  first  and  chief  place  to  Konig.  His  method  has  been 
improved  by  different  operators,  e.g.  Israel  and  Watson  Cheyne. 

The  parts  concerned  in  the  operation  are  rendered  as  sterile  as  possible. 
By  a  curved  transverse  incision  at  the  deepest  part  of  the  depression, 

^  In  Sir  W.  MacCormac's  case,  quoted  below,  the  tip  and  alse  of  the  nose  had  sloughed 
in  infancy,  after  the  injection  of  a  large  naevus  with  the  liquor  ferri  pernitratis. 

2  On  this  subject  a  paper  by  Dr.  John  B.  Roberts,  of  Pliiladelphia  (Ann.  of  Surg., 1910, 
vol.  li,  p.  173)  may  be  consulted.  It  gives  much  useful  information  on  the  operative 
correction  of  syphilitic  and  other  deformities  of  the  nose. 

^  Dr.  Stephen  H.  Watts  has  described  a  case  of  successful  rhinoplasty  by  means  of  « 
transplanting  a  finger  (An7i.  of  Surg.,  1910,  vol.  li,  p.  191).     Dr.  Leonard  Freeman  has 
described  a  method  of  correcting  saddle- nose  by  inserting  a  celluloid  plate  (A7in.  of  Surg., 
1907,  vol.  xlvi,  p.  206). 

443 


444  OPERATIONS  ON  THE  HEAD  AND  NECK 

which  enters  the  nasal  cavity  and  is  carried  with  sufficient  freedom 
through  all  adhesions  and  what  is  left  of  the  bony  framework  (with  a  fine 
saw  or  a  chisel),  and  through  the  cartilaginous  septum  sufficiently  to 
hberate  the  soft  parts  of  the  nose  below,  these  are  replaced  so  that  there  is 
no  tendency  for  them  to  spring  back  into  the  place  where  the  tip  of  the 
nose  should  naturally  be.  In  cases  where  the  skin  over  the  upper  two- 
thirds  of  the  nose  is  sound  and  sufficient,  a  vertical  incision  is  made  from 
the  root  of  the  nose  dowTi  its  centre  to  where  the  curved  transverse  incision 
was  made.  At  the  upper  end  of  this  vertical  incision  two  slightly  curved 
ones  with  the  convexity  upwards  are  carried  outward  for  about  an  inch 
at  first,  and  by  this  means  two  lateral  flaps  are  raised  off  the  centre  of  the 
nose.  They  should  not  be  raised  more  widely  at  this  stage,  as  this  step 
would  cause  needless  and  troublesome  hsemorrhage. 

The  bridge  to  the  nose  is  then  made  by  taking  a  flap  from  the  fore- 
head. Two  incisions  going  down  to  the  bone,  beginning  about  half  an 
inch  above  the  root  of  the  nose,  and  each  about  one-eighth  of  an  inch 
from  the  middle  line,  are  carried  upwards  to  the  roots  of  the  hair  if  need- 
ful. A  transverse  cut  of  similar  depth  joins  the  upper  ends  of  these 
incisions.  With  a  narrow  chisel  introduced  first  at  the  sides  and  then 
above,  and  sloped  sufficiently,  the  flap  of  skin  and  external  table  of  the 
frontal  bone  is  raised  from  the  diploe.  When  the  lower  end  of  the  flap  is 
reached  the  bone  is  broken  across  here.  Konig  now  inverts  the  flap  before 
transplanting  it,  so  that  the  shell  of  bone  forms  the  outer  and  the  skin  the 
inner  surface  of  the  nose,  and  brings  down  a  skin  flap  in  the  usual  way 
from  one  side  of  the  forehead,  which  is  placed  on  the  raw  surface  of  the 
first  flap.  This  method  may  be  required  where  the  soft  parts  over  the 
bridge  of  the  nose  are  much  altered  ;  it  obviously  entails  much  more 
scarring  than  that  of  Israel  and  Watson  Cheyne,  where  the  second  flap  is 
taken,  as  described  below,  from  the  nose  itself.  The  skin  upon  the 
deeper  surface  of  the  flap  is  shaved  off  where  this  is  needful  in  order  to 
cause  it  to  adhere  to  the  remaining  tissues  of  the  bridge,  which  are  also,  in 
their  turn,  refreshed.  In  either  case  the  narrow  flap  from  the  forehead 
must  be  long  enough  for  its  free  edge  to  be  stitched  with  fine  sterihsed 
catgut  to  the  tip  of  the  nose  in  its  normal  position  without  any  tension 
whatever.  This  is  sometimes  difficult  to  ensure  when  the  hairs  grow  low 
down  upon  the  forehead.  If.  to  secure  the  above  object,  the  two  incisions 
on  the  forehead  are  prolonged  downwards,  care  must  be  taken  not  to 
imperil  the  vascularity  of  the  flap. 

The  two  lateral  flaps  which  were  raised  sufficiently  in  order  to  allow 
the  frontal  strip  to  be  placed  in  position  on  the  bridge  of  the  nose  are  now 
carefully  raised  by  curving  outwards  the  two  incisions  at  their  upper 
extremities. 

Troublesome  bleeding  is  often  met  with  as  the  flaps  are  raised.  When 
sufficiently  raised  they  are  united  with  sterihsed  horsehair  and  very  fine 
salmon-gut  sutures  in  the  middle  fine  over  the  raw  surface  of  the  median 
frontal  strip  which  has  been  reflected  do^vnwards. 

The  incision  in  the  forehead  is  sutured  and  should  leave  a  linear  scar. 
In  about  a  month's  time  the  base  of  the  reflected  frontal  strip  is  divided, 
and  any  redundancy  and  folds  remaining  are  removed  by  suturing  the 
divided  base  into  place  after  small  elhptical  portions  of  skin  have  been 
removed. 

Sir  Watson  Cheyne  recommends  that  a  long  splinter  of  rabbit's  femur 
be  used  to  keep  the  tip  of  the  nose  in" position. 


REPAIR  OF  THE  NOSE  445 

The  following  account  of  this  most  important  step  is  taken  from 
Sir  Watson  C'hcyne's  paper  ^  : 

"  Tlie  patient,  aged  18,  had  received  a  severe  injury  to  the  bridge  of  his  nose 
(?  fracture)  when  twelve  months  old,  this  being  followed  by  sup|)uration  from  the 
nose,  and,  during  the  next  few  months,  by  discharge  of  portions  of  the  nasal  bones. 
The  result  was  loss  of  the  bony  bridge.  There  was  practically  no  bony  bridge 
present  ;  some  rough  bone,  no  doubt  of  periosteal  origin,  could  be  felt  covering 
the  space  between  the  two  maxilla;  in  the  situation  of  the  nasal  bones.  There  was, 
fortunately,  very  little  tilting  forward  of  the  tip  of  the  nose,  and  it  was  not  necessary 
at  the  operation  to  cut  into  the  nasal  cavity  to  rectify  tlxis  deformity.  The  patient 
having  been  anaesthetised,  a  curved  incision  with  the  convexity  to  the  right  was 
made,  beginning  above  rather  to  the  left  of  the  middle  line  at  the  root  of  the  nose, 
and  terminating  below  rather  to  the  left  of  the  middle  line  about  half  an  inch  below 
the  commencement  of  the  cartilage  of  the  nose  ;  the  convexity  of  the  curve  at  its 
centre  extended  on  to  the  cheek.  The  incision  at  the  upper  part  went  down  to  the 
bone,  and  at  the  lower  part  to  the  nasal  cartilage.  The  flap  was  then  turned  over 
to  the  left,  an  attempt  being  made  to  peel  off  the  periosteum  from  the  nasal  bones, 
which,  however,  failed  owing  to  the  great  irregularity  of  the  new  bone.  While 
the  bleeding  was  being  arrested  by  pressure,  a  rabbit  was  killed  by  chloroform, 
immersed  in  bichloride  of  mercury  solution  (1  in  2000)  to  fix  the  hair,  and  rapidly 
skinned  by  one  of  the  dressers.  One  of  the  thighs  being  then  disarticulated  at  the 
hip,  the  soft  parts  over  the  femur  were  detached,  the  periosteum  being  left,  and 
with  a  pair  of  cutting  pliers  the  bone  was  split  up  longitudinally  into  several  frag- 
ments. The  wound  being  now  uncovered,  a  fragment  about  two  inches  in  length 
was  first  inserted  into  the  nasal  cartilage  at  the  lower  part,  pushing  down  the  tip 
of  the  nose,  and  then  wedged  against  the  frontal  bone  at  its  upper  part.  Four  or 
five  smaller  fragments  were  now  laid  around  this  till  the  necessary  height  for  the 
bridge  was  obtained.  The  skin  flap  was  then  replaced,  but  before  it  could  be  made 
to  meet  it  was  necessary  to  undermine  it  well  towards  the  left  side.  The  wound 
healed  by  first  intention,  but  ten  days  after  the  operation  a  little  glairy  fluid  was 
let  out  at  the  upper  part.     The  result,  nine  months  later,  was  excellent." 

B.  Operations  for  complete  Restoration.  Several  operations  have 
been  described  so  as  to  suit  the  varying  conditions  met  with,  but  it  is 
increasingly  rare  to  meet  with  cases  requiring  complete  restoration  of  the 
nose.     The  first  three  of  the  following  will  be  found  most  useful  : 

(1)  Methods  by  double  or  superimposed  flaps,  based  upon  that  of 
Konig. 

(2)  Keegan's  operation  (Fig.  172). 

(3)  Synie's,  from  the  cheeks  (Figs.  173). 

(4)  The  Indian  or  frontal. 

(5)  The  Italian  or  Tagliacotian. 

Before  deciding  which  operation  he  will  make  use  of  in  restoring  the 
nose,  the  surgeon  will  investigate  the  following  points  :  How  far  is  the 
bony  framework  of  the  nose  destroyed  ?  If  the  cartilages,  septum, 
vomer,  ethmoid,  and  nasal  bones  are  very  deficient,  however  well  made 
the  single  flap,  and  however  skilfully  it  is  adjusted,  it  will  tend,  after 
looking  extremely  well  at  first,  to  sink  down  to  the  level  of  the  cheeks. 
The  final  result  of  complete  rhinoplasty  is  rarely  satisfactory.  In  Till- 
man's words,  "  The  nose  is  at  first  very  good,  but  it  soon  shrinks.  The 
art  of  rhinoplasty  consists  in  making  a  nose  with  a  good  profile,  long, 
high,  and  pointed  ;  but  this,  as  a  permanent  result,  is  seldom  attained." 
If  he  proposes  to  take  flaps  from  the  cheeks,  the  surgeon  must  examine 
how  far  these  are  plentiful,  and  free  from  old  scars.  So,  too,  if  the  forehead 
is  to  furnish  the  flaps,  how  far  it  is  a  capacious  one  and  free  from  hairs. 

(1)  Methods  by  Double  or  Superimposed  Flaps,  based  upon  that  of 
Konig.  Owing  to  the  ultimate  disappointment  which  is  certain  with 
the  single  flap,  an  operation  based  on  the  method  which  has  been  given 
1  Clin.  Soc.  Trans..  1899,  vol.  xxxiii,  p.  218. 


446 


OPERATIONS  ON  THE  HEAD  AND  NECK 


in  detail  above  is  always  to  be  preferred.  The  central  skin  and  bone 
forehead  flap  must  be  cut  much  broader,  Rotter  says  3-5  cm.  broad. 
It  should  be  turned  down  at  its  base  so  that  the  skin  lies  internally.  After 
three  or  four  weeks  it  is  skin-grafted,  or  covered  with  a  flap  taken  laterally 
from  the  forehead.  If  the  superficial  surface  be  extensively  bony  the 
bone  is  divided  longitudinally  on  either  side,  with  a  fine  sharp  saw,  so 
that  the  central  part  forms  the  bridge  and  the  lateral  only  supports  it. 
But,  as  a  rule,  the  bone  splinters  too  easily  for  this  step  to  be  feasible.  As 
the  deep  surface  of  the  flap  is  turned  forwards  any  bone  that  exfoliates 
is  easily  removed. 

A  columella  must  be  made  subsequently  (p.  449).     This  should  always 
be  as  narrow  as  possible,  otherwise  breathing  will  be  interfered  with. 


A. 

Fig.  172.     Keegan's  method  of  rhinoplasty.     A,  Incisions  on  nose, 
of  incision  on  forehead. 


B,  Outline 


Many  other  details  will  be  gathered  from  the  account  of  the  methods 
which  follow. 

(2)  Keegan's  Method  of  Rhinoplasty.  This  method  has  been  introduced  i  by 
Surgeon-Major  Keegan,  whose  name  is  so  well  known  in  relation  with  lithotrity. 
As  Residencv-Surgeon  for  many  years  at  Indore  he  had  ample  opportunities  of 
performing  rhinoplasty— slicing  off  the  soft  parts  of  the  nose  being  a  very  common 
mutilation  in  India,  especially  by  the  hands  of  jealous  husbands.  Such  cases  are 
most  favourable  for  operative  measm-es,  the  patients  being  young  and  healthy, 
and  the  bridge  of  the  nose  left.  It  will  be  seen  that  superimposed  flaps  are  used. 
"  The  patient  having  been  fully  ansesthetised,  the  cavities  on  both  sides  of  the 
septum  are  plugged  with  pledgets  of  wool,  to  which  sutures  are  attached.  The 
operation  is  begun  by  carrying  two  converging  incisions  from  two  points  slightly 
external  to  the  roots  of  the  alaj  nasi  to  two  points  about  three-quarters  of  an  inch 
apart  on  the  bridge  of  the  nose,  where  a  jiair  of  spectacles  would  rest.  These  two 
points  are  now  joined  by  a  horizontal  incision.  This  horizontal  incision  is  bisected, 
and  a  perpendicular  incision  is  drawn  downwards  from  the  point  of  bisection 
nearly  as  far  as  where  the  nasal  bones  join  on  to  the  cartilage  of  the  nose.  In  other 
1  Lancet,  1891,  vol.  i,  p.  419. 


HEPAlll  OF  THE  NOSE 


447 


words,  this  pcM'jHMidicular  iiu'ision  follows  Iho  course  of  juiic'titn  of  tlie  nasal 
bones,  but  is  not,  eairied  down  as  far  as  their  inferior  borders.  Tiie  skin  and  tissues 
are  now  disset-tetl  from  olT  t  he  nasal  bones  from  above  downwards  in  two  Haps,  A  BCD 
and  1']1<\!H,  as  in  the  appeniletl  diagram  (Fig.  172a).  The  two  inferior  liorders 
of  the  Haps,  viz.  CD  and  CH,  are  not  interfered  with,  and  constitute  the  attach- 
nuMit  of  the  tlajjs  to  the  structures  and  tissues  which  clothe  the  inferior  borders  of 
the  nasal  bones  where  they  join  on  to  the  cartilage  of  the  nose.  If  these  two  Haps 
are  reHected  downwards  so  that  their  raw  surfaces  look  forwards  and  their  cutaneous 
surfaces  look  backwards,  it  will  be  found  that  they  overlap  in  the  centre.  The 
siu-geon  has,  therefore,  a  I'edundancy  which  he  can  utilise  a  little  later  on,  when  he 
has  raised  the  Haj)  from  the  forehead.  He  now  proceeds  to  do  this.  A  i)iece  of 
brown  paper  renderetl  adhesive,  corresponding  in  outline  with  the  Ha])  (Fig.  172b) 
considered  suitable  to  the  case  in  hand,  is  stuck  Hrmly  on  to  the  forehead  in  a 
slanting  direction.  And  then  a  ve^y  sharp  knife  is  run  round  the  border  of  the 
l)ai)er.  The  i)a])er  is  now  removed,  and  the  Haj)  is  quickly  raised  from  the  forehead. 
This  Hap  should  embrace  all  the  tissues  down  to  the  periosteum,  and  should  be 
subjected  to  as  little  handling  as  possible.  The  sides  of  the  gap  now  left  in  the 
forehead  are  a])proximated  as  quickly  as  possible  with  horseliair  sutures,  and  it 
is  surprising  how  small  a  raw  surface  is  left  behindi  on  the  forehead  if  the  approxima- 
tion  of  the  sides  of  the  gaj)  be  judiciously  and  expeditiously  carried  out.  Attention 
is  now  directed  to  preparing  a  nidus  or  bed  for  the  recejjtion  of  the  columna,  and 
this  does  not  require  any  description.     The  two  flaps  ABCD  and  EFGH,  which 


A.  B. 

Fig.  173.     Syme's  method  of  rhinoplasty.     A,  Shape  of  flaps  from  the  cheeks. 
B,  Mode  of  adjustment. 


have  been  already  raised  from  off  the  nasal  bones,  are  now  reflected  downwards, 
and,  as  they  overlap  in  the  centre,  two  triangular-shaped  pieces  are  cut  away,  and 
placed  in  the  middle  of  the  gap  left  in  the  forehead,  in  order  to  expedite  the  healing 
af  the  frontal  scar.  The  forehead  flap  is  now  brought  down  over  the  nasal  bones 
and  rests  interiorly  on  the  two  reflected  nasal  flaps,  and  the  nostrils  of  the  newly 
formed  nose  are  therefore  lined  inside  with  the  skin  of  the  reflected  nasal  flaps. 
The  free  inferior  margins  of  the  forehead  flaj)  and  the  nasal  flap  are  now  brought 
together  by  horsehair  sutures.  The  columnar  portion  of  the  forehead  flap  is  now 
fixed  in  tlie  bed  prepared  for  it  by  sutures,  and  the  two  original  incisions  drawn 
from  the  root  of  the  ate  nasi  on  either  side  to  the  bridge  of  the  nose  are  now 
deepened  and  bevelled  off  for  the  reception  of  the  sides  or  lateral  margins  of  the 
forehead  flap.  The  lateral  margins  of  the  forehead  flap  are  most  accurately  attached, 
by  means  of  horsehair  sutures,  to  the  bed  prepared  for  them.  Two  pieces  of  drainage- 
tubing  are  inserted  in  the  newly  formed  nostrils.  If  the  root  or  pedicle  of  the  new 
nose  is  sufficiently  broad  and  is  not  dragged  upon,  and  the  angular  artery  has  not 
been  wounded,  then  all  will  go  well  and  there  need  be  no  fear  of  slougliing.  I  allow 
a  fortnight  to  elapse  before  dividing  the  root  of  the  new  nose,  and  in  doing  so  I  cut  a 
wedge-shaped  slice  out  of  the  root,  so  that  the  new  nose  may  not  be  parrot-shaped. 
As  the  inside  of  each  nostril  is  clothed  with  skin,  the  drainage-tubes  may  be  discarded 
after  ten  days." 

(3)  Syme's,  from  the  Cheeks  (Fig.  173).  This  method  is  described  by  its 
inventor  in  his  Observations  in  Clinical  Surgery,  p.  56.  Besides  doing  away 
with  a  more  conspicuous  scar,  it  is  claimed  that  this  method  enables  a  nose 
thus  constructed  to  have  its  sensations  in  correspondence  with  the  part  from 
which  it  was  derived.  To  counterbalance  the  above  is  the  future  shrinking  of  the 
flaps. 

^  Any  such  raw  surface  should  be  grafted. 


448  OPERATIONS  ON  THE  HEAD  AND  NECK 

The  following  drawings  show  the  shape  of  the  flaps  and  the  manner  of  their 
adjustment. 

New  fiaps  of  the  shape  given  in  Fig.  173a  are  marked  out  on  the  cheeks  with 
their  conjoint  jjedicle  above  at  the  root  of  the  nose,  between  the  two  inner  canthi, 
extending  so  far  downwards  and  outwards  upon  the  cheek  as  to  secure  sufficient 
amjileness  for  the  new  nose,  according  to  careful  measurements  already  taken. 
The  old  nose  being  got  read}-  by  careful  paring,  the  flaps  thus  marked  out  are 
dissected  up  and  united  in  the  middle  line  by  three  or  fovu-  sutures,  while  the  outer 
margins  are  fixed  on  each  side  to  the  raw  surface  at  a  projjer  distance  from  the 
na.sal  orifice.  BelU  advises  that  if  any  part  of  the  old  sejjtum  remain,  it  should 
be  made  very  useful  as  a  fixed  point,  a  straight  needle  being  thrust  through  one 
flap  close  to  its  outer  lower  edge,  then  through  the  septum,  and  out  at  a 
corresponding  point  of  the  other  flap.  The  edges  of  the  wounds  left  in  the  cheeks 
can  generally  be  partially  united  by  sutures  of  silver  wire  or  fishing-gut  ;  and  the 
triangular  portion,  which  must  l>e  left  to  heal  by  granulation,  proves  an  advantage, 
as  bv  its  depression  it  enhances  the  apparent  height  and  jjrominence  of  the  new 
organ.  The  cavity  of  the  new  nose  should,  as  long  as  is  needful,  be  kept  at  first 
gently  supported  and  distended  by  drainage-tubes  drawn  over  pieces  of  catheter, 
through  which  the  patient  can  breathe. 

(4)  The  Frontal  or  Indian  Method.^  This  method  has  been  used  when  the  .soft 
parts  of  the  cheeks  are  insufficient,  when  they  are  too  cicatricial,  or  when  an 
operation  making  use  of  them  has  failed.  Its  chief  objections  are  the  large  frontal 
scar,  and  the  liability  of  the  single  flap,  though  abundant  and  jtrominent  at  first,  to 
shrink  and  fall  in  later  on. 

A  piece  of  thin  gutta-percha  or  leather,  sterilised  by  sufficient  immersion  in 
1  in  20  carbolic  acid,  is  so  cut  that  when  folded  it  is  of  suitable  shap>e  and  size  for 
the  new  organ  ;  it  is  then  laid,  oi)ened  out,  upon  the  forehead,  and  the  dimensions 
marked  out  with  an  aniline  pencil  or  tincture  of  iodine.  The  flap  thus  drawn  should 
be  of  pyriform  shape,  and,  owing  to  the  retraction  of  the  skin,  should  measure  a 
quarter' of  an  inch  more  than  the  model  in  even.'  direction.  The  average  dimen- 
sions of  the  flap  were  thus  given  by  Sir  J.  E.  Erichsen  :  *  "  \Mien  the  whole  nose 
requires  restoration,  it  is  usually  necessary  to  make  it  about  two  and  a  half  to 
three  inches  long,  and  from  three  to  three  and  a  quarter  inches  wide  at  its  broadest 
part." 

For  the  frontal  flap  thus  mapped  out  a  bed  is  now  prepared  by  paring  the  old 
nose  into  a  raw  triangular  surface  ;   in  doing  this  the  knife  must  be  u.sed  obliquely, 
cutting  from  without  inwards  towards  the  middle  line,  so  as  to  leave  a  grooved 
surface  sloping  inwards.     The  warning  of  Erichsen  *  should  here  be  remembered, 
not  to  remove  the  parts  too  widely,  lest  the  cheeks  later  on  retract  and  flatten  out 
the  nose.     The  bleeding  being  arrested  by  sponge-pressnre,  torsion,  lea\ing  on 
Spencer  Wells's  forceps  (but  not  in  this  case  by  ligature),  and  covering  over  the  raw 
surface  with  sterilised  lint  and  hot  boracic-acid  lotion,  the  frontal  flap  previouslj- 
marked  out  may  now  be  raised.     This  is  done  by  running  a  scaljjel  down  to   the 
periosteum,  along  the  traced  line,  taking  care  that  the  pedicle  be  sufficiently  long 
to  bear  a  little  twisting  and  sufficiently  broad  and  thick  to  secure  the  presence  of 
one,  if  not  both,  of  the  frontal  arteries.     To  avoid  any  risk  of  stoppage  of  its  blood- 
supplv  and  sloughing  it  is  well  to  place  the  incision  for  the  pedicle  a  little  obliquely, 
with  one  side  descending  a  little  lower  than  the  other,  viz.  on  the  side   to  which 
the  flap  is  to  be  twisted.     \Miere  the  level  of  the  hauy-  scalp  admits  of  it,  this  flap 
should  lie  a  little  obliquely,  the  tension  being  thiLS  lessened.     WTiere  necessarj-,  the 
flap  may  be  taken  transversely  above  one  or  other  eyebrow  ;   but  the  oVjjection  to 
this  is,  that  the  retraction  of  the  scar  upon  the  forehead  draws  the  corresponding 
eyebrow  upwards  (Stimson).     The  frontal  flap,  however  placed,  is  now  raised  from 
l>elow  upwards,  so  that  the  neces.sary  hjemorrhage  is  rendered  as  little  embarra.ssing 
as  jK)ssible,  and  with  no  more  handling,  or  pinching  with  forceps,  than  is  unavoid- 
able.    The  knife  should  be  kept  away  from  the  flap  towards  the  periosteum,  and 
u.sed  in  the  same  plane  throughout,  without  any  scoring  whatever.     The  h*morrhage, 
free  at  first,  is  readily  arrested  by  fore i -pressure  (leaving  on  Spencer- Wells  forceps 
for  a  while),  or  by  sponge-pressure.     The  flap  being  sufficienth*  raised  to  hang 
freelj-  and  without  tension,  is  then  twisted  slighth"  to  one  side  (that  on  which  the 
pedicle  has  been  cut  longest),  and  brought  down  and  adjasted  to  the  pared  edges 

1  Manual  of  Surgical  Operations,  fourth  edition,  p.  176. 

2  Introduced  into  European  surgery  bj-  Carpue  in  1816. 
'  Surg.,  vol.  ii,  p.  608. 

*  Loc.  supra  cit.,  p.  609. 


KEPAIR  OF  THE  NOSE  449 

below  by  means  of  numerous  fine  sutures  of  sahnon-gut,  fine  silver  wire,  and  horse- 
hair, all  being  introdueed  with  very  small  needles. 

If  the  contlition  of  the  forehead  has  admitted  of  taking  a  columella  from  there, 
an  appropriate  groove  must  also  have  been  cut  in  the  up])er  part  of  the  median  line 
of  the  lip,  and  the  two  carefully  adjusted.  If  no  columella  can  be  taken  from  the 
forehead,  the  upper  lip  must  furnish  it,  either  now,  if  the  ])atient's  condition  admits 
of  it,  or  later  on,  when  the  iiedicle  of  the  frontal  (lap  is  divided.  If  no  columella 
is  made  now,  the  liaj),  when  attached,  nuist  be  supported  by  gently  introducing 
appropriate  sized  plugs  of  iodoform  gauze  wrung  out  of  lysol  lotion.  If  a  columella 
is  made,  two  bits  of  rh'ainage  tid)e  or  Jacques'  catheter  are  introduced.  The  parts, 
being  painted  with  collodion  and  iodoform,  are  well  covered  in  with  salicylic  wool, 
but  in  keeping  this  in  position  no  pressure  must  be  made  with  bandages  on  the  new 
nose. 

The  forehead  wound,  on  which  sponge-pressure  has  been  made,  is  now  partially 
closed  with  one  or  two  hare-lip  pins  and  sutures,  but  in  introducing  these  great 
care  nuist  be  taken  not  to  constrict  the  pedicle  of  the  frontal  Hap.  Now,  and  later 
on,  healing  may  be  here  promoted  by  skin-grafting  by  Thiersch's  method  (p.  42). 

The  chief  points  in  the  after-treatment  are  not  to  change  the  ,clressings  too 
frequently,  to  use  the  utmost  gentleness  in  doing  so,  to  remove  the  sutures  gradually, 
and  to  be  on  guard  to  prevent  the  onset  of  infection  or  of  secondary  hsemorrhage. 
The  former  will  be  known  by  a  sudden  rise  of  temperature,  vomiting  or  nausea,  and 
is  best  treated  by  hot  boracic-acid  fomentations  and  by  a  sharp  purge.  Hsemorrhage 
may  occur,  according  to  Sir  J.  E.  Erichsen,i  as  late  as  the  ninth  day.  It  must  be 
met  by  careful  plugging  with  aseptic  gauze  dusted  with  iodoform  or  wi"ung  out  of 
adrenalin. 

The  Hap  remains  oedematous  for  some  time,  but,  if  not  going  to  slough,  it  will 
be  found  warm  and  sensitive.  If  too  much  swelling  persist,  careful  punctiform 
scarification  should  be  used. 

Separation  of  the  root  of  the  flap.  Thi-ee  months  after  the  first  operation,^  i.e. 
not  until  the  flap  has  finished  slmnking,  the  pedicle  is  divided  with  a  narrow 
straight  bistoury  and  cut  somewhat  wedge-shaped,  with  the  apex  upwards,  an 
appropriate  resting-place  being  fashioned  for  it  in  the  skin  beneath,  which  up  to 
this  time  has  not  been  touched.  A  few  of  the  fine  sutures  already  mentioned  are 
then  inserted. 

If  the  patient  has  been  feeble,  or  if  the  cheeks  are  very  cicatricial,  and  thus  the 
new  blood-supply  to  the  frontal  flap  be  insufficient,  some  sloughing  may  take  place, 
but  this  is  rare. 

Formation  of  a  new  columella.  If  this  was  not  made  at  the  time  of  the  first 
operation,  it  should  be  done  at  the  same  time  that  the  pedicle  is  divided.  It  is 
rare  that  a  forehead  is  sufficiently  high  to  obtain  an  adequate  columella,  and  the 
additional  thickness  and  vascularity  of  the  lip  make  it  much  more  desirable  to  take 
one  from  here.  Two  assistants  with  a  finger  and  thumb  at  each  angle  of  the  mouth 
controlling  the  coronary  arteries,  and  at  the  same  time  making  the  parts  tense,  the 
sm-geon  with  a  straight  narrow  knife  transfixes  the  root  of  the  lip  just  to  one 
side  of  the  middle  line  and  cuts  straight  down  through  the  free  border  ;  a  similar 
incision  is  made  on  the  opposite  side  of  the  middle  line,  and  a  narrow  strip,  about  a 
quarter  of  an  inch  in  width,  is  thus  detached  save  above.  It  is  well,  in  a  man,  to 
shave  off  the  skin  and  hair  follicles,  and  the  lip  being  pared,  and  the  remains  of 
the  old  columella  appropriately  freshened,  the  fraenum  is  freely  divided,  and  tha 
new  one  united  to  the  remains  of  the  old  and  to  the  alse  by  one  or  two  fine  sutures. 
The  cut  smrfaces  of  the  lip  are  then  brought  most  accm-ately  into  apposition  with  a 
silver  sutiu-e  opposite  to  the  coronary  arteries,  and  several  points  of  fine  salmon-gut 
and  horsehair.     A  few  more  are  next  inserted  to  fm'ther  adjust  the  columna. 

(5)  Italian  or  Tagliacotian  Method.  This  has  been  but  very  rarely  made 
use  of  in  this  country  owing  3  to  the  irksomeness  which  the  needful  position  entails, 
and  the  need  of  a  complicated  special  apparatus. 

On  the  other  hand,  the  absence  of  any  additional  scars  on  the  forehead  and 
cheeks,  and  the  abundant  flap  which  can  always  be  obtained,  are  so  important 

1  Loc.  supra  cit.,  p.  611,  is  mentioned  a  case  of  Lord  Lister's,  in  which  haemorrhage 
took  place  on  the  ninth  day,  the  patient  losing  over  a  pint  of  blood. 

*  The  time  usually  given,  i.e.  four  to  six  weeks,  so  as  to  allow  of  establishment 
of  the  blood-supply  to  the  flap,  is  insufficient. 

*  In  cases  where  the  destruction  is  very  gi-eat,  where  other  methods  have  failed,  where 
the  skin  available  on  the  face  is  much  scarred  or  of  doubtful  soundness,  the  Tagliacotian 
method  is  especially  indicatefl. 

SURGERY  I  29 


450  OPERATIONS  ON  THE  HEAD  AND  NECK 

that  it  may  be  thought  worth  whik>  to  try  this  method  in  female  patients  who  have 
sufficient  time  and  means,  who  object  to  tlie  forehead  scar,  and  who  will  put  up  with 
the  inconvenience  of  cramjjed  constraint  for  two  or  three  weeks. 

Sir  W.  MacCormac  brought  a  case  before  the  Clinical  Society  i  in  which  this 
method  had  answered  well  in  a  girl  aged  16.  The  following  account  is  taken  from 
his  paper.  Means  for  keeping  the  patient's  arm  in  the  needful  position  for  the 
requisite  period  were  thus  provided  : 

"  A  pair  of  ordinary  stout  well -fitting  stays  were  first  procured,  to  which  were 
attached  two  perineal  straps,  to  prevent  displacement  upwards.  A  helmet,  partly 
made  of  leather,  was  connected  with  the  stays  by  a  leather  band  running  up  the 
centre  of  the  neck  and  back.  A  leather  armpiece,  strengthened  by  a  steel  band, 
was  moulded  so  as  to  extend  from  the  wrist  to  the  shoulder,  where  it  was  buckled 
to  the  stays.  The  wrist  and  hand  were  fastened  to  the  helmet  by  a  gauntlet,  while 
the  elbow  could  be  fixed  steadily  in  any  required  position  by  straps  running  from  it 
to  the  stays,  and  to  the  sides  of  the  headi^iece,  so  that  there  was  nowhere  any  undue 
strain,  the  pressure  being  so  evenly  distributed  that  each  strap  was  almost  slack. 
This  apparatus  was  next  applied  for  some  days  beforehand,  so  that  any  point  of 
undue  press^ire  might  be  remedied.  The  girl  was  able  to  sleep  soundly  in  it,  and  it 
gave  promise  of  proving  perfectly  efficient.  Meanwhile  I  modelled  on  the  deficient 
nose  a  gutta-percha  substitute,  and  from  this  was  able  to  project  on  a  flat  surface 
the  extent  of  the  deficiency.  The  fii'st  part  of  the  operation  was  performed  thus  : 
A  flap  was  marked  out  on  the  imier  aspect  of  the  left  upper  arm,  more  than  double 
the  actual  size  of  the  estimated  deficiency.  The  left  arm  was  the  one  chosen  to 
supply  the  flap,  and  the  right  side  of  the  nose  the  one  first  operated  on,  the  septum 
being  fashioned  at  the  same  time.  The  flap  was  left  attached  to  the  upper  part 
of  the  arm  by  a  broad  long  pedicle,  and  so  arranged  that  there  should  be  no  traction 
whatever  upon  it,  whilst  the  raw  surface  from  which  it  was  taken  should  be  accessible 
for  daily  dressing.  With  the  flap  I  dissected  up  the  subcutaneous  fat  down  to  the 
muscular  sheath.  Immediate  retraction  both  of  the  flap  and  of  the  denuded  jjart 
of  the  arm  took  place  to  a  large  extent,  so  that  the  raw  sm-face  on  the  latter  was 
almost  co-extensive  with  the  whole  inner  surface  of  the  girl's  arm,  the  flap  appearing 
quite  small  in  comparison.  I  now  made  a  slightly  curved  incision,  nearly  parallel 
to  the  free  border  of  the  nose  on  the  right  side,  and  about  tlu-ee  lines  above  it, 
corresponding,  in  fact,  to  where  the  alar  furrow  should  normally  exist.  This 
incision  was  prolonged  some  little  distance  into  the  cheek  in  the  line  of  the  cheek 
furrow,  wliilst  the  remains  of  the  septum  were  split  open  in  the  median  line.  This 
nasal  flap  could  now  be  tiurned  down  so  as  to  become  horizontal,  or  rather  a  little 
depressed  below  the  horizontal  line,  to  allow  for  retraction  of  the  ingrafted  piece. 
A  triangular  gap,  the  apex  pointing  towards  the  cheek,  was  thus  left  exposed  on 
the  right  lateral  aspect  of  the  nose,  and  into  this  the  triangular-shaped  piece  from 
the  arm  was  inserted,  and  acciu'ately  attached  by  suture,  the  portion  to  form  the 
septum  being  sutirred  in  the  groove  already  formed  by  splitting  the  septum.  In 
this  way  there  was  no  paring  of  edges,  nor  was  a  single  particle  of  nose  tissue 
sacrificed,  whilst  by  having  so  large  a  line  of  attachment,  being  almost  surrounded 
by  living  tissue,  the  new  flap  was  much  more  likely  to  adhere  satisfactorily  in  the 
first  instance,  and  from  its  freer  blood -supply  less  prone  perhaps  to  subsequent 
contraction.  Union  took  place  in  great  part  by  first  intention,  some  suppuration 
setting  in  on  the  eighth  day.  Healing  was  not  complete  for  nearly  three  weeks.  At 
this  date  the  operation  was  completed  by  detaching  the  flap  from  the  arm,  cutting  this 
so  as  to  give  it  a  triangular  shajie,  and  jireparing  the  left  side  of  the  nose  to  receive  it 
in  a  manner  precisely  similar  to  the  right  side.  The  perfect  vitality  of  the  now 
completely  severed  tissue  of  the  arm  was  made  apparent  by  copious  haemorrhage, 
and  healing  was  complete  in  a  fortnight.  After  the  first  forty-eight  hours  scarcely 
any  inconvenience  was  felt  from  the  apparatus,  save  for  a  slight  excoriation  on  one 
shoulder.  The  result  was  good,  but  it  was  expected  that  further  contraction  would 
much  improve  the  aspect  of  the  nose,  the  new  organ  being  fully  large." 

Grafting  bone, 2  e.g.  that  of  the  rabbit,  so  as  to  restore  the  bony 
bridge.     This  method,  made  use  of  by  Sir  Watson  Cheyne,^  with  great 

^  Clin.  80c.  Trans.,  vol.  x,  p.  181.  Three  figures  are  given  of  the  patient  before  and 
after  the  operation,  and  of  the  apparatus  used. 

^  Hardie  and  others  have  replaced  the  bony  framework,  causing  the  freshened  tip 
of  the  left  forefinger  to  heal  into  the  vivified  u^jper  angle  of  the  nasal  defect.  Fifteen 
weeks  later  the  finger  was  amputated  in  the  middle  of  the  uioper  phalanx. 

3  Clin.  Soc.  Trani.,  vol.  xxxiii,  1899,  p.  218. 


REPAIR  OF  THE  NOSE 


451 


success  in  a  case  of  ihiiioplasty,  will  probably  be,  iiiiich  used  in  the  future 
for  reforming  the  bony  framework  of  the  nose,  either  in  place  of  taking 
bone  and  periosteum  in  the  frontal  flap,  or  in  cases  where  this  method 
has  failed.     Tt  has  been  described  at  p.  445. 

Causes  oJ  Failure  after  Complete  Rhinoplasty  : 

(1)  Gangrene  and  sloughing. 

(2)  Secondary  luemorrhage. 

(3)  Infection  of  the  wound,  erysipelas,  &c. 

(4)  Shrinking  and  consequent  shapelessness  of  the  new  nose. 

(5)  Destruction  of  the  new  nose  by  recurrence  of  the  old  disease. 

C.  Operations  for  Partial  Restoration  of  the  Nose.  These  are  very 
numerous,  and  have  usually  been  designed  for  special  cases.  A  few  only 
will  be  alluded  to  here. 

(i)  In  cases  where  the  lower  third  of  the  nose  is  left  untouched  and 
the  central  portion  especially  destroyed.     Small  square  flaps  are  raised 


Fig.  174.     Rhinoplasty.     Single 
lateral  flap.     (Stimson.) 


Fig.  175.     Rhinoplasty.     Uenonviller's 
method.     (Stimson.) 


from  the  sides  of  the  nose  and  cheeks,  to  which  a  small  flap  from  the 
forehead  may  be  added,  and  united  in  the  middle  line. 

(ii)  Single  Lateral  Flap.  This  may  be  taken  in  many  different  ways, 
(a)  From  the  cheek,  at  the  side  of  and  below  the  nose.  This  flap  may 
be  raised  horizontally,  the  pedicle  lying  outwards  on  the  cheek.  This  is 
merely  a  modification  of  Syme's  operation.  It  has  given  excellent  results 
after  operations  for  lupus,  rodent  ulcer,  and  epithelioma,  where  the 
cheeks  are  fairly  full  and  rich  in  fat  (Fig.  174). 

(b)  From  the  opposite  side  (Langenbeck).  Here  the  flaps  are  taken 
vertically.  The  apex  of  the  flap  is  left  attached  to  the  inner  angle  of  the 
eye,  on  the  same  side  as  the  deficiency,  while  the  base  comes  from  the 
ala  of  the  soimd  side  (Fig.  174  B). 

(c)  M.  Denonviller's  Method.  A  border  that  has  already  cicatrised 
is  made  use  of  so  as  to  prevent  subsequent  narrowing.  A  triangular 
flap  is  marked  out  by  incisions  shown  in  Fig.  175,  the  pedicle  being 
internal.  The  flap,  having  been  carefully  raised  with  a  strip  of  cartilage 
in  its  lower  margin,  is  displaced  downwards  into  position,  and  retained 
there  by  the  V-shaped  wound  being  sutured  in  the  shape  of  an  inverted  A- 

In  all  the  above  methods,  if  cartilage  is  not  included  in  the  free  border 
which  is  to  form  the  new  ala,  the  flaps  should  be  cut  long  enough  to  allow 
of  turning  this  border  upon  itself  and  thus  giving  a  thicker  and  more 
natural  appearance  to  it,  and  in  all,  care  must  be  taken  that  the  new  ala 


452  OPERATIONS  ON  THE  HEAD  AND  NECK 

is  patent,  and  there  is  no  after-displacement  of  the  upper  Hp  or  lower 
eyelid. 

{d)  M.  Weher's  Method.  The  flap  is  taken  from  the  upper  lip  :  on 
account  of  the  hair  follicles  this  plan  is  best  suited  to  women.  An  oval 
flap  is  taken,  usually  from  the  centre  of  the  lip,  with  its  pedicle  left 
attached  close  to  the  columella  and  its  free  margin  reaching  to  the 
prolabium.  The  flap,  which  consists  only  of  part  of  the  thickness  of  the 
lip,  is  turned  up,  and  stitched  to  the  remains  of  the  ala,  which  have  been 
refreshed.  The  wound  in  the  lip  is  closed  or  grafted.  In  three  or  four 
weeks  this  pedicle  is  divided,  and  may  be  so  united  to  the  inner  surface  of 
the  flap  as  to  give  it  a  thicker  and  rounded  margin. 

Subcutaneous  Injection  of  Sterilised  Paraffin,  especially  as  a  means  of 
correcting  saddle-nose.  This  method  was  first  introduced  by  Gersuny 
of  Vienna  in  1899.  The  following  details  are  largely  taken  from  the 
writings  of  Dr.  Walker  Downie,^  Mr.  Stephen  Paget,^  and  Dr.  Milligan 
of  Manchester.^  Mr.  Paget  has  operated  on  twenty-six  cases  ;  the 
results  shown  in  many  of  the  photographs  which  accompany  his  and 
other  papers  on  this  subject  are  admirable. 

Sterihsed  parafB.n  with  a  melting-point  of  110°  F.  to  115°  F.  is  used. 
If  the  melting-point  be  only  104°  F.  it  tends  to  set  in  the  needle,  if  it  be 
as  high  as  125°  F.  to  135°  F.  it  is  very  difficult  to  prevent  its  diffusion, 
while  this  degree  of  heat  may  do  damage  to  the  tissues ;  finally,  too, 
liquid  paraffin  may  escape  after  the  needle  is  withdrawn.  Mr.  Paget 
having  tried  many  forms  of  needle,  prefers  that  of  Eckstein.  The  syringe 
and  the  proximal  half  of  the  needle  are  jacketed  with  india-rubber,  the 
syringe  is  easily  worked  with  one  hand,  and  there  is  a  screw-nut  on  the 
piston  which  prevents  the  paraffin  going  in  with  a  jerk,  and  it  cannot 
inject  too  much  paraffin.  The  skin  is  duly  sterihsed.  A  general 
ansesthetic  is  usually  required,  especially  on  the  first  occasion  The 
paraffin  and  syringes — it  is  best  always  to  have  two  syringes,  in  case  one 
gets  out  of  order — are  kept  in  a  water-bath  6°  or  7°  above  the  melting- 
point.  The  skin  is  nicked  for  the  needle  ;  about  6  c.c.  of  the  paraffin  are 
taken  up,  and  the  syringe  held  in  the  water-bath  while  the  screw-nut  is 
adjusted  ;  then  the  needle  is  dipped  for  a  second  or  two  into  boiling 
water.  It  should  not  be  passed  through  the  flame  of  a  spirit  lamp,  for 
this  method  stains  the  paraffin  in  it.  To  prevent  diffusion  into  the 
eyelids  and  forehead,  an  assistant  should  make  strong  pressure  with  his 
finger  and  thumbs,  meeting  in  a  ring,  especially  over  the  lateral  aspects 
of  the  nasal  bones  near  the  inner  canthi.  Dr.  Milligan  has  used  a  thin 
strip  of  lead  moulded  around  the  area  of  operation ;  on  this  pressure  is 
made.  The  needle  is  quickly  driven  into  the  subcutaneous  tissues,  its 
point  being  well  driven  down  towards  the  tip  of  the  nose,  from  above, 
or  introduced  a  little  to  one  side  of  the  middle  line,  below  the  point  where 
the  bridge  ought  to  be  and  directed  upwards.  The  injection  should  be 
made  at  about  the  rate  of  one  cm.  every  ten  seconds.  It  is  better  to 
inject  too  little  than  too  much  paraffin,  a  second  or  a  third  injection 
being  made  later,  if  needful.  The  needle  should  not  be  entirely  with- 
drawn until  the  amount  of  paraffin  required  is  injected  and  the  moulding 
carried  out.  This  is  carried  out  by  the  left  hand  ;  the  insertion  of  a  little 
finger  in  the  nostril  is  sometimes  a  help.     The  paraffin  begins  to  set  in  less 

1  Brit.  Med.  Jovrn..  vol.  viii.,  1902,  and  Clin.  Soc:  Trans.,  vol.  xxxvi.  p.  128. 

2  Ibid.,  January  3,  1903. 

3  Med.  Chron.,  1902,  vol.  iv,  p.  333. 


REPAIR  OF  THE  NOSE  453 

t  IiiUi  ;i  luimitc,  but  remains  d()U<:;liy  lor  about  a  quarter  of  an  liour.  The 
niouldiny  and  S(|ueeziii<i;  the  nose  into  a  ^ood  shape  must  be  done  pretty 
vigorously,  and  nmst  not  cease  till  the  parafUn  is  unimj)i'essionable.  The 
puncture  is  closed  with  collodion,  aiul  icetl  boracic  lotion  applied  for  a  few 
hours.  The  immediate  etTect  of  the  injection  is  to  make  the  surrounding 
skin  pale  as  well  as  tense.  This  pallor  soon  passes  off.  Pain  is  not,  as  a 
rule,  nuich  complained  of.  If  no  anaesthetic  is  given,  there  must  be  no 
movement  when  the  })uiu'ture  is  made.  As  to  the  permanency  of  the 
results.  Dr.  Milligan  states  that  cases,  carefully  watched  for  over  a  year, 
have  shown  no  tendency  to  alter  to  any  appreciable  extent.  Even  if, 
aftei"  some  years,  absorption  should  take  place,  repetition  of  the  injec- 
tion would  always  be  possible.  Difficulties  in  effecting  much  improve- 
ment will  chiefly  arise  in  the  following  cases  (Paget)  :  Where  the  skin  is 
adherent,  as  after  scarring  due  to  syphilis,  in  cases  chiefly  congenital. 
Here  the  subcutaneous  use  of  a  tenotome  may  help.  Connell,^  in  the 
case  of  very  tight  tissues,  loosens  them  a  few  days  before  with  a  tenotome  ; 
at  the  time  of  the  injection  he  uses  sterilised  saline  solution  before  the 
paraffin. 

The  following  are  the  chief  sequelae  which  may  be  more  or  less 
disastrous. 

(1)  Unless  sufficient  pressure  is  maintained  all  round  the  area  in- 
jected, very  disfiguring  nodules  of  paraffin  may  remain  in  the  adjacent 
loose  cellular  tissue.  The  after-removal  of  them  is  a  matter  of  the  greatest 
difficulty  from  their  adhesion  to  the  connective  tissue. 

(2)  Thrombosis  of  the  facial  vein  and  pulmonar}'  embolism  have 
very  rarely  followed  the  injection  of  paraffin.  In  the  Lancet  for  April  9, 
1904,  a  case  is  published  in  which  the  injection  of  paraffin  was  followed 
immediately  by  blindness  of  the  right  eye,  probably  from  embohsm  of  the 
central  artery  to  the  retina. 

An  injection  had  been  made  on  two  previous  occasions  without  any  untoward 
result.  A  mixtui-e  of  paraffin  and  white  vaseline  at  a  tempei'ature  of  110°  F.  was 
injected  from  below  upwards.  At  the  moment  of  injection  the  patient  stated 
that  he  could  not  see.  A  slight  ecchymosis  on  the  tip  of  the  nose  perhajjs  indicated 
puncture  of  a  vein.  Twenty-five  minutes  after  tlie  injection  it  was  found  that  the 
inferior  branch  of  the  central  artery  of  the  retina  was  collapsed  and  empty. 

(3)  Suppuration  is  extremely  rare  after  the  operation  for  saddle-nose. 
That  the  method  of  paraffin  may  be  followed  after  an  interval  of 

months  or  years  by  very  serious  suppuration,  is  shown  by  Mr.  F.  C.  Wallis.^ 
Two  cases  are  recorded  in  which  this  method  had  been  employed  for  pro- 
lapse of  the  uterus  and  rectum  especially.  It  is  pointed  out  that  paraffin, 
though  sterile  when  introduced,  cannot  be  relied  upon  to  remain  so, 
especially  in  regions  where  pyogenic  micro-organisms  always  abound. 

Many  other  instances  in  which  Gersuny's  method  has  been  suggested  or 
employed — many  of  them  extra vagant^ — are  recorded  in  the  above  papers. 
Amongst  the  most  promising  are  the  filling  up  of  large  cavities  left  after 
operations  on  the  mastoid  bone,  elevation  of  depressed  scars,  especially 
about  the  face,  and  elevation  of  the  cheek  after  removal  of  the  upper 
jaw.  Connell  ^  gives  a  good  illustration  of  a  case  where  he  succeeded  in 
restoring  the  tip  of  a  nose  (which  had  been  bitten  off)  by  the  injection  of 
paraffin. 

^  Journ.  Amer.  Med.  Assoc,  September  1903. 
2  Lancet,  January  28,  1905,  p.  221. 
*  Loc.  supra  cit.,  Fig.  16,  p.  580. 


CHAPTER  XXII 

OPERATIONS  ON  THE  NASAL  FOSS^,  REMOVAL  OF 
FOREIGN  BODIES.  TURBINECTOMY.  OPERATIONS  FOR 
DEFLECTED  SEPTUM.  REMOVAL  OF  NASAL  POLYPI. 
OPERATION  FOR  NASO-PHARYNGEAL  FIBROMA  AND 
SARCOMA.  REMOVAL  OF  ADENOIDS  AND  ENLARGED 
TONSILS 

The  Removal  of  Foreign  Bodies  from  the  Nose.  Patients  with  foreign 
bodies  in  the  nose  are  usually  children,  and,  on  this  account,  it  may  be 
impossible  to  obtain  a  history  of  the  insertion  of  the  suspected  object. 

The  existence  of  a  foul  blood-stained  discharge  from  one  nostril 
in  a  child  should  always  suggest  to  the  surgeon  the  possibility  of  a  foreign 
body.  Occasionally  the  foreign  body  may  be  seen  on  examination  with 
the  nasal  speculum,  in  which  case  it  may  be  extracted  by  means  of  a  pair 
of  bent  serrated  nasal  forceps.  In  a  child  a  general  anaesthetic  will 
probably  be  required,  and  a  finger  should  also  be  placed  in  the  naso- 
pharynx in  case  the  object  should  be  displaced  and  escape  into  the  naso- 
pharynx through  the  posterior  nares.  A  strabismus  hook  may  be  used 
instead  of  the  serrated  forceps.  Often  the  presence  of  blood  and  pus 
prevent  a  satisfactory  view  of  the  foreign  body.  The  following  method 
will  then  generally  prove  successful.  A  strong  probe,  or  a  probe-pointed 
director,  is  introduced  along  the  floor  of  the  nasal  fossa  until  it  is  well 
beyond  the  foreign  body.  The  end  of  the  probe  which  is  held  in  the 
hand  is  then  depressed,  and  at  the  same  time  the  instrument  is  drawn 
forwards  through  the  anterior  nares.  By  this  manoeuvre  the  foreign 
body  is  dislodged  and  forced  forwards  through  the  nostril.  No  attempts 
should  be  made  to  dislodge  a  foreign  body  by  syringing  ^  on  account  of  the 
danger  of  forcing  septic  material  into  the  tympanum  and  thus  setting  up 
otitis  media. 

Turbinectomy.  Complete  removal  of  the  inferior  turbinated  bone. 
at  one  time  a  frequent  operation,  is  now  very  seldom,  if  ever,  carried  out, 
as  it  is  found  that  complete  removal  of  this  bone  is  followed  by  an  in- 
tractable form  of  rhinitis  and  chronic  inflanmiatory  troubles  in  the 
pharynx  and  larynx.  Partial  removal  of  the  inferior  turbinate- — usually 
the  anterior  end — and  of  the  middle  turbinate  are,  however,  frequently 
called  for. 

Indications.  (1)  When  the  nasal  fossa  is  obstructed  in  cases  of 
hypertrophic  rhinitis.  (2)  In  conjunction  with  submucous  resection  of 
the  nasal  septum.  (3)  As  a  preliminary  to  draining  the  maxillary 
antrum  through  the  nasal  fossa.     (4)  In  the  treatment  of  some  of  the 

^  Syringing  through  the  posterior  nares  by  means  of  a  special  tube  attached  to  a 
Higginson's  syringe  is  quite  safe,  and  will  generally  prove  successful. 

454 


OPERATIONS  ON  THE  NASAL  FOSS.E  455 

more  ronioto  se([ue]cTO  of  nasal  obstruction  such  as  chronic  mifldle  ear, 
catarrh,  chronic  laryngitis,  and  in  some  cases  of  asthma. 

Removal  of  the  posterior  extremity  of  the  inferior  turbinate  is  indi- 
cated in  cases  of  "  moriform  hypertrophy  "  of  the  mucous  membrane  in 
this  situation.  Removal  of  the  anterior  end  of  the  middle  turbinate  is 
rarely  required  for  hypertrophy.  It  is,  however,  frequently  called  for 
in  the  treatment  of  chronic  suppuration  in  the  frontal  sinus  and  in  the 
ethmoidal  cells,  and  in  th<>  ti'catment  of  nasal  poly])i. 

Removal  of  the  Anterior  End  oi  the  Inferior  Turbinate.  This  opera- 
tion may  be  carried  out  after  the  application  of  cocaine  and  adrenalin, 
or  under  general  anaesthesia .  In  the  latter  case  the  nasal  fossa  should 
be  previously  painted  with  adrenalin  to  diminish  the  amount  of  hsemor- 
rhage.  A  pair  of  curved  nasal  scissors  are  introduced  into  the  nasal 
fossa,  one  blade  passing  beneath  the  bone  and  the  other  above  it.  The 
portion  to  be  re  moved. usually  about  the  anterior  third,  is  thiLs  divided  clo.se 
to  its  attachment  to  the  superior  maxilla.  A  strong  nasal  snare  is  then 
inserted  and  manipulated  so  that  the  ^^^re  loop  encircles  the  loose  portion. 
This  is  then  tightened  and  the  pedicle  is  thus  cut  through.  If  preferred 
this  may  be  divided  by  a  pair  of  punch  forceps  instead  of  by  the 
snare. 

After-Treatment.  It  is,  as  a  rule,  not  necessary  to  use  a  plug,  but 
if  there  is  much  haemorrhage  a  strip  of  sterile  lint  impregnated  with 
sterihsed  vasehne  may  be  lightly  packed  in  and  left  in  situ  for  the  first 
twenty-four  hours.  The  subsequent  treatment  consists  in  daily  irriga- 
tion -^^dth  a  dilute  alkaline  lotion  containing  some  mild  antiseptic  such  as 
boric  acid.  In  cases  where  the  obstruction  is  caused  by  an  hypertrophy 
of  the  nmcous  membrane  alone,  a  strip  of  this  may  be  removed  from  the 
lower  border  by  the  scissors  or  cutting  forceps,  the  bone  itself  not  being 
di\dded. 

Removal  of  the  Posterior  End  of  the  Inferior  Turbinate.  A  mass  of 
hypertrophied  mucous  membrane  in  this  situation — "moriform  hyper- 
trophy " — may  be  removed  by  means  of  a  strong  snare  which  is  intro- 
duced through  the  anterior  nares.  The  loop  is  then  manipulated  round 
the  mass  with  the  help  of  a  finger  in  the  naso-phar}mx.  A  general 
anaesthetic  is  necessary,  partly  on  accomit  of  the  discomfort  of  the 
operator's  finger  in  the  naso-pharjmx,  but  also  on  account  of  the  shrinking 
of  the  growth  which  results  from  the  application  of  cocaine  and  adrenalin. 

Removal  of  the  Anterior  Extremity  of  the  Middle  Terminate.  This  may 
be  carried  out  in  a  similar  way  to  that  described  for  the  inferior  turbinate. 

Operations  for  Deflected  Nasal  Septum.  The  older  operations  have 
been  practically  superseded  by  the  operation  of  submucous  resectiou. 

Indications.  *(1)  To  remove  an  obsti-uction  to  nasal  breathing.  The 
deflected  septum  may  completely  block  one  nostril,  and  owing  to  hyper- 
trophy of  the  inferior  turbinal  on  the  concave  side  the  other  nostril  may 
be  more  or  less  obstructed.  Mouth-breathing  with  its  serious  conse- 
quences will  be  the  result.  (2)  In  the  treatment  of  the  more  di.stant 
effects  of  mouth-breathing,  when  this  is  caused  by  the  septal  deformity. 
Among  these  troubles  are  post-nasal  catarrh,  chronic  inflaimnatory 
troubles  in  the  larynx  and  pharynx,  and  chronic  Eustachian  and  middle 
ear  catarrh.  (3)  To  gain  access  to  the  posterior  part  of  the  nasal  fossa 
for  the  treatment  of  nasal  polypi  or  sinus  disease. 

The  success  of  this  operation  is  largely  due  to  the  following  facts  : 
(1)  The  deflected  portion  of  the  septum  is  completely  removed.     (2)  The 


456  OPERATIONS  ON  THE  HEAD  AND  NECK 

mucous  membrane  is  not  removed  or  seriously  damaged.  The  small  inci- 
sion required  should  Ileal  by  primary  union.  (3)  The  after-treatment, 
which  is  not  prolonged,  is  simple  and  causes  but  slight  inconvenience  to 
the  patient.  (4)  The  operation  can  be  carried  out  under  local  anaesthesia 
if  this  is  thought  desirable.  A  general  anaesthetic  is,  however,  always 
indicated  in  nervous  patients.  (5)  The  external  appearance  of  the 
nose  is  not  altered. 

It  should  be  especially  noted  that  there  is  no  falling  in  of  the  bridge  of 
the  nose,  even  after  a  subsequent  blow  or  other  injury. 

Instruments.  The  following  special  instruments  (Fig.  177):  Ballen- 
ger's  swivel  knife  ;  several  blunt  raspatories  of  different  curvature  ; 
Killian's  nasal  needle  ;  a  large  Thudicum's  speculum  ;  strong  punch 
forceps  and  a  small  gouge  and  mallet  for  remo^^ng  bony  spurs  from  the 
nasal  spine  and  crest  of  the  superior  maxillary.  The  surgeon  should  also 
be  provided  with  a  frontal  lamp,  as  a  good  light  is  essential. 

The  Operation.  Should  it  be  decided  to  perform  the  operation  under 
local  anpesthesia,  both  nasal  fossae  should  be  packed  half  an  hour  before 
the  commencement  with  strips  of  sterilised  lint  soaked  in  a  mixture  of 
equal  parts  of  adrenalin  (1  in  1000)  and  cocaine  hydrochloride  (20  per  cent.). 
On  account  of  the  toxic  properties  of  the  latter  drug  it  is  best  not  to  inject 
it  beneath  the  mucous  membrane.  If  general  anaesthesia  be  employed, 
cocaine  and  adrenalin  must  still  be  applied  to  minimise  the  amount  of 
bleeding.  In  this  case  the  application  of  equal  parts  of  adrenalin  (1  in 
1000)  and  cocaine  (5  per  cent.)  in  the  same  way  for  twenty  minutes  will 
suffice. 

Before  commencing  the  operation  these  plugs  are  removed,  but  it  is 
well  to  push  a  strip  of  sterilised  hnt,  secured  by  a  piece  of  silk  or  cat-gut, 
to  the  back  of  each  nasal  fossa  in  order  to  prevent  blood  making  its  way 
back  into  the  respiratory  passages. 

A  curved  incision,  about  a  quarter  of  an  inch  behind  the  junction  of  the 
skin  and  mucous  membrane,  is  made  with  a  small  scalpel  or  tenotomy 
knife  over  the  displaced  septum  in  the  obstructed  nostril  (Fig.  176  A). 
The  incision,  which  curves  backwards  below  to  the  floor  of  the  nose, 
extends  down  to,  but  not  through,  the  cartilage.  If  the  adrenalin  has 
acted  satisfactorily  there  will  be  little  or  no  bleeding.  Should  there 
be  much  bleeding  a  further  application  of  this  di"ug  should  be  made 
before  proceeding  with  the  operation.  A  blunt  raspatory  is  then 
introduced  between  the  cartilage  and  the  perichondrium  (Fig.  176  B)  ; 
care  must  be  taken  that  the  raspatory  is  not  inserted  between  the 
mucous  membrane  and  the  perichondrium,  for  in  this  case  attempts 
at  separation  will  lead  to  tearing  of  the  former  membrane.  When 
the  interval  between  cartilage  and  perichondrium  is  i'dentified,  it  will 
be  found  that  the  soft  layers  can  be  readily  separated  from  the 
cartilage.  The  greatest  care  must  be  taken  not  to  tear  the  mucous 
membrane.  At  first  a  straight  or  slightly  curved  raspatory  may  be 
used.  When  a  spur  or  sharp  bend  in  the  deflection  is  reached  a  raspatory 
with  a  greater  curve  may  be  employed.  It  is  at  such  places  that  the 
mucous  membrane  is  in  greatest  danger  of  injury.  It  A^'ill  often  be 
desirable  to  leave  these  spots  until  an  area  of  the  cartilage  has  been 
removed  and  a  better  view  thus  obtained.  The  muco-perichondrium 
should  be  separated  from  the  cartilage  to  the  very  back  of  the  deflected 
portion,  above  well  up  into  the  attic  of  the  nose,  and  below  to  the  nasal 
crest  of  the  superior  maxilla. 


OPERATIONS  ON  THE  NASAL  FOSS^. 


457 


The  cartihi^c  must  now  be  cut  through  in  the  line  of  the  original 
incision  witiiout  injuring  the  nuicous  membrane  of  the  opposite  nasal 
fossa.  To  guard  against  this  accident  a  finger  of  the  left  hand  may  be 
placed  in  the  opposite  nostril.  The  interval  between  the  muco-peri- 
chondrium  and  the  cartilage  on  this  side  must  now  be  sought  for  and 
identified.  The  soft  parts  are  then  separated  from  the  cartilage  by- 
means  of  laspatories,  as  in  the  case  of  the  convex  side,  the  same  care 


Fig.  176.     Submucous  Resection  of  the  Nasal  Septum. 

being  taken  to  avoid  injury  to  the  mucous  membrane.  The  large 
Thudicum's  speculum  is  then  introduced  through  the  incision  in  the 
mucous  membrane,  one  blade  passing  between  the  muco-perichondrium 
and  the  convex  surface  of  the  cartilage,  and  the  other  between  the  muco- 
perichondrium  of  the  opposite  side  and  the  concave  surface  of  the 
cartilage  (Fig.  176  C). 

The  swivel  knife  (Fig.  177),  which  will  cut  in  any  direction,  is  then 
applied  to  the  anterior  end  of  the  displaced  cartilage  which  is  now  freely 
seen  between  the  two  blades  of  the  speculum.  T  he  knife  is  first  made  to 
cut  horizontally  backwards,  just  above  the  nasal  crest.  It  is  then  made  to 
cut  upwards  and  finally  downwards  and  forwards,  so  that  a  large  area  of  the 
displaced  cartilage  is  removed. 


458  OPERATIONS  ON  THE  HEAD  AND  NECK 

The  septum  is  now  carefully  inspected,  when  other  portions  of  dis- 
placed cartilage  above,  below,  or  behind  the  area  removed  will  probably 
be  seen.  These  are  cleared  of  muco-perichondrium  by  a  raspatory  and 
excised  either  by  the  swivel  knife  or  by  punch  forceps.  The  long  speculum 
is  now  withdrawn  and  the  nasal  fossae  inspected  through  the  ordinary 
nasal  speculum.  This  wnll  probably  reveal  some  obstruction  due  to  dis- 
placement or  overgrowth  of  the  nasal  spine  and  crest,  or  at  the  junction  of 
the  cartilage  and  the  vomer.     With  the  improved  view  now  obtained  after 


l"     FULLSlZECLTICR 


Fig.  177.     Ballenger's  swivel  knife. 

removal  of  the  displaced  cartilage,  the  muco-periosteum  can  be  detached  in 
these  situations  A^athout  tearing.  The  bone  may  be  removed  with  strong 
punch  forceps  or  cutting  forceps,  or  by  a  small  gouge  and  mallet,  the  latter 
being  generally  required  for  the  nasal  spine.  This  must  be  persisted  in 
until  all  the  displaced  structures  have  been  completely  removed.  All  loose 
pieces  and  any  semi-detached  fragments  are  then  picked  out  and  the  space 
between  the  two  detached  layers  of  muco-perichondrium  is  cleaned  and 
dried  with  pledgets  of  sterilised  lint.  The  large  speculum  is  then  with- 
drawn, and  the  two  layers  are  allowed  to  fall  together  ;  the  small  in- 
cision is  then  closed  by  two  or  three  catgut  sutures  inserted  by  the  hook- 
hke  nasal  needle.  It  will  probably  now  be  found  necessary  to  remove  the 
anterior  end  of  the  enlarged  inferior  turbinal  which  is  usually  found 
in  the  fossa  bounded  by  the  concave  side  of  the  original  deformity 
{see  p.  455). 

Two  pieces  of  sterilised  lint  are  now  rolled  up  to  form  two  plugs  about 
the  size  of  the  little  finger.  Each  is  smeared  with  sterilised  vaseline, 
and  one  is  inserted  into  each  nasal  fossa,  which  is  thus  lightly  plugged. 

AJter-Treatment.  The  plugs  are  taken  out  at  the  end  of  forty-eight 
hours  and  need  not  be  replaced.  Daily  irrigation  with  alkaline  boracic 
lotion  is  then  all  that  is  required. 

The  patient  may  be  able  to  breathe  through  the  nose  satisfactorily 
in  a  few  days,  but  in  many  cases  the  full  benefit  is  not  experienced  until 
all  swelling  has  subsided,  which  may  be  after  two  or  three  weeks. 

Generally  speaking,  this  operation  is  not  a  difficult  one,  in  spite  of  the 
small  wound  through  which  a  large  portion  of  the  cartilaginous  and  bony 
septum  has  to  be  removed.  Efficient  hsemostasis  is  of  the  greatest  im- 
portance. If  the  nose  is  continually  flooded  with  blood  the  operation 
may  be  both  tedious  and  difficult.  Careful  preliminary  treatment  with 
cocaine  and  adrenalin  and  the  occasional  application  of  the  same  solution, 
if  necessary  during  the  course  of  the  operation,  will  usually  be  successful 
in  controlling  haemorrhage.  The  presence  of  the  plugs  will  prevent  the 
formation  of  a  hsematoma  between  the  two  layers  of  mucous  membrane. 
Should  this  troublesome  complication  appear  it  will  be  necessary  to  open 
up  the  wound  and  turn  out  the  clot.  The  most  difficult  part  of  the  opera- 
tion is  usually  the  removal  of  the  bony  nasal  crest,  but  this  is  essential  for 
a  completely  successful  result.     Tearing  of  the  nmcous  membrane  must 


REMOVAL  OF  NASAL  POLYPI  459 

be  avoided  by  careful  and  delicate  manipulation  of  the  raspatories, 
and  by  making  sure  sure  that  these  are  in  the  interval  between  the 
cartilage  and  the  perichondrium. 

REMOVAL  OF  NASAL  POLYPI 

Before  an  operation  is  undertaken  on  nasal  polypi  it  must  always  be 
remembered  that  they  fall  into  two  chief  groups  :  (a)  those  in  which 
they  occur  alone  or  with  merely  a  chronic  osteitis  of  the  subjacent  bones  ; 
(6)  those  in  which  caries  of  the  bones  and  disease  of  the  accessory  sinuses 
coexist.  In  these  latter  cases  suppuration — often  very  profuse — is 
always  present,  and  there  will  be  evidence  of  carious  bone  to  the  probe 
or  to  the  finger,  when  the  patient  is  under  a  general  anaesthetic  ;  the 
symptoms,  especially  headache,  w411  be  aggravated. 

In  many  cases,  no  doubt,  the  obstinacy  with  which  nasal  polypi 
tend  to  persist  and  recur  is  explained  by  the  coexisting  bone  disease 
being  overlooked.  The  same  tendency  does,  however,  exist  in  cases  of 
nasal  polypi  without  suppuration  or  bone  disease  and  with  only  the 
usual  clear  watery  discharge.  This  is  due  to  their  occupying  sites  of 
difficult  access,  and  to  the  sensitiveness  of  the  nasal  mucous  membrane 
interfering  with  their  complete  removal.  While  the  majority  of  simple 
polypi  can  be  readily  removed  under  local  anaesthesia,  a  general  anaes- 
thetic is  advisable  in  these  recurrent  cases. 

The  treatment  will  depend  upon  the  nature  of  the  case. 

A.  Treatment  of  Simple  Nasal  Polypi.  It  must  be  remembered  that 
these  are  invariably  attached  to  the  region  of  the  middle  meatus,  and 
that  the  size  of  the  polypus  and  the  nature  of  the  pedicle  vary  immensely. 
In  some  cases  there  will  be  one  very  large  polypoid  mass  occupying  the 
entire  nasal  fossa,  while  in  others  there  w^ll  be  a  large  number  of  smaller 
masses  varying  in  size  from  a  pea  to  a  cherry  or  even  larger.  In  the  latter 
group,  as  the  more  anteriorly  situated  are  removed,  others,  occupying  the 
posterior  part  of  the  fossa,  come  into  view\  Their  mobility  varies  con- 
siderably. The  manipulations  necessary  to  remove  those  in  front  may 
displace  others  to  the  upper  and  back  part  of  the  nasal  fossa,  where  they 
are  readily  overlooked.  Such  mobile  polypi  may  often  be  brought  into 
view  and  rendered  more  accessible  by  making  the  patient  forcibly  blow 
his  nose.  The  posterior  rhinoscopic  mirror  is  of  great  service  in  detecting 
polypi  which  have  been  displaced  backwards  into  the  naso-pharynx. 

These  simple  polypi  should  be  removed  by  some  form  of  nasal  snare. 
Though  the  polypi  themselves  are  insensitive,  the  nasal  mucous  mem- 
brane is  by  no  means  so.  Anaesthesia  may  be  secured  by  spraying  the  nasal 
fossa  with  equal  parts  of  adrenahn  (1  in  1000)  and  cocaine  (5  per  cent.), 
or  better,  by  plugging  the  fossa  with  a  strip  of  ribbon  gauze  soaked  in 
equal  parts  of  a  20  per  cent,  solution  of  cocaine  and  1  in  1000  solution  of 
adrenalin  or  one  of  its  substitutes,  such  as  hemisine.  The  plug  should  be 
left  in  situ  for  half  an  hour  and  removed  just  before  the  commencement 
of  the  operation. 

Krause's,  Blake's,  and  Lack's  are  the  handiest  and  most  useful  forms 
of  snare.  Blake's  is  a  very  convenient  form  and  is  best  for  all  ordinary 
dehcate  polypi  and  for  those  attached  high  up.  Krause's  (Fig.  178)  is  suit- 
able for  larger  and  tougher  growths,  while  Lack's,  which  is  a  stronger  instru- 
ment worked  by  a  screw,  can  be  relied  upon  to  remove  the  toughest  polypi 
or  part  of  the  middle  turbinate  itself.     In  any  case  too  fine  wire  should 


460 


OPERATIONS  OX  THE  HEAD  AND  NECK 


not  be  used,  as  it  soon  gets  damaged,  and  moreover  it  cuts  the  neck  of 
each  polypus  through  instead  of  pulUng  the  growth  away  with  its  base,  and, 
if  possible,  a  little  bone  in  it.  A  small  ring  knife  should  always  be  at 
hand  in  case  there  should  be  any  small  sessile  polyj^i  which  cannot  be 
seized  by  the  snare.  The  patient  should  sit,  facing  the  surgeon,  with 
his  head  supported  by  an  assistant  or  by  a  head-rest.  Good  illumina- 
tion is  essential,  and  this  may  be  secured  either  by  the  frontal  lamp  or 
bv  the  forehead  mirror  and  reflected  lisht.     The  anterior  nares  having 


Fig.  178.     Kra use's  nasal  polypus  snare. 


been  held  open  by  a  full-sized  Thudicum's  speculum,  the  vrire  loop  is 
introduced  in  the  vertical  plane  between  the  growth  and  the  septum.  It 
is  then  made  to  encircle  the  polypus  by  slight  movements  backwards  and 
forwards,  and  by  rotating  the  instrument  in  an  upward  and  outward 
direction.  In  this  way  the  loop  reaches  the  pedicle  of  the  polypus,  which 
almost  invariably  is  attached  in  the  region  of  the  middle  meatus.  The 
snare  is  next  tightened  until  a  firm  grip  is  secured  and  the  polypus  then 
removed,  partly  by  pulling,  and  partly  by  twisting.  The  pedicle  should 
not  be  cut  through  by  the  loop,  as,  in  this  case,  the  base  \n\\  be  left 
behind  and  a  recurrence  is  then  almost  certain.  When  the  first  growth 
has  been  removed  others  will  probably  come  into  view.  These  must  be 
treated  in  the  same  way  until  the  fossa  is  quite  clear.  During  these 
manipulations  one  or  more  polypi  may  readily  be  forced  back  into  the 
naso-pharynx  or  into  the  upper  and  back  part  of  the  nasal  fossa.  Such 
polypi  may  be  brought  forward  when  the  patient  blows  his  nose,  and  if 
necessary  a  finger  may  be  introduced  into  the  naso-pharynx  to  make 
sure  that  this  is  clear. 

Where  the  middle  turbinate  is  much  enlarged,  where  it  is  covered 
with  sessile  polypi,  or  when  it  is  found  to  be  carious,  it  is  quite  easy  to 
cut  it  away  in  two  or  three  pieces  \\'ith  a  Meyer's  ring  knife.  When,  how- 
ever, it  is  thought  likely  that  the  bone  vdW  require  removal,  a  general 
anaesthetic  will  be  desirable  {vide  infrd).  The  haemorrhage,  which  may  be 
rather  free,  usually  stops  spontaneously,  or  may  be  checked  by  sponging 
with  ice-cold  water.  Plugging  should  be  avoided  on  account  of  the  danger 
of  retention  of  septic  discharges,  which  may  even  lead  to  meningitis.  After 
twenty-four  hours  the  nasal  fossa  may  be  gently  irrigated  with  warm 
alkaline  boracic  lotion,  and  this  may  be  repeated  twice  daily  until  the 
discharge  ceases. 

The  patient  should  be  seen  after  an  interval  of  four  weeks,  when  the 
nasal  cavity  is  again  inspected  and  any  pol\'pi  which  escaped  removal 


REMOVAL  OF  NASAL  POLYPI  461 

oil  tlie  first  occasion,  or  wliicli  liave  reappeared,  are  treated  in  the  same 
way. 

B.  Treatment  of  obstinately  Recurring  Polypi,  and  where  caries  of  tlie 
ethmoid  is  known  to  be  present.  A  general  anaesthetic  is  desirable  for 
this  operation,  though,  with  a  view  to  avoiding  excessive  haemorrhage, 
the  nasal  fossa  should  be  prepared  with  adrenalin  and  cocaine  as  re- 
commended for  the  preceding  operation.  The  patient  must  be  in  the 
horizontal  position  on  a  couch  or  operating  table,  and  the  nasal  fossa 
must  be  well  illuminated,  preferably  by  a  frontal  lamp.  The  special 
instruments  required  are  Grunwald's  nasal  punch  forceps,  Luc's  nasal 
forceps,  and  Meyer's  ring  knife. 

One  blade  of  the  forceps  is  introduced  beneath  the  middle  turbinal 
and  the  other  between  this  bone  and  the  septum.  A  large  mass  of  poly- 
poid tisssue  and  carious  ethmoid  is  thus  grasped  and  is  removed  by 
twisting  and  pulling.  The  forceps  are  then  again  introduced,  and  further 
masses  of  diseased  tissue  are  removed.  In  this  way  the  ethmoidal  cells 
and  even  the  sphenoidal  sinus  are  opened  up.  The  ring  knife  or  a  Volk- 
mann's  spoon  may  be  used  for  removing  projecting  ridges,  and  for  clearing 
out  cavities  which  cannot  be  satisfactorily  explored  by  the  forceps.  The 
greatest  care  must  be  taken  throughout  not  to  injure  the  cribriform  plate, 
which  delicate  structure  alone  intervenes  between  the  cranial  cavity  and 
the  septic  and  diseased  bone  of  the  nasal  fossa.  To  this  end  all  pushing, 
scraping,  or  boring  movements  in  the  direction  of  the  roof  of  the  fossa 
are  to  be  avoided.  All  pressure  from  instruments,  either  forceps,  sharp 
spoon,  or  ring  knife,  should  be  made  towards  the  outer  or  the  inner  wall. 
During  such  an  operation  the  haemorrhage,  in  spite  of  the  preliminary 
preparation,  is  likely  to  be  severe.  Besides  the  danger  of  blood  passing 
back  into  the  naso-pharynx  and  the  larynx,  the  haemorrhage  will  obscure 
the  field  of  operation.  This  difficulty  may  be  overcome  by  allowing  the 
patient's  head  to  hang  over  the  edge  of  the  couch,  or  better,  by  a  pre- 
liminary plugging  of  the  posterior  nares.  Sir  St.  Clair  Thomson  advises 
that  this  be  carried  out  in  the  following  manner.  "  A  sterilised  sponge, 
about  the  size  of  a  tangerine  orange,  is  squeezed  very  dry  and  tied  round 
its  centre  with  a  piece  of  tape  or  a  stout  silk  ligature,  leaving  two  free 
ends  of  about  twelve  inches  in  length.  A  soft  rubber  catheter  is  passed 
along  the  floor  of  the  nose  till  it  appears  below  the  soft  palate,  when  the 
end  is  seized  with  forceps  and  drawn  through  the  mouth.  To  this  end 
one  of  the  tapes  is  made  fast,  so  that  when  the  catheter  is  withdrawn  from 
the  nose,  the  sj)onge  is  pulled  up  into  the  post-nasal  space  ;  the  other  end 
hangs  out  of  the  mouth.  The  two  tapes  are  tied  together  over  the  upper 
lip."  The  same  surgeon  recommends,  when  bleeding  obscures  the  field 
of  operation,  plugging  with  strips  of  gauze  soaked  in  adrenalin  or  a  10  per 
cent,  solution  of  hydrogen  peroxide.  The  plug  may  be  left  in  situ  for  a 
few  minutes.  When  the  operation  is  completed  the  haemorrhage  usually 
ceases  spontaneously  when  the  post-nasal  sponge  is  withdrawn,  or,  if 
necessary,  the  means  suggested  at  p.  460  may  be  tried.  Plugging  the 
nasal  fossa  should  be  avoided  on  account  of  the  danger  of  sepsis. 

Dangers  of  the  Operation.  It  must  be  admitted  that  this  operation  is 
by  no  means  free  from  risks.  The  chief  of  these  is  sepsis.  Even  apart 
from  injury  to  the  cribriform  plate,  which  has  been  mentioned  above, 
intracranial  complications  such  as  meningitis  or  cerebral  abscess  may 
occur.  Haemorrhage  has  already  been  discussed.  In  addition  to  this. 
Sir  St.  Clair  Thomson  mentions  injury  to  the  os  planum  of  the  ethmoid 


462  OPERATIONS  ON  THE  HEAD  AND  NECK 

with  emphysema  of  the  eyeUds,  ecchyraosis  of  the  eyehds  or  even  an 
orbital  abscess. 

C.  Moure's  Operation  and  Rouge's  Operation  (q.v.).  Owing  to  the 
improved  technique  of  intranasal  operations,  these  methods  are  not  now 
likely  to  be  required  for  polypi  or  for  other  simple  growths  of  the  nasal 
fossae. 

OPERATIONS  FOR  NASO-PHARYNGEAL  FIBROMA  OR  SARCOMA, 
AND  MALIGNANT  GROWTHS  OF  THE  NOSE 

(Figs.  179-182) 

Naso-Pharyngeal  Fibroma  or  Sarcoma.  Attachments  and  Relations. 
The  surgeon  should  consider  these  carefully  before  deciding  what  opera- 
tion he  will  adopt  for  one  of  these  most  dangerous  growths. 

They  will  vary  according  to  the  duration  of  the  growth.  The  primary 
origin  is  most  frequently  from  the  base  of  the  skull,  arising  in  the  thick 
periosteum  invested  by  mucous  membrane,  which  covers  in  the  roof 
of  the  nose  and  top  of  the  pharynx,  especially  the  adjacent  parts  of 
the  basi-sphenoid  and  basi-occipital.  Less  frequently  they  may  arise 
in  the  pterygoid  fossae  and  adjacent  plates,  or  from  around  the  posterior 
nares.  Dr.  Sands  ^  points  out  that  the  region  in  which  a  naso-pharyngeal 
fibroma  can  originate  is  one  of  narrow  limits,  corresponding  with  the 
margins  of  the  posterior  nares  and  the  summit  of  the  pharynx.  It  is 
thus  one  that  can  be  satisfactorily  explored  with  the  finger,  and  by  this 
means  a  growth  should  be  detected  in  its  early  stage  and  removed  while 
small.  Where  the  growth  is  a  sarcoma,  owing  to  the  structure  of  its 
vessels,  and  its  tendency  to  ulceration,  a  prehminary  examination  may 
cause  severe  bleeding. 

While  the  above  are  the  most  frequent  attachments  of  the  growths, 
it  should  always  be  remembered  that  when  one  of  these  fibromata  has 
existed  for  some  time,  when  they  are  sloughy,  when  previous  attempts 
have  been  made  to  remove  them — under  these  conditions  the  growth  is 
very  likely  to  have  taken  on  secondary  attachments.  A  common  instance 
of  these  is  seen  when  a  growth  springing  from  the  base  of  the  skull  forms 
adhesions  to  the  pterygoid  fossae.  In  advanced  cases  these  growths, 
when  malignant,  extend  very  widely  and  often  insidiously,  making  their 
way  along  the  nasal  fossae  and  extending  through  the  numerous  fissures 
and  foramina  into  the  accessory  sinuses,  adjacent  fossae,  and  even  into 
the  cranial  cavity.  In  such  cases  it  is  often  impossible  to  say  exactly 
where  the  growth  started. 

If  secondary  attachments  are  made  out  to  exist,  the  next  question 
will  be,  how  far  are  these  intimate  and  close  ?  How  far  is  the  growth 
not  only  in  contact  mth,  but  how  far  has  it  actually  absorbed  bones,  such 
as  those  of  the  nose  ?  How  far  has  it  got  into  the  antrum,  and  thus 
come  to  resemble  closely  a  growth  of  the  upper  jaw  ?  Again,  swelling  of 
the  cheek,  with  protrusion  of  the  eye,  will  point  to  an  operation,  osteo- 
plastic or  otherwise,  on  the  upper  jaw.  In  the  same  way  extension  of  the 
growth  into  the  zygomatic  and  temporal  fossae  will  render  the  prognosis 
unfavourable.  Finally,  any  symptoms  pointing  to  softening  of  the  base  of 
the  skull  and  implication  of  the  membranes,  e.g.  headache,  tendency  to 
coma,  convulsions,  •with,  evidence  of  pyrexia,  will  be  conclusive  against 

^  "  On  Naso-Pharyngeal  Polypi  "  :    Dr.  Brown-Sequard's  Arch,  of  Sci.  and  Pract. 
Med.,  No.  6. 


NASOPHARYNGEAL  1  n?ROMA  AND  SARCOMA      463 

any  operation,  even  when  most  carefully  performed.  On  the  other  hand, 
where  the.  evidence  only  points  to  the  threatening  of  meningitis,  it  may  be 
possible  to  prevent  this  by  an  operation. 

The  site  and  width  of  the  attachment  of  these  growths  having  been 
spoken  of,  it  remains  to  call  attention  to  one  or  two  practical  points  in  their 
structm"e.  While  usually  fibromata  at  first,  and  often  so  throughout 
their  course,  they  can  make  their  way,  like  sarcomata,  through  adjacent 
bony  walls.  Metastases  are  said  to  be  rare.  The  growths  are  often 
very  vascular,  especially  from  the  character  of  their  veins,  which  have  no 
sheath,  and,  therefore,  cannot  retract  when  divided,  and  which  often 
assume  the  character  of  cavernous  tissue  ;  hence  the  readiness  with 
which  they  bleed,  even  when  touched  with  a  probe.  Large  growths  are 
prone  to  ulceration  on  the  surface,  hence  another  cause  of  haemorrhage, 
and  also  of  infection.  From  their  tendency  to  occur  in  about  the  decade 
from  15  to  25,  epistaxis  and  any  evidence  of  nasal  obstruction  at 
this  age  should  always  call  for  an  early  and  thorough  examination  of  the 
naso-pharynx. 

Methods  of  Removal.  Several  will  be  given,  owing  to  the  great  diffi- 
culty of  exposing  the  root  of  the  growth.  On  the  whole  the  best  methods 
are  through  the  nasal  fossae  or  through  the  upper  jaw,  as  these  promise 
to  give  the  best  access  in  the  largest  number  of  cases.  The  three  methods 
first  given  are  rarely  to  be  adopted.  They  are  only  suited  to  small 
growths,  those  of  the  nature  of  myxo-fibroma — for  all  varieties  of 
fibroma  are  present  here — ^those  with  a  distinct  and  narrow  pedicle, 
which  can  not  only  be  reached  but  also  commanded  (two  different 
things),  and  cases  where  no  secondary  adhesions  have  been  contracted. 

(i)  Avulsion.  This  method,  tearing  away  with  suitably  curved 
forceps  introduced  either  by  the  nose  or  by  the  mouth,  aided  in  either 
case  by  a  finger  passed  behind  the  soft  palate,  is  only  suitable  to  the 
above  cases,  and  in  none  is  it  without  danger. 

The  serious  haemorrhage,  and  the  probable  incompleteness  of  the 
operation,  are  always  strongly  against  making  use  of  avulsion.  Here,  as 
elsewhere,  removal,  piecemeal,  of  a  growth  is  most  misatisfactory,  either 
mahgnant,  or  on  the  high  road  to  become  so. 

(ii)  Ligature.  This  again  is  only  suitable  to  very  few  cases,  e.g.  where 
the  pedicle  is  distinct  and  fairly  thin,  and  where  the  growth  is  not  very 
vascular,  e.g.  a  myxo-fibroma,  and  where  it  has  contracted  no  adhesions. 
Li  less  suitable  cases,  in  addition  to  the  probability  of  return  in  the  root, 
the  infection  and  the  foetor  which  accompanies  the  sloughing  process  is 
a  most  serious  drawback.  The  patient's  head  being  brought  a  little  over 
the  table,  so  that  the  blood  shall  escape  readily,  the  mouth  is  opened  with 
an  efficient  gag.  A  loop  of  wire  sufficiently  stout  and  softened  is  most 
carefully  adjusted  romid  the  attachment  of  the  fibroma,  having  been 
passed  by  the  nose,  and  aided  by  a  finger  behind  the  soft  palate.  The 
ecraseur  is  then  fitted  on,  and  the  wire  tightened  very  slowly.  Spare 
wires  should  be  at  hand.  Ether  should  be  given  first,  and  then  chloro- 
form by  the  nostril.  Care  must  be  taken  in  such  cases  to  prevent  the 
growth,  when  the  pedicle  is  divided,  falling  upon  the  larynx. 

(iii)  EXCISION  BY  AN  OPERATION  INVOLVING  REMOVAL  OF 
BONE,  OSTEOPLASTIC  OR  OTHERWISE.  These  cases  may  be  divided 
as  follows  : 

A.  Those  in  which  the  attack  is  made  through  the  mouth. 

B.  Those  where  the  attack  is  made  through  the  nose. 


464  OPERATIONS  ON  THE  HEAD  AND  NECK 

C.  Those  in  which  the  attack  is  made  by  removing  the  upper  jaw, 
partially  or  completely,  or  by  resecting  this  bone  osteoplastically. 

A.  Operation  Jor  Naso-pharyngeal  Fibroma  through  the  mouth.  This 
operation  was  strongly  advocated  by  M.  Nekton.  It  consists  in 
slitting  the  uvula  and  soft  palate  exactly  in  the  middle  line  from 
before  backwards,  then  prolonging  this  incision  along  the  centre  of  the 
posterior  half  of  the  hard  palate,  going  here  down  to  the  bone  ;  from 
the  end  of  this  incision  two  others  are  made  slightly  obliquely  outwards 
towards  the  teeth,  also  going  down  to  the  bone.  The  flaps,  together  with 
the  periosteum,  are  then  detached,  so  as  to  form  nearly  rectangular  flaps. i 
Two  large  holes  are  next  drilled  through  the  hard  palate,  each  well  to  one 
side  of  the  middle  line,  the  intervening  bone  is  cut  away  by  placing  the 
ends  of  cutting-pliers  in  each  of  these  holes,  and,  by  making  lateral  cuts 
back  to  the  free  border  of  the  hard  palate,  a  rectangular  portion  of  the 
posterior  half  of  the  bony  vault  is  removed. 

The  mucous  membrane  and  the  periosteum  on  the  upper  surface 
of  the  bone,  which  will  now  be  found  detached,  are  divided,  and,  if  it  be 
needful  to  get  more  room,  more  or  less  of  the  vomer  is  cut  away.  Room 
being  thus  obtained,  the  fibroma  is  removed  and  its  attachments  dealt 
with.  If  all  the  growth  is  got  away  satisfactorily,  the  palate  flaps  are 
united  in  the  ordinary  way  ;  if  further  treatment  is  required,  staphylor- 
raphy  must  be  performed  later. 

Preliminary  laryngotomy  should  be  performed,  owing  to  the  proximity 
of  the  larynx. 

The  advantages  of  this  operation,  when  contrasted  with  removal  of 
the  upper  jaw,  are  at  first  sight  considerable. 

(1)  There  is  no  deformity  left  on  the  face  ;  (2)  the  parts  cut  through 
are  less  important ;  (3)  mastication  is  not  interfered  with  by  removal  of 
the  teeth  ;  (4)  the  operation  is  said  to  be  less  difficult ;  (5)  the  haemor- 
rhage is  claimed  to  be  less,^  no  large  vessels  being  cut  through  ;  (6)  the 
growth  is  attacked  directly  ;  (7)  through  the  gap  thus  left  the  surgeon 
can  again  attack  the  growth,  within  a  few  days  if  he  has  been  unable  to 
complete  the  operation,  or  later  on  if  reappearance  takes  place  ;  (8)  the 
gap  can  easily  be  dealt  with  later  on  by  staphylorraphy,  or  by  wearing  an 
obturator. 

The  first  three  advantages  are,  no  doubt,  of  great  value  if  the  growth 
can  be  entirely  dealt  with  by  this  method  ;  the  inveterate  way  in  which 
they  reappear,  if  incompletely  dealt  with,  neither  surgeon  nor  patient 
would  be  wise  in  running  great  risks  for  the  sake  of  what  one  may  call 
rather  aesthetic  advantages.^    There  is  no  doubt  that,  in  a  few  cases,  to 

^  This  detachment  is,  as  is  well  known  in  staphylorraphy,  difficult  posteriorly,  at  the 
junction  of  the  palates,  and  is  best  effected  by  raspatories  (p.  509). 

2  This  is  very  doubtful.  Bleeding  from  the  divided  and  partially  resected  palate 
will  be  very  near  the  larynx.  Again,  if  troublesome  haemorrhage  take  place  from  the 
root  of  the  fibroma,  it  will  be  more  difficult  to  deal  with  it  by  this  route  than  by  the 
nasal  or  maxillary  routes,  or  by  a  combination  of  these.  Dr.  Sands  (loc.  supra  cii.),  in 
removing  a  fibroma  by  this  method,  had  surrounded,  without  difficulty,  the  pedicle 
with  an  ecraseur  chain.  This  breaking,  the  pedicle,  which  was  stout  and  firm,  was 
divided  with  scissors  as  close  to  the  skull  as  possible.  Copious  hemorrhage  followed,  and 
much  time  was  consumed  in  unsuccessful  attempts  to, secure  a  large  artery  which  had 
retracted  to  the  deepest  part  of  the  wound,  and  which  was  inaccessible  to  the  ligature. 
The  bleeding  finally  ceased  in  consequence  of  the  prostration  of  the  patient,  who  had 
several  alarming  attacks  of  syncope.  The  growth  reappearing,  it  was  removed  by  the 
method  of  Maisonneuve.  Though  it  was  not  thought  prudent  to  attempt  the  removal  of 
a  small  prolongation  which  ran  into  the  sphenoidal  sinus,  no  reappearance  had  apparently 
taken  place  nine  months  later. 

'  Attention  may  here  be  drawn  to  the  great  frequency  of  these  fibromata  in  males,  in 


NASOPHARYNGEAL  FIBROMA  465 

be  niontioned  a  little  later,  where  the  polypus  is  of  moderate  size,  distinctly 
pedunculated,  and  attached  low  down,  e.g.  about  the  posterior  nares,  or 
well  forward  on  the  base  of  the  skull,  the  operation  will  be  easier,  the 
haemorrhage  will  be  less,  and  the  growth  will  be  more  directly  attacked. 
The  advantage  of  a  future  staphylorraphy  is,  like  those  given  first,  not 
of  sufficient  value  to  recommend  this  operation  if  it  is  wanting  in  others 
more  important. 

Turning  to  the  cases  themselves,  Dr.  Robin  Masse  has  collected 
twenty-six  treated  by  this  method,  twelve  having  been  under  the  hands 
of  M.  Nelaton  himself.  Of  these  twenty-six,  thirteen  are  said  to  have  been 
successful,  but  it  is  not  stated  for  how  long  they  were  followed  up.  In  one 
case,  in  which  the  after-history  is  given,  a  small  reappearance  took  place 
two  years  later  from  the  pedicle,  and  was  destroyed.  While  suited  to  the 
cases  mentioned  above,  the  method  could  scarcely  be  made  use  of  success- 
fully in  large  polypi,  in  the  case  of  those  with  secondary  attachments 
or  large  sessile  bases,  or  in  the  case  of  those  which  have  extended  into  the 
pterygoid  fossae,  or,  in  fact,  beyond  the  naso-pharynx.  Save  by  French 
surgeons,  it  does  not  appear  to  have  been  much  used,  from  the  belief 
that  the  space  given  is  too  limited.^ 

Dr.  Sands  ^  points  out  that,  in  the  majority  of  cases  in  which  surgeons 
have  operated  through  the  palate,  they  have  had  to  leave  the  wound  open 
in  order  to  remove  the  pedicle  later.  This  step  is  by  no  means  so  easy  as 
might  be  imagined,  and  in  many  cases  the  surgeon  has  been  driven  later 
to  make  use  of  another  operation  when  the  patient's  condition  was  less 
satisfactory.  Furthermore,  repeated  irritation,  in  the  shape  of  attempts 
at  destruction  of  the  pedicle  with  caustics,  the  cautery,  &c.,  is  too  hkely  to 
result  in  rapid  sarcomatous  growth. 

B.  Operation  for  Naso-pharyngeal  Fibroma  through  the  Nose  and  for 
Malignant  Growths  of  the  Nose.     Under  this  heading  will  be  included  : 

(1)  Oilier 's  operation. 

(2)  Rouge's  operation. 

(3)  Moure's  operation. 

(4)  Langenbeck's  operation. 

These  operations  through  the  nose  are  only  suitable  for  cases  in  which 

whom  the  growth  of  hair  will  largely  conceal  the  facial  deformity  consequent  on  opera- 
tioiLs  through  the  upper  jaw.  In  young  patients,  where  the  mouth  is  small  and  the 
growth  large,  tliis  operation  will  be  out  of  the  question. 

1  Mr.  Stonham  (Lancet,  January  7,  1888)  has  recorded  a  case  of  naso-pharyn- 
geal  fibroma,  in  which  "  the  soft  palate  was  divided  in  the  middle  line,  and  an  attempt 
made  to  remove  the  gi-o-wi;h  through  the  mouth  ;  but  this  plan  failing  to  give  sufficient 
room,  the  nasal  cavity  was  opened  up,"  and  the  growth  thus  successfully  removed.  Mr. 
Southam  found  that  division  of  the  soft  palate  gave  insufficient  access  to  the  broad  base  of 
the  growth  ;  attempts  to  turn  the  upper  jaw  out  still  gave  insufficient  access  ;  removal 
of  this  bone,  the  orbital  plate  being  left,  was  followed  by  a  good  result.  The  sphenoidal 
sinas  was  opened  and  plugged.  Mr.  Walsham  {Med.  Soc.  Trans.,  vol.  xix,  1896,  p.  394), 
speaking  in  favour  of  this  operation,  said  that  he  had  had  to  deal  with  growths  of  this 
kind  on  several  occasions,  and  had  always  succeeded  in  obtaining  adequate  exposure 
by  splitting  the  soft  and  cutting  away  the  hard  palate.  He  pointed  out  that  these 
gro-niihs,  though  thej^  maj-  extend  into  the  nose,  and  even  cause  the  eyeball  to  protrude,  do 
not  usually  involve  the  turbinals  or  upper  jaw  ;  there  was  consequently,  as  a  rule,  no 
need  for  turning  the  jaw  outwards  to  get  a  good  exposure.  Mr.  WaUis  (ibid.)  also 
remarked  on  the  excellent  exposure  which  this  method  afEorded  him  in  a  case  of  large 
naso-pharyngeal  growth  attached  to  the  internal  pterygoid  plate.  Prof.  Annandale 
(Lancet,  January  26,  1889)  reports  three  cases  in  which,  after  division  of  the  hard  and  soft 
palate,  the  maxillae  were  forcibly  separated.  The  gap  attained  was  very  limited,  only 
half  to  one  inch.     The  results  are  not  encouraging. 

^  "  On  Naso-Pharyngcal  Polypi,"  Dr.  Brown  Sequard's  Arch,  of  Sci.  and  Pract 
Med.,  No.  6. 

SURGERY  I  30 


466  OPERATIONS  ON  THE  HEAD  AND  NECK 

the  disease  is  well  within  reach.  They  may  also  be  used  in  doubtful  cases 
for  exploratory  purposes.  In  case  of  naso-pharyngeal  growth,  as  the 
room  which  they  give,  and  the  access  which  they  afford,  will  probably 
be  found  insufficient,  additional  room  must  be  obtained  by  removal  of 
part  of  one  or  both  maxilla}. 

(1)  OUier's  Operation  (Fig.  179).  In  this  method  the  nasal  fossa) 
are  exposed  by  turning  the  nose  downwards.  M.  Ollier's  incision  begins 
at  the  edge  of  the  bone,  close  behind  the  ala  of  the  nose,  and  is  carried 
upwards  along^its  side  to  the  highest  part  of  the  depression  between  the 
eyes,  and  then  across,  down  to  the  corresponding  point  on  the  other  side. 
The  bone  is  sawn  through  in  the  line  of  the  transverse 
part  of  the  incision,  the  necessary  liberating  incisions 
made  in  the  septum  and  the  side,  and  the  nose 
turned  down.  The  septum  is  pressed  aside,  the 
growth  removed,  its  base  curetted  or  cauterised,  and 
the  nose  replaced. 

(2)  Rouge's  Operation.     Owing  to  the  improved 
methods  of  operating  through    the    anterior  nares 
Fir..  170.  this  operation  is  less  frequently  called  for  than  in 

former  days.  It  is  still  occasionally  indicated  when 
the  surgeon  desires  to  gain  free  access  to  the  nasal  cavities,  without  an 
external  scar,  in  the  following  cases  :  (1)  In  inveterately  recurring  nasal 
polypi  persisting  after  the  steps  advised  at  p.  461.  (2)  For  the  re- 
moval of  large  sequestra.  (3)  For  the  removal  of  malignant  growths  of 
the  nose  and  the  naso-pharynx.  (4)  In  some  cases  of  extensive  lupus  of 
the  nasal  mucous  membrane.  (5)  As  a  means  of  exploring  the  nasal 
fossae. 

Oferation.  An  anaesthetic  having  been  administered,  the  surgeon 
must  decide  as  to  what  steps  he  will  take  to  prevent  the  blood  from  getting 
down  into  the  pharynx.  This  may  be  done  by  plugging  the  posterior 
nares,  or  better,  by  the  intratracheal  method  of  anaesthesia  (p.  781),  or 
by  performing  laryngotomy,  the  pharynx  being  then  plugged  with 
sterilised  gauze.  A  good  light  is  necessary,  and  this  may  be  secured  by 
the  frontal  head  light. 

The  upper  lip  is  raised  and  everted  by  an  assistant,  who  stands 
behind  the  head  of  the  patient,  holding  it  firmly  at  the  angles  of  the 
mouth.  An  incision  is  then  made  through  the  mucous  membrane 
covering  the  alveolar  process,  just  below  the  line  of  reflection  to  the  hp, 
commencing  opposite  the  first  molar  tooth  on  one  side  and  extending 
to  a  corresponding  position  on  the  other.  By  means  of  an  elevator  the 
soft  parts  are  separated  in  an  upward  direction,  so  that  the  orifices  of 
the  nasal  fossae  are  brought  into  view.  The  cartilaginous  nasal  septum 
is  then  detached  by  scissors  from  the  nasal  spine  of  the  superior  maxilla, 
and  the  lower  lateral  cartilages  from  the  upper  jaw,  the  adjacent  parts 
of  the  cheek  being  also  freed  at  the  same  time,  so  as  to  admit  of  the 
nose  and  hps  being  hfted  up  sufiiciently  to  explore  the  nasal  cavities. 
After  the  haemorrhage  has  been  checked  a  strong  light  can  be  thrown  into 
the  fossae  from  the  frontal  lamp,  and  the  necessary  treatment  carried  out. 
After  any  dead  bone  has  been  removed,  the  sharp  spoon  applied,  any 
growth  excised,  or  any  polypi  or  lupus  dealt  with,  the  soft  parts  are 
replaced  and  secured  with  a  few  catgut  stitches.  Care  must  be  taken 
afterwards  to  keep  the  mouth  clean,  and  irrigation  of  the  nasal  fossae 
will  also  be  required. 


NASO  rilAUVNGEAL  FIBROMA 


467 


The  great  advantages  of  this  operation  are  that  free  access  to  the 
nasal  fossae  is  obtained  without  leaving  any  scar  on  the  face,  and  that 
no  special  instruments  are  required. 

The  following  casp,  recorded  by  Mr.  H.  Tilley.i  is  a  good  example  ot  a  large, 
deeply -seated  nasal  tumour  removed  by  a  modified  Rouge  "s  operation.     The  patient, 
aged  48,  had  complained  of  nasal  obstruction  with  epistaxis  and  discharge  for  twelve 
months.     The  posterior  half  of  the  left  nasal  fossa  was  comjjletely  filled  by  a  dark 
red  easily  bleeding  mass  of  growth.     After  a  preliminary  laryngotomy  and  j)lugging 
of  the  phar\iix  an  incision  was  made  under  the  lip  from  the  right  canine  fossa  to 
the  left  malar  process.     The 
anterior  half  of  the  septum 
was  detached   and  the    soft 
parts  turned  upwards.      The 
removal    of  the    left  canine 
fossa  and  ascending   process 
of  the  superior  maxilla  then 
enabled  the  growth  to  be  re- 
moved.    The  soft  parts  were 
replaced  and  kejit  in  position 
by  a  few  interrupted  sutiu"c  s. 
The  growth  was  a  rapidly  in- 
creasing soft  fibroma  growing 
fi'om    the   posterior  wall   of 
the  maxillary  antrum. 

(3)  Moure's  Opera- 
tion.^ This  operation 
gives  excellent  access  to 
the  deeper  regions  of  the 
nose.  Sir  St.  Clair 
Thomson  ^  says  that 
"  this  operation  is  par- 
ticularly suitable  for  ma- 
hgnant  growths  origina- 
ting in  the  upper  or  inner  walls  of  the  maxillary  sinus,  the  ethmoidal  laby- 
rinth, the  deeper  regions  of  the  nose,  the  naso-pharynx.  or  the  sphenoid. 
It  might  be  required  for  very  vascular  naso-phar}nigeal  fibromata  with  ex- 
tensive prolongations.  It  is  very  suitable  for  necrosis — generally  syphiHtic 
— of  the  sphenoid  when  threatening  the  base  of  the  brain." 

Operation.  As  in  Rouge's  operation,  the  ansesthetic  should  be  ad- 
ministered either  through  a  laryngotomy  tube  or  by  the  intratracheal 
method  to  obviate  the  danger  of  the  haemorrhage  which  may  be  severe. 
It  is  desirable  that  the  interior  of  the  nose  should  be  previously  treated 
with  a  solution  of  cocaine  and  adrenalin.  The  operation  is  thus  described 
by  Sir  St.  Clair  Thomson.* 

"  An  incision  is  made  from  the  inner  border  of  the  eyebrow,  along  the 
side  of  the  nose,  until  it  enters  the  lower  margin  of  the  nasal  orifice.  A 
second  incision,  starting  from  the  same  spot,  above,  is  next  carried  round 
the  lower  margin  of  the  orbit  and  outwards  as  far  as  the  malar  eminence. 
The  lobule  of  the  nose  is  then  detached,  so  that  the  fleshy  parts  of  the 
nose  can  be  thrown  over  to  the  opposite  side,  while  a  triangular  flap  is 
turned  downwards  and  outwards.  With  a  raspatory  the  nasal  process 
of  the  frontal  bone,  the  nasal  bone,  the  ascending  process  of  the  superior 
maxilla,  and  the  canine  fossa,  are  next  exposed.     The  lachrymal  sac  is 

1  Proc.  Boy.  Soc.  Med.,  Larynq.  Sec.  April  1910.  p.  96. 

■'  Moure,  Bevue  hehdomadaire  de  Laryngologie,  October  4,  1902. 

^  Diseases  of  the  Nose,  p.  712.  *  Loc.  supra  cit. 


Fio.  180.      The  incision  through  the  mucous  mem- 
brane of  the  gum  in  Rouge's  operation. 


468  OPERATIONS  ON  THE  HEAD  AND  NECK 

carefully  defined  and  retracted.  A  chisel  is  first  driven  through  the 
superior  maxilla,  close  to  its  junction  with  the  malar  bone,  but  avoiding 
the  infra-orbital  nerve,  and  the  section  is  carried  downwards  to  the  canine 
fossa  until  it  reaches  the  alveolar  border.  From  the  lower  extremity  of 
this  incision^ — which  of  course  enters  the  maxillary  sinus — the  bone  which 
separates  it  from  the  pyriform  fossa  is  broken  through  with  stout  forceps. 
In  this  way  the  antro-nasal  wall  is  detached  close  to  the  floor  of  the  nose, 
and  can  be  removed  together  with  the  inferior  turbinal.  The  nasal  bone 
itself  is  next  removed,  together  with  part  of  the  lachrymal  bone  and  the 
nasal  process  of  the  frontal.  Finally  the  middle  turbinal  and  lateral 
mass  of  the  ethmoid  are  removed  with  punch  forceps,  Volkmann's  sharp 
spoon  or  a  ring  knife.  A  gouge,  or  Killian's  eye  protector,  is  then  slipped 
inwards  and  downwards  at  the  upper  part  of  this  opening  until  it  comes 
in  contact  with  the  body  of  the  sphenoid.  An  assistant  holds  it  closely 
parallel  to  the  cribriform  plate,  where  it  acts  as  a  protector.  With  a 
long  sharp  spoon,  acting  from  above  downwards  and  forwards,  the 
ethmoidal  labyrinth  can  be  cleared  away  with  any  tumour  which  may 
have  infiltrated  it.  The  os  planum,  if  not  already  destroyed,  can  be 
removed,  so  as  to  obtain  access  to  the  orbit.  Direct  approach  is  given  to 
the  sphenoidal  sinus.  The  septum  can  be  readily  resected,  but  an 
endeavour  should  always  be  made  to  preserve  a  strip  of  cartilage  under 
the  bridge  of  the  nose  to  prevent  any  external  deformity.  It  is  needless 
to  say  that  great  care  must  be  taken  while  working  close  to  the  cribri- 
form plate. 

A  malignant  tumour  can  then  be  removed  with  forceps,  sharp  spoons, 
and  the  fingers,  any  prolongations  being  followed  into  the  naso-pharynx, 
the  maxillary  sinus,  the  sphenoidal  sinus,  the  lateral  mass  of  the  ethmoid, 
or  even  into  the  pterygo-maxillary  fossse.  Success  largely  depends  on 
the  care  with  which  this  curettage  is  carried  out.  It  should  be  followed 
by  the  apphcation  of  caustics  or  Paquelin's  cautery.  Bleeding  is  generally 
abundant  at  first.  It  can  be  controlled  with  tampons  and  the  use  of 
hydrogen  peroxide.  When  the  whole  of  the  malignant  growth  has  been 
removed,  hsemorrhage  generally  stops  spontaneously.  Firm  packing  of 
the  wound  is  therefore  unnecessary  and  is  best  avoided.  The  large  cavity 
is  filled  with  one  long  strip  of  one-inch  ribbon  gauze,  which  is  left  project- 
ing from  the  nostril,  and  the  skin  incisions  are  carefully  brought  together 
with  silkworm-gut  sutures.  Healing  takes  place  by  first  intention.  There 
may  be  a  little  flattening  of  the  side  of  the  nose,  but  there  is  no  disfigure- 
ment, and  a  few  months  afterwards  it  is  difficult  to  detect  any  trace  of  the 
operation.  The  strip  of  gauze  is  removed  in  twenty-four  to  forty-eight 
hours,  and  simple  intranasal  cleansing  measures  are  then  instituted." 

Sir  St.  Clair  Thomson  ^  ha?  recorded  two  cases  which  show  the  value  of  Moure's 
operation  in  the  removal  ot  large  deep-seated  growths  from  the  nasal  fossae.  The 
first  patient  was  a  lady,  aged  70,  from  whom  he  had  removed  an  endothelioma 
involving  the  right  ethmoid  and  maxillary  antrum.  The  second  was  a  lady,  aged  50, 
who  had  a  glandular  epithelioma  in  much  the  same  situation,  causing  swelling  of 
the  left  cheek  and  bulging  of  the  canine  fossa.  There  was  no  recm-rence  after  four 
months.  In  neither  case  was  there  any  disfigurement,  and  the  scar  could  only  be 
detected  with  difficulty. 

(4)  Von   Langenbeck's    Operation    (Fig.  181).      A   curved   incision, 

with  the  convexity  forwards,  is  made  from  the  inner  edge  of  the  eyebrow 

on  to  the  bridge  of  the  nose,  and  thence  downwards  into  the  naso-labial 

fold.     The  flap  of  skin  thus  marked  out  is  then  dissected  up  in  a  backward 

1  Proc.  Roy.  Sec.  Med.,  Clin   Sec,  March  1913. 


NASOPHARYNGEAL  II  H1U)I\IA 


469 


Fi(!.      181.      V.     Langcnbcck's 

operation    of    rest'ctioii  of    the 

nasal  process  and  nasal   bone. 

(Esmarch  and  Kowalzig.) 


direction.  'Vhe  nasal  caitila^e  luiviii'if  been  severed  at  its  jUJicti(3n  with 
the  bone,  a  sliort,  sti'ong,  narrow-bhuled  finger-saw  is  inserted  into  tliis 
opening  and  the  nasal  process  of  the  upper  jaw  is  sawn  through  up  to 
the  lachrymal  sac  ;  the  saw  is  next  carried  inwards  through  the  roots  of 
the  nasal  process  of  the  superior  maxilla  and  the  nasal  bone,  and  lastly 
downwards  tliiough  the  nasal  bone  itself.  The  removal  of  this  sawn-out 
lamella,  consisting  of  the  nasal  process  of 
the  upper  jaw,  part  of  the  lachrymal  and 
the  nasal  bone,  gives  space  enough  for 
the  inspection  of  the  whole  interior  of  the 
nasal  cavity,  the  posterior  nares,  and  the 
lower  portion  of  the  body  of  the  sphenoid 
bone. 

Though,  as  a  rule,  no  deformity  of  the 
face  follows  on  the  removal  of  this  piece  of 
bone.  Von  Langenbeck  modified  this  oper- 
ation into  an  osteoplastic  one.  Thus  he 
sawed  through  the  nasal  process  covered 
with  the  periosteum  only,  so  far  as  the 
lachrymal    bone,    and    upwards    through 

the  nasal  bone ;  then  inserting  an  elevator,  he  raised  the  thin  bony 
flap,  which  gave  away  above.  At  the  close  of  the  operation  this  flap 
was  replaced. 

C.  Operations  for  Naso-pharyngeal  Fibroma  by  removal  of  the  Upper  Jaw. 

(i)  Completely  ;  (ii)  Partially  ;  or  (iii)  By  osteoplastic  operation  on 
this  bone. 

(i)  Complete  Removal  of  the  Upper  Jaw.  This  has  been  already  fully 
described  (p.  425). 

(ii)  Partial  Removal  of  the  Upper  Jaw.  These  operations  are  very 
numerous ;  one  or  two  will  be  mentioned  as  specimens.  Of  these 
operations  the  second  is  to  be  preferred.  Removal  of  the  entire  jaw  is 
not  usually  needful.  The  orbital  plate  can  be  left.  The  objections  to 
the  osteoplastic  method,  which  are  considerable,  are  given  below  (p.  472). 
Removal  of  the  lower  portion  of  the  jaw  will  give  a  good  exposure, 
especially  if  the  surgeon  combines  it  with  a  simultaneous  attack  through 
the  nose,  if  needful.  As  the  orbital  and  malar  processes  are  left,  the 
subsequent  disfigurement  is  slight.  The  skill  of  the  dentist  will  meet 
the  sacrifice  of  the  alveolar  portion. 

A.  Method  of  Maisonneuve  and  Guerin.  The  essential  point  is  to  get  rooiji  for 
attacking  the  fibroma  by  removal  of  the  lower  part  of  the  jaw.  The  bone  is  exposed 
by  Fergusfeon's  incision,  the  hard  and  soft  palate  are  divided  in  the  middle  line,  and 
the  latter  detached  transversely  on  the  side  to  be  operated  upon.  The  hard  palate 
is  divided  in  the  middle  line  by  saw  and  bone-forceps,  working  from  the  nose  into 
the  mouth.  By  a  transverse  section  with  a  narrow-bladed  saw  introduced  into  the 
nose,  and  made  to  cut  horizontally  outwards,  the  facial  aspect  of  the  bone  is  divided 
as  far  as  the  maxillary  tuberosity.  This  section  should  pass  above  the  roots  of  the 
teeth  and  below  the  infra-orbital  foramen.  The  lower  part  of  the  jaw  is  then 
strongly  depressed,  and  thus  detached,  consisting  of  the  alveolar  and  palatine 
processes,  a  portion  of  the  body,  and  a  varying  amomit  of  the  pterygoid  processes 
which  usually  comes  away  with  it.     The  fibroma  is  then  extirpated." 

B.  Method  of  Beraud.  In  this  the  upper,  not  the  lower,  part  of  the  jaw  is 
removed,  so  as  to  preserve  intact  the  teeth  and  alveolar  process. 

(iii)  Osteoplastic  Operations  on  the  Upper  Jaw.  In  this  the  bone  is 
cut  through  by  various  incisions,  turned  in  different  directions  on  some 


470 


OPERATIONS  ON  THE  HEAD  AND  NECK 


uncut  attachments,  as  on  a  hinge,  and  then  fitted  down  again  after  the 
removal  of  the  growth. 

Method  of  Prof.  Langenheck  (Fig.  182).  This  is  one  of  the  best 
known  of  the  above j  operations.  Its  object  is  to  get  at  the  fibroma, 
especially  if  it  be  one  in  the  pterygo-maxillary  fossa,  without  interfering 
with  the  alveolar  and  palatine  processes  or  with  the  orbital  plate.  While 
this  operation  seems  well  suited  to  its  object,  its  drawbacks  are  certainly 
considerable,  for  (1)  there  is  the  great  difficulty  of  raising  so  fixed  a 
bone,  and  again  of  getting  it  evenly  into  place — thus  the  operation  is  pro- 
longed and  the  haemorrhage  very  severe  ;  (2)  if  the  upper  jaw  has  to  be 
sawn  from  behind  forwards,  this  cannot  be  done  easily  unless  the  fossae  at 
the  back  of  the  jaw  and  the  spheno-palatine  foramen  are  much  dilated  ; 
(3)  if  the  growth  has  extended  into  the  naso-pharynx,  this  region  will  not 
be  well  exposed  ;  (4)  very  disfiguring  scars  are  left,  especially  objection- 
able in  the  case  of  a  female  patient. 

Two  semilunar  incisions  (1  and  2,  Fig.  182),  wdth  their  convexities  downwards, 
are  made  across  the  facial  aspect  of  the  upj)er  jaw,  the  lower  running  from  the  ala 


V 


A.  B. 

Fig.    182.     A,    V.  Jjangcnbeek's  osteoplastic  and  temporary  resection  of  the 

upper  jaw.     The  skin  incisions  are  shown  meeting  on  the  zygoma.     (Esmarch 

and  Kowalzig.)     B,  The  same  operation.     The  lines  for  the  .saw  through  the 

zygoma  and  upjicr  jaw.     (Esmarch  and  Kowalzig.) 


of  the  nose  to  the  middle  of  the  malar  bone,  the  second  starting  from  the  nasal 
process  of  the  frontal  and  passing  just  below  the  orbit  to  meet  the  first  where  this 
ended. 

If  needful,  owing  to  the  extension  of  growths  backwards,  the  meeting  of  these 
incisions  may  be  carried  back  along  the  zygoma  (b.  Fig.  182  B).  Each  cut  is  made 
down  to  the  bone,  but  the  skin  is  not  reflected.  To  avoid  needless  loss  of  blood, 
the  lower  skin  incision  and  section  of  bone  are  made  first,  and  then  the  upper 
division  of  skin  and  bone.  At  the  outer  end  of  the  lower  one  the  masseter  is  de- 
tached from  the  zygoma,  and  if  the  growth  has  extended  out  into  the  zygomatic 
fossa  it  will  now  come  into  view  on  dividing  the  buccal  fascia.  Professor  Langenbeck 
found  at  this  stage  that  by  pressing  the  growth  to  one  side  and  depressing  the  lower 
jaw  he  could  pass  his  finger  tlnough  the  pterygo-maxiHary  fissm-e  into  the  spheno- 
maxillary fossa,  and  so  on  tlnough  the  spheno-palatine  foramen  into  the  nose,  all 
these  parts  being  enlarged  by  the  pressure  of  the  growth.  By  means  of  a  narrow 
straight  saw  introduced  tlie  same  way  the  upper  jaw  was  cut  through  horizontally 
(a.  Fig.  182  B)  from  behind  forwards,  while  a  forefinger  passed  by  the  mouth  kept 
the  tip  of  the  saw  from  striking  against  the  septum  nasi.  (If  the  right  upper  jaw 
is  operated  on,  the  surgeon  will  saw  outwards  from  the  nose.)  The  saw  was  now 
applied  along  the  upper  incision  so  as  to  divide  the  zygoma  (b.  Fig.  182  B),  the  frontal 
process  of  the  malar,  and  the  upper  jaw(c.  Fig.  182  B),  just  below  the  lachrymal  sac, 


NASOPHARYNGEAL  FIBROMA  471 

uj)  to  tln'  inner  end  of  the  incision.  The  portion  of  the  upper  jaw  thus  marked  out 
now  only  remained  attached,  at  its  inner  part,  to  the  nasal  bone,  and  nasal 
process  of  the  frontal.  Tpon  these  connactions,  as  upon  a  hinge,  the  piece  of 
bone  was  slo.vly  laised  by  means  of  an  elevator  introduced  under  t'le  malar  bone, 
upwards  and  inwards,  until  the  malar  bone  was  nearly  in  the  middle  of  the  face. 
The  growth  was  now  completely  exposed.  The  operation  took  an  hour,  and  was 
attended  with  much  luBinorrhagc,  most  of  which  stopped  spontaneoasly.  The  wounds 
healed  well,  a  tendency  of  the  bone  to  rise  being  met  by  pressme. 

The  Choice  of  an  Operation  Jor  Removal  of  Naso-Pharyngeal  Fibroma. 

The  relative  values  of  several  of  the  above  operations  have  already  been 
briefly  given.  The  surgeon  will  have  to  weigh  duly  the  following  :  on  the 
one  hand,  the  desire  to  get  the  growth  away  with  as  httle  mutilation  and 
danger  to  his  patient  as  possible,  and,  on  the  other,  the  fact  that  these 
growths  are  most  certainly  malignant  in  character,  and  that  any  partial 
operation,  while  probably  as  difficult  and  as  bloody  as  one  on  a  larger 
scale,  will,  if  incomplete,  be  certain  to  lead  to  increased  growth  in  the 
tumour  by  the  irritation  which  it  causes. 

A¥hatever  operation  is  chosen,  it  will  usually  be  wise,  in  order  to 
diminish  the  risk  of  haemorrhage,  to  perform  a  preliminary  laryngotomy 
and  to  plug  the  fauces  with  an  aseptic  sponge.  The  laryngotomy  tube 
should  usually  be  removed  immediately  after  the  operation.  The  more 
modern  method  of  intratracheal  administration  of  the  ansesthetic  may 
also  be  employed.  Destruction  of  the  root  of  the  fibroma  is  effected 
by  a  powerful  curette,  or  a  gouge,  or,  better  still,  diathermy  may  be 
employed.  The  risk  of  reappearance  is  great  if  the  root  be  not  completely 
destroyed. 

For  naso-pharyngeal  growths  which  come  early  under  treatmeni, 
in  which  the  growth  is  of  moderate  size,  with  an  attachment  situated 
well  forward  in  the  roof  of  the  pharynx  or  within  easy  reach  from  the 
posterior  nares,  especially  one  which  can  be  made  out  to  occupy  chiefly 
the  region  of  the  nose,  such  an  operation  as  that  of  Moure  may  be  made 
use  of. 

In  cases  of  greater  difficulty,  from  the  longer  duration,  more  extensive 
attachments,  larger  size,  and,  with  this  last,  the  certainty  of  a  more 
extensive  base  and  numerous  large  sinus-hke  vessels,  the  question  of 
deformity  and  disfigurement  must  be  entirely  set  aside. ^  In  order  to 
secure  adequate  space  for  making  certain  of  all  the  attachments  of  the 
tumour,  for  eradicating  these,  and,  at  the  same  time,  satisfactorily 
meeting  the  haemorrhage  which  is  usually  inevitable,  a  freer  removal  of 
bone  will  be  required.  No  doubt,  for  this  purpose,  partial  or  complete 
removal  of  the  upper  jaw  should  follow  the  preKminary  attack  by  the 
nose.  Every  surgeon  who  has  performed  the  removal  of  the  upper  jaw 
knows  how  free  is  the  access  which  it  gives  to  the  back  of  the  nose  and 
to  the  pharynx.  A  further  advantage,  pointed  out  by  Dr.  Sands,  is  the 
follo^^^ng,  that  owing  to  the  wide  gap  left  by  this  operation,  reappearance 
of  the  disease  can  be  more  readily  recognised  and  treated  than  after  any 
osteoplastic  operation. 

Dangers  and  Drawbacks  of  Osteoplastic  and  other  Operations  for 
Naso-Pharyngeal  Fibroma.  Many  of  these  have  been  already  given 
under  the  head  of  Removal  of  the  Upper  Jaw  (p.  430)  ;  others,  more 
particularly  to  be  expected  here,  are  : 

^  The  reader  may  agam  be  reminded  that  these  naso-pharyngeal  polypi  usually  occur 
in  males,  often  in  lads  or  young  adults.  The  growth  of  hair  which  can  usually  be  secured 
in  these  ca>es  lessens,  to  a  coniderable  degree,  the  amount  of  disfigurement  which  oijera- 
tions  on  a  larger  scale  entail. 


472  OPERATIONS  ON  THE  HEAD  AND  NECK 

(1)  Hemorrhage,  not  from  large  arteries,  as  the  internal  maxillary, 
but  from  the  fact  that  the  very  numerous  vessels  of  the  growth  are  em- 
bedded in  close  fibrous  tissue  and  thus  cannot  retract,  and  that  many  of 
the  veins  are  large  and  sinus-like.  The  ways  in  which  this  risk  should 
be  met  have  already  been  indicated.  Hsemorrhage  from  the  base  of  the 
growth,  if  persistent,  must  be  arrested  by  adrenalin  chloride,  the  cautery, 
or  by  plugging. 

(2)  ilfewm^i'fis,  from  damage  to  the  base  of  the  skull  (p.  461),  or  from 
inflammation  spreading  to  the  membranes  of  the  brain.  Mr.  Stonham  ^ 
states  that  "it  is  a  common  experience  that  after  removal  of  these 
polypi  the  patient  suffers  from  intense  headache,  principally  referred  to 
the  occipital  region,  but  it  usually  passes  off  in  a  few  days." 

(3)  Necrosis  and  exjoliation. 

(4)  Non-union  of  a  temporarily  resected  fragment. 

(5)  Reappearance.  The  best  protection  against  this  risk  is  either 
adequate  exposure  of  the  growth,  especially  its  base,  and  then  complete 
destruction  of  this  by  a  powerful  cuiette  or  a  gouge,  or  by  diathermy. 

Operations  on  the  Sphenoidal  Sinuses.  As  in  the  case  of  the  other  accessory 
sinuses  of  the  nose,  the  sphenoidal  sinus  may  be  the  seat  of  acute  or  clironic  sup- 
puration. This  condition  is  extremely  serious  on  accomit  of  the  proximity  of  the 
cavernous  sinuses  and  the  base  of  the  brain,  a  thin  plate  of  bone  alone  intervening. 
The  symptoms  may  be  obscure  and  the  diagnosis  is  often  difficult. 

Operation.  The  nasal  fossae  must  be  thoroughly  prepared  ■with  a  solution  of 
cocaine  and  adrenalin,  care  being  taken  that  the  upper  and  posterior  regions  of  the 
nasal  cavity  are  effectively  treated.  A  general  anjesthetic  is  then  administered  and 
the  middle  turbinated  bone  is  removed.  If,  as  is  frequently  the  case,  the  posterior 
ethmoidal  cells  are  also  diseased,  these  should  be  curetted  and  scraped  out,  all 
carious  bone  and  diseased  tissue  being  removed  by  forceps  or  the  ring  knife.  With 
the  help  of  a  good  light  the  opening  of  the  sphenoidal  sinus  will  then  be  seen,  or  if 
not  identified  its  position  will  be  indicated  by  a  probe  introduced  tlirough  the  anterior 
nares  in  a  line  passing  from  the  anterior  nasal  spine  and  crossing  the  centre  of  the 
middle  turbinate.  Free  drainage  is  then  secured  by  breaking  away  the  whole  of 
the  anterior  wall  of  the  sinus  by  means  of  blmit  hooks  and  Grunwald's  forceps. 
The  cavity  itself  should  not  be  curetted  for  fear  of  damaging  its  roof.  The  sinus  is 
tlien  lightly  packed  with  a  strip  of  sterile  ribbon  gauze  which  is  removed  in  twenty- 
four  hours  and  the  cavity  then  irrigated  daily  with  warm  boracic  lotion. 

Removal  of  Pituitary  Tumours.  These  may  be  mentioned  here  since  in  most 
of  tlie  operations  which  have  been  designed  access  has  been  gained  to  the  sella 
turcica  by  the  nasal  route.  Diseases  of  the  pituitary  body  have  attracted  a  good 
deal  of  attention  in  recent  years,  and  the  possibility  of  the  successful  operative 
treatment  of  tumours  in  this  very  inaccessible  region  has  been  shown  bj^  the  work 
of  Horsley,  Cushing,^  Krause,  Hirsch  '  and  others.  Those  who  desire  fiill  informa- 
tion on  this  most  interesting  subject  are  referred  to  a  discussion  opened  by  Professor 
Schafer  before  the  Sections  of  Neurology  and  OiJhthalmology  of  the  Royal  Society 
of  Medicine.*  Here  full  information  vdW  be  fomid  as  to  the  structure  and  fvmctions 
of  the  pituitary,  and  of  its  chseases  and  their  sj^mptoms,  diagnosis,  and  treatment, 
with  a  number  of  instructive  cases.  It  will  suffice  to  point  out  here  that  the  most 
characteristic  symptoms  of  a  pituitary  tumour  are  a  condition  of  acromegaly 
associated  with  bitemporal  hemianopia  (blinchiess  in  the  temiaoral  jDortions  of  the 
visual  field  owing  to  atrophy  of  the  nasal  half  of  the  retina,  the  result  of  pressure 
on,  or  involvement  by  the  growth  of  the  optic  chiasma).  A  radiographic  examination 
is  often  of  great  use  in  the  diagnosis  by  showing  an  enlargement  of  the  sellaturcica. 

^  Loc.  supra  cit. 

~  "  The  Pituitary  Body  and  its  Disorders,"  1912. 

^  Hirsch.  Archiv.  f.  Laryngol.,  Berlin,  1912.  xxvi.  p.  529. 

*  Proc.  Roy.  Soc.  Med.,  Sec.  Neurol,  and  Ophth.,  1913,  vol.  vi.  No.  7.  Mr.  Thorburn 
{Brit.  Journ.  Surg.,\o\.  i,  p.  183)  has  published  a  detailed  account  of  a  case  of  sellar 
decompression  for  a  glioma  of  the  pituitary.  The  trans-nasal  route  of  Schloffer,  as 
modified  by  v.  Eiselsberg,  was  employed.  The  patient  died  of  septic  meningitis 
following  removal  of  a  portion  of  the  tumour  three  months  later. 


REMOVAL  OF  PITUITARY  TUMOURS  473 

Dr.  William  Hill  in  the  above-quototl  discussion  mcntiontd  no  less  than  22 
methods  whieli  have  been  employed.  In  11  of  these  the  septal  route  is  followed. 
The  Killian-Hirseh  method  commences  with  Killian  s  subnmcous  resection  of  the 
sei)tum,  followed  by  resection  of  the  anterior  walls  and  septum  of  the  sphenoidal 
sinuses  and  removal  of  the  floor  of  the  sella  turcica.  Grahaui  obtains  more  room  by 
enlarging  one  anterior  narial  opening  by  an  anterior  incision  forwards  and  upwards, 
or  by  vertical  Hssure  of  the  tip  of  the  nose  and  columella,  followed  by  the  Killian- 
Hirseh  operation,  as  described  in  the  case  quoted  below.  Halstead  and  Cushing 
displace  the  nose  upwards  bj'  a  sublabial  oral  incision  as  in  Rouge's  operation,  and 
then  proceed  to  the  submucous  resection.  Four  of  the  methods  are  lateral  nasal 
(or  ethmoidal)  routes  in  which  the  operation  resembles  Moure's  or  Langenbeck's, 
which  have  been  already  described.  Four  of  the  methods  are  external  rhinotomies 
with  combined  septal  and  ethmoidal  resections.  In  the  remaining  three  the  nasal 
route  is  not  adopted. 

The  following  most  interesting  case  of  cyst  of  the  pituitary  fossa  shown  by 
Mr.  C.  I.  Graham  before  the  Larpigological  Section  of  the  Royal  Society  of  Medicine 
in  1913  is  an  example  of  the  Killian-Hirseh  operation  with  Mr.  Graham's  modifica- 
tions. Tlie  patient,  a  woman  aged  37  was  admitted  to  St.  Marj^s  Hospital  for 
failing  sight,  headaches,  drowsiness,  slow  mental  reaction,  and  incontinence  of 
urine.  The  right  eye  was  blind  and  there  was  optic  atrojjhy,  while  in  the  left  eye 
there  was  vision  in  the  nasal  portion  of  the  field.  At  the  operation  illumination 
was  obtained  by  a  Xernst  light  reflected  from  a  frontal  mirror.  An  incision  was 
made  commencing  at  the  tip  of  the  nose  and  was  carried  to  the  upper  lip,  dividing 
the  colmnella  and  about  ^  in.  of  the  philtrum,  keeping  accurately  in  the  mid-line. 
The  free  edge  of  the  septal  cartilage  was  defined  and  the  skin  of  the  vestibule  raised 
on  each  side  from  the  septum.  Haemorrhage  here  caused  some  difficulty.  The 
mucous  membrane  was  easih'  raised  from  the  sides  of  the  sejJtum  to  within  1  in. 
of  the  posterior  edge.  The  mucous  flaps  were  held  aside  by  a  speculum  with 
narrow  3  in.  blades.  The  mucous  membrane  over  the  posterior  edge  and  upper 
part  of  the  vomer  was  raised  bj'  means  of  a  dental  "  stopper  "  which  terminates 
in  a  single  corkscrew  turn  ;  the  excursion  of  the  instrument  along  the  posterior 
edge  of  the  vomer  was  controlled  by  the  left  index  finger  in  the  post -nasal  space. 
Killian "s  long  nasal  speculum  ^vith  fiat  blades  i  in.  by  4J  in.  was  then  substituted 
for  the  smaller  instrument,  and  the  vomer  was  t^\'ist£d  from  its  attachment  to  the 
sphenoid  by  means  of  Luc's  forceps.  To  give  more  room  the  middle  turbinates 
were  forcibly  separated  by  means  of  a  metal  glove  stretcher,  the  blades  being 
inserted  into  the  tvumel  bomided  by  the  two  layers  of  mucous  membrane.  The 
mucous  membrane  was  then  elevated  from  the  anterior  siu-face  of  the  sphenoid  so 
that  the  ostia  of  the  sinuses  were  clearly  seen.  The  position  of  the  pituitarj^  fossa 
was  fomid  by  taking  a  line  which  commences  at  the  j miction  of  the  alse  nasi  and 
upper  lip,  and  runs  upwards  and  backwards  towards  the  junction  of  the  pinna 
with  the  side  of  the  head,  and  this  line  will  be  found  to  pass  immediately  beneath 
the  outer  and  lower  margin  of  the  orbit.  The  opening  into  the  pituitary  fossa  was 
made  by  placing  a  long  chisel  in  the  correct  line,  with  the  cutting  edge  against  the 
roof  of  the  sphenoidal  sinus,  and  then  cracking  the  bone  by  a  few  gentle  taps  with 
a  hammer,  a  mastoid  burr  with  a  small  head  completing  the  stage.  Immediately 
the  bone  was  removed  about  3ij  of  bloodstained  fluid  escaped,  and  when  this  was 
removed  the  diu-a  mater  was  fomid  to  be  lying  against  the  opening.  After  enlarging 
the  opening  in  the  bone  the  dura  mater  was  incised,  but  as  this  gave  rise  to  brisk 
haemorrhage  on  each  of  two  attempts,  the  operation  was  concluded  by  swabbing 
out  the  woimd  with  mops  soaked  in  1  in  4000  aqueous  biniodide  of  mercury  lotion 
and  then  inserting  a  suture  in  the  skin  womid  which  was  covered  with  a  sealed 
dressing.  The  patient  was  discharged  twenty-five  days  after  the  operation,  with 
comi^lete  relief  of  all  symj^toms  except  the  sight,  which  she  thought  had  improved 
slightly.  Two  months  later  a  second  operation  was  performed  for  a  return  of 
symptoms,  and  the  patient  died  in  three  days.  At  the  necropsy  a  malignant  growth 
was  fomid  extending  into  the  floor  of  the  fourth  ventricle. 

The  following  methods  of  reaching  the  pituitary  have  also  been  employed, 
(a)  By  a  lateral  subtemporal  craniotomy  as  recommended  by  CiLshing  ;  (b)  by  an 
anterior  frontal  craniotomy  as  suggested  by  Krause.  In  both  these  operations, 
after  free  removal  of  bone  the  frontal  lobes  are  raised  until  the  jiituitary  is  brought 
into  ^iew.  (c)  Kocher  suggests  that  the  reflexion  of  both  upper  jaws  with  di\nsion 
of  the  hard  and  the  soft  palate  followed  by  removal  of  the  vomer  and  of  the  lower 
wall  of  the  sphenoidal  sinus  would  lead  one  dowii  to  the  point  where  the  pituitary 
body  could  b?  removed  from  the  sella  turcica. 


474  OPERATIONS  ON  THE  HEAD  AND  NECK 

These  oi^erations  have  not  yet  been  sufficiently  tried  to  permit  of  a  satisfactory 
estimate  of  their  relative  merits.  The  advantage  of  the  Killian-Hirsch  method 
would  appear  to  be  that  infection  of  the  womid  is  less  likely,  its  disadvantage  that 
the  exposure  in  the  deep  narrow  wound  is  necessarily  incomplete.  The  ethmoidal 
route  would  appear  to  be  very  liable  to  infection  of  the  wound  as  the  nasal  fossse 
are  extensively  opened.  Kocher's  operation,  though  severe,  would  provide  a  good 
view,  though  the  dangers  of  infection  would  be  present.  The  methods  of  craniotomy, 
temporal  or  frontal,  could  scarcely  satisfactorily  exjiose  the  pituitary,  but  benefit 
might  result  from  the  decompression  thus  provided. 

REMOVAL  OF  ADENOIDS  AND  OF  ENLARGED  TONSILS 

The  symptoms  produced  by  enlargement  of  these  structures  are  so  well 
known  that  their  detailed  consideration  is  not  required  here.  It  will  be 
sufficient  to  point  out  that  the  severity  of  the  symptoms  rather  than  the 
extent  of  the  enlargement  should  guide  the  surgeon  when  recommending 
operation.  It  must  also  be  remembered  that  adenoids  may  be  the  cause 
of  "  reflex  "  symptoms  such  as  nocturnal  enuresis,  convulsions,  and 
laryngismus  stridulus.^  In  slight  cases,  where  the  surroundings  are  satis- 
factory and  where  attention  will  be  duly  j)aid  to  carrying  out  palliative 
treatment,  atrophy  may  be  expected  to  follow.  Nose-breathmg,  even  if 
systematically  carried  out,  will,  however,  have  no  curative  effect  on 
established  adenoids,  any  more  than  it  will  upon  enlarged  tonsils.  Where 
the  adenoids  or  enlarged  tonsils  have  caused  enlargement  of  the  cervical 
glands,  operation  is  indicated,  but  the  surgeon  should  prepare  the  rela- 
tions for  the  possibility  of  suppuration  in  the  glands  after  the  operation, 
especially  where  the  vitality  is  poor,  the  surroundings  misatisfactory,  the 
glands  already  tuberculous,  or  where  another  member  of  the  family 
suffers  from  a  like  condition  of  the  glands. 

Anaesthetic.  These  operations  are  carried  out  by  many  continental 
surgeons  and  by  a  few  in  this  country  without  any  anaesthetic.  Though 
the  operation  takes  but  a  short  time,  yet  some  dehberation  is  desirable, 
and  hence  general  anaesthesia,  which  will  last  a  few  minutes,  is  strongly 
indicated.  The  anaesthetic  employed  will  depend  to  a  large  extent  on 
the  custom  of  the  operator.  Chloroform  should,  however,  except  in 
certain  special  circumstances  when  it  will  be  given  by  a  skilled  anaesthetist, 
be  avoided.  It  is  distinctly  dangerous,  and  a  large  number  of  fatalities 
have  occurred  during  its  use  for  these  small  operations.  If  the  patient 
is  over  twelve  years  of  age  .^nitrous  oxide  gas  may  be  employed.  If 
desired  this  can  be  followed  by  ether.  Ethyl  chloride  is  occasionally 
used  for  younger  children,  but  it  is  more  satisfactory  that  the  patients 
shall  be  anaesthetised  with  A.C.E.  or  the  C.E.  mixture.  The  anaesthetic 
should  be  pushed  to  such  an  extent  that  the  corneal  reflex  is  just  lost, 
but  the  coughing  and  swallowing  reflexes  are  not  abolished. 

The  removal  of  adenoids  will  be  first  described,  then  the  removal  of  the 
tonsils,  and  finally  the  operation  when  both  these  structures  are  en- 
larged. 

Removal  of  Adenoids.  The  patient  should  be  anaesthetised  on  a 
couch  or  operating  table  in  a  good  fight.  The  position  is  of  considerable 
importance.     It  is  best  for  the  head  to  be  turned  to  the  right  side,  and 

^  It  may  be  here  pointed  out  that  several  other  morbid  conditions  may  give  rise  to 
similar  symi^toms.  (1)  Diminutive  anterior  and  posterior  nares  ;  (2)  low  pharyngeal 
vault ;  (3)  paresis  of  pharyngeal  muscles  ;  (4)  prominent  crest  of  the  vomer  ;  (n)  forward 
projection  of  the  ujDper  three  cervical  vertebrae,  especially  the  Atlas  ;  {^i)  retropharyngeal 
abscess  ;  (7)  webs  ;  (8)  new  growths,  such  as  a  sarcoma  springing  from  the  base  of  the 
skull. 


REMOVAL  OF  ADENOIDS  475 

the  left  shoulder  to  be  raised  by  the  nurse.  This  will  be  satisfactory 
both  for  the  operator  and  the  anaisthetist,  for  the  blood  will  either  escape 
from  the  nostrils  or  run  down  into  the  hollow  of  the  right  cheek.  Or 
the  patient  lies  on  his  back,  with  the  shoulders  a  little  raised,  and  the 
head  thrown  back,  and  hanging  over  the  end  of  the  table  (Rose's  position). 
In  this  position  the  head  is  supported  by  an  assistant  or  nurse.  It  is 
now  but  seldom  employed,  as  it  has  two  serious  disadvantages :  it  con- 
siderably increases  the  congestion  and  so  the  amount  of  bleeding,  and 
also,  by  throwing  forward  the  upper  cervical  vertebra3,  renders  access 
to  the  naso-pharynx  distinctly  more  difficult.  The  instrument  to  use 
is  Gottstein's  curette  or  some  modification  of  this,  such  as  Kirstein's. 
Sir  St.  Clair  Thomson's  modification  of  this  instrument  is  provided  with 
a  cage  and  teeth  to  secure  the  growth  when  it  has  been  cut  away. 

The  artificial  nail,  fitting  the  end  of  the  finger,  is  now  seldom  employed. 
Forceps  are  useful  in  some  cases  for  removing  masses  partially  detached 
by  the  curette,  or  when  there  is  a  mass  of  considerable  size  springing  from 
the  lateral  pharyngeal  wall.  The  best  pattern  is  Sir  St.  Clair  Thomson's 
modification  of  Lowenberg's  forceps.  This  instrument  is  particularly 
light  and  short,  making  it  easy  to  use  the  finger  at  the  same  time.  With 
these  and  all  modifications  of  Lowenberg's  forceps  opening  laterally, 
care  must  be  taken  not  to  damage  the  orifices  of  the  Eustachian  tubes. 

The  patient  having  been  ansesthetised  to  the  proper  degree,  the 
ansesthetist  adjusts  a  gag,  either  Doyen's  or  Mason's  pattern,  and  opens 
the  mouth  widely,  but  not  to  the  full  extent  possible,  as  this  may  em- 
barrass the  breathing. 

The  surgeon  then  depresses  the  tongue  with  a  spatula  or  with  the 
left  forefinger,  and  holding  the  curette  firmly  in  the  right  hand,  introduces 
it  behind  the  soft  palate  into  the  naso-pharynx.  Care  must  be  taken 
that  the  instrument  is  in  the  correct  position  or  the  uvula  or  soft  palate 
may  be  damaged.  The  curette  may  also  be  easily  introduced  in  the 
following  way  :  it  is  inserted  over  the  base  of  the  tongue  with  the  curved 
portion  directed  downwards  towards  the  epiglottis.  Having  reached 
the  back  of  the  pharynx  it  is  rotated  through  an  angle  of  180°,  and  thus 
slips  behind  the  soft  palate.  In  either  case  its  position  must  be  verified 
by  the  forefinger,  or  by  gently  drawing  the  instrument  forwards,  when 
it  will  be  felt  to  impinge  against  the  back  of  the  na^sal  septum.  The 
handle  is  now  depressed  so  that  the  cutting  edge  is  pressed  firmly  against 
the  anterior  part  of  the  roof  of  the  pharynx.  The  patient's  head  is  now 
steadied,  and  a  firm  sweeping  cut  made,  the  cutting  end  of  the  curette  being 
made  in  one  continuous  movement  to  pass  along  the  roof  and  the  posterior 
wall  of  the  naso-pharynx,  and  to  be  withdrawn  from  the  mouth.  In  the 
majority  of  cases  the  detached  mass  of  hypertrophied  adenoid  tissue  will 
come  away  with  the  curette,  especially  if  St.  Clair  Thomson's  instrument  is 
used.  The  forefinger  is  then  again  introduced,  and  if  any  adenoid  tissue 
is  still  felt,  one  (or  more)  similar  applications  of  the  curette  is  made.  The 
lateral  aspects  of  the  pharynx  must  be  strictly  avoided,  especially  the 
vicinity  of  the  Eustachian  tubes.  That  all  cuts  are  made  in  the  middle 
line  may  be  ensm-ed  by  keeping  the  shaft  of  the  instrument  in  line  with 
the  incisor  teeth.  Small  masses  at  the  side  of  the  pharynx  will  atrophy 
when  the  main  mass  has  been  removed  ;  larger  ones  may  be  broken  up 
by  the  finger,  or  removed,  as  may  also  any  loose  tags  attached  to  the 
posterior  pharyngeal  wall,  by  St.  Clair  Thomson's  forceps. 

The  amount  of  haemorrhage  varies  ;  it  is  not  often  severe,  and  usually 


476  OPERATIONS  ON  THE  HEAD  AND  NECK 

soon  ceases  spontaneously.  The  blood  escapes  from  the  anterior  nares 
or  collects  in  the  hollow  of  the  cheek,  whence  it  may  readily  be  sponged 
away.     Swabbing  the  back  of  the  throat  should  be  avoided. 

Removal  of  Enlarged  Tonsils.  This  is  usually  effected  by  means  of 
the  tonsil  guillotine.  The  remarks  about  anaesthesia  made  above  with 
reference  to  the  removal  of  adenoids  apply  to  this  operation  also.  The 
patient  should  lie  flat  on  his  back  ^nth  the  head  shghtly  extended.  As 
the  operator  should  be  well  over  the  patient  a  couch  is  better  than  the 
ordinary  operating  table.  If  the  latter  be  employed  the  surgeon  should 
be  provided  with  a  suitable  footstool.  When  the  patient  is  anaesthetised 
the  anaesthetist  or  an  assistant  opens  the  mouth  with  a  gag,  either  Doyen's 
or  Mason's,  inserted  on  the  left  side.  The  left  tonsil  should  be  removed 
first.  The  guillotine  is  introduced  well  to  the  back  of  the  pharynx,  and, 
with  the  help  of  the  left  index  finger,  the  enlarged  structure  is  manipulated 
through  the  window  of  the  instrument,  an  assistant  meanwhile  supporting 
the  tonsil  by  pressing  the  soft  tissues  inwards  just  behind  the  angle  of  the 
jaw.  The  mndow  of  the  guillotine  is  then  firmly  pressed  against  the 
outer  wall  of  the  pharynx,  to  effect  which  the  shaft  may  be  carried  in- 
wards towards  the  mid-hne.  With  the  thumb  of  the  right  hand  the 
cutting  blade  is  now  pressed  home.  The  tonsil  is  either  cut  clean  away, 
or  the  base  is  partly  cut  and  partly  crushed  into  a  pedicle,  which  is 
readily  torn  through  by  one  or  two  twisting  movements  of  the  instrument. 
In  either  case  the  left  index  finger  should  be  placed  behind  the  tonsil  to 
assist  in  its  withdrawal  and  to  prevent  it  falhng  back  into  the  pharjnix. 
The  operator,  who  looks  towards  the  patient's  head  during  the  removal 
of  the  left  tonsil,  now  turns  romid,  looking  towards  the  patient's  feet, 
and  removes  the  right  tonsil  in  exactly  the  same  way.  There  is  no  need 
to  change  the  gag  to  the  opposite  side. 

Directly  the  second  tonsil  is  removed  the  patient's  left  shoulder  is 
raised,  so  that  the  blood  runs  down  into  the  hollow  of  the  right  cheek, 
whence  it  can  be  easily  sponged  away.  Haemorrhage  may  sometimes 
be  troublesome  after  removal  of  the  tonsils  {vide  infra). 

Removal  of  Adenoids  and  Enlarged  Tonsils.  Both  operations  are 
very  frequently  carried  out  under  the  same  anaesthetic.  The  tonsils  should 
first  be  removed  in  the  way  described  above.  The  patient  is  then  turned 
on  his  right  side  and  the  operation  for  removal  of  the  adenoids  per- 
formed. 

Enucleation  of  the  Tonsils.  The  above  operation  ^vith  the  guillotine 
does  not  completely  remove  the  tonsil.  When  effectively  carried  out 
there  is  but  little  tendency  for  the  small  remaining  portion  to  give 
rise  to  further  trouble.  There  are,  however,  certain  cases  in  which  it 
is  not  a  satisfactory  operation.  This  is  especially  the  case  when  the 
tonsil,  though  enlarged,  does  not  markedly  project :  a  thin  superficial  shce 
taken  away  is  then  unlikely  to  do  good.  It  is  also  unsatisfactory  in  the 
case  of  small  septic  tonsils  often  met  with  in  adults  which  cannot  be  cut 
away  vAih  the  guillotine.  In  these  cases,  especially,  enucleation  is 
indicated. 

Enucleation.  The  patient,  who  should  lie  on  his  back  with  the 
shoulders  slightly  raised,  is  anaesthetised  in  a  good  hght.  The  mouth 
is  well  opened  and  the  tongue  drawn  forwards  by  an  assistant  either  by 
tongue  forceps  or  by  a  suture  passed  through  it  near  the  tip.  The 
mucous  membrane  is  then  divided  along  the  whole  length  of  the  anterior 
pillar  of  the  fauces,  either  by  means  of  curved  scissors  or  by  one  of  the 


REMOVAL  OF  ADENOIDS  477 

special  iiistrunuMits  designed  for  this  purpose.  The  tonsil  is  now  seized 
and  drawn  inwards  by  a  pair  of  long  curved-tooth  dissecting  forceps. 
The  capsule  of  the  tonsil,  a  bluish- white  membrane,  now  comes  into  view. 
By  means  of  the  finger  or  with  the  help  of  the  curved  scissors,  this  is 
separated  from  the  muscular  wall  of  the  pharynx,  and  the  tonsil  is  thus 
completely  removed.  There  is  not  usually  much  haemorrhage,  and  the 
blood  can  be  sponged  away  with  sterilised  swabs  on  appropriate  holders 
by  an  assistant. 

After-treatment.  The  patient  should  be  kept  on  one  side  for  some 
time  after  the  operation,  and  carefully  watched,  especially  on  account  of 
the  vomiting  of  blood,  which  is  almost  certain  to  follow.  The  haemor- 
rhage, severe  at  the  time,  soon  ceases,  and  very  rarely  causes  anxiety. 
Occasionally  the  bleeding  is  profuse,  or  may  be  long  continued.  In 
such  cases,  iced  boracic  acid  to  the  face,  syringing  hot  water  through 
the  anterior  nares,  the  patient  being  in  the  position  above  advocated, 
or  the  use  of  adrenalin  chloride,  1  in  1000,  must  be  tried.  The  child, 
if  delicate,  should  be  kept  in  bed  for  two  or  three  days,  and  in  damp 
or  wet  weather  should  not  leave  the  house  for  a  week.  For  the  first 
twenty-four  hours  the  food  should  be  cold.  As  a  rule,  especially  in  little 
children,  where  the  parts  are  so  small  and  delicate,  any  use  of  the  syringe 
or  Politzer's  bag  is  to  be  deferred  until  sufficient  time  has  elapsed  to  show 
the  result  of  the  operation.  Warm  boracic  acid  may  be  used  if  the  dis- 
charge show  signs  of  becoming  muco-purulent.  The  friends  should  be 
prepared  for  the  breathing  being  even  worse  than  usual  for  the  first  two 
or  three  days.  Improvement,  especially  in  the  gain  in  nose-breathing, 
begins  from  the  fourth  to  the  seventh  day.  Nose-breathing  exercises — 
a  most  important  part  of  the  after-treatment — should  be  started  on  the 
foiu'th  day.  The  child  should  be  made  to  lie  on  its  back  with  the  hands 
behind  the  head,  for  ten  minutes,  three  times  a  day,  and  practise  breathing 
deeply  through  the  nose  alone.  This  will  cause  atrophy  of  any  remaining 
adenoids  and  greatly  help  the  clearing-up  of  symptoms. 

Complications  and  Sequelae.  (1)  and  (2)  Hcetnorrhage  and  Shock. 
These  have  already  been  mentioned,  and  it  may  here  again  be  pointed 
out  that,  in  addition  to  deaths  under  chloroform,  there  have  been  fatal 
results  from  hsemorrhage.  While  the  bleeding  usually  ceases  quickly  of 
itself,  fatal  cases  have  undoubtedly  occurred  both  at  the  time  and  a  few 
hours  later.  In  a  few  this  result  may  have  been  due  to  haemophilia  ;  in 
others,  from  the  accidental  tearing  off  of  pharyngeal  mucous  membrane, 
or  direct  injury  to  a  large  blood-vessel,  both  these  accidents  being  more 
likely  to  occur  with  Lowenberg's  forceps.  Where  the  bleeding  is  exces- 
sive the  face  should  be  sponged  with  ice-cold  water.  When  this  is  not 
successful  the  naso-pharynx  may,  when  the  bleeding  follows  an  operation 
for  adenoids,  be  packed  with  sterilised  gauze,  which  may  be  wTung  out  of  a 
solution  of  adrenalin.  If,  as  is  more  likely  to  be  the  case,  the  haemorrrhage 
follows  removal  of  the  tonsils,  the  mouth  may  be  widely  opened,  the  side 
from  which  the  blood  comes  ascertained  by  inspection,  and  pressure  then 
applied  by  a  sterilised  swab  on  a  holder  to  the  bleeding  surface  inside  the 
mouth  while  counter-pressure  is  made  from  outside  behind  the  angle  of  the 
jaw.  It  has  also  been  recommended  that  sutures  be  passed  deeply  be- 
tween the  pillars  of  the  fauces  ;  while  as  a  last  resource,  should  these 
methods  fail,  the  external  or  common  carotid  may  be  ligatured.  The 
haemorrhage  in  these  serious  cases  usually  comes  from  one  of  the  tonsillar 
arteries  :   it  is  said  that  the  internal  carotid  may  be  injured,  though  as 


478  OPERATIONS  ON  THE  HEAD  AND  NECK 

this  is  situated  behind  the  tonsil  and  external  to  the  superior  constrictor, 
it  is  difficult  to  see  how  this  can  happen.  The  serious  bleeding  which 
would  ensue  could  only  be  met  by  immediate  pressure  as  described  above 
and  ligature  of  the  common  carotid. 

(3)  Broncho-Pneumonia  from  the  entrance  of  blood  into  the  lungs. 

(4)  Infection  of  the  Raw  Surface.  This,  naturally,  cannot  be  rendered 
or  kept  aseptic,  and  the  superficial  sloughs  which  form  may  closely 
resemble  diphtheritic  membrane  in  appearance. 

(5)  Ear  Trouble.  In  a  few  cases  pain  in  the  ears  is  complained  of, 
probably  due  to  entrance  of  blood  into  the  tympanum  along  the  Eustachian 
tubes.  Another  rare  and  more  serious  aural  complication  is  otitis  media 
from  injury  to  the  Eustachian  tube,  infection  of  the  wound,  or  unwise  use 
of  the  nasal  douche.  If  deafness  was  present  before  the  operation  and 
is  not  improved  ten  days  after,  Politzerisation  will  be  indicated. 

(6)  It  is  not  very  uncommon  for  some  of  the  cervical  glands  to  become 
painful  and  swollen,  but,  unless  the  wound  has  been  infected,  especially 
if  the  patient's  vitality  is  very  low,  suppuration  does  not  follow. 

(7)  Exanthemata.  It  is  of  great  importance  that  after  the  operation 
the  patient  is  not  exposed  to  the  virus  of  scarlet  fever,  diphtheria,  or 
sewer  gas. 

(8)  Injury  to  the  Tongue.  This  may  happen  when  enlarged  tonsils 
are  removed  by  the  guillotine,  but  not  in  the  hands  of  a  skilful  or  ex- 
perienced operator. . 

(9)  Question  of  Reappearance.  This  is  regarded  by  some  as  frequent. 
It  is,  however,  distinctly  rare  when  the  operation  has  been  properly  per- 
formed, and  the  after-treatment  efficiently  carried  out,  though  parents 
are  Hable  to  take  several  conditions  which  may  coexist  with  adenoids  for 
the  reappearance  of  the  adenoids  themselves.  Reappearance  or,  more 
correctly,  persistence  of  adenoids,  is  not  uncommon  when  the  operation 
has  been  done  "  against  time,"  either  for  show,  or  because  the  operator 
is  nervous  about  the  ansesthetic.  If  the  adenoids  have  been  properly 
dealt  with,  and  mouth-breathing  persists,  some  other  cause  must  be  sought 
for.  Very  likely  nose-breathing  has  not  been  assiduously  practised, 
or  some  such  condition  as  enlarged  tonsils,  deviation  of  the  septum, 
enlargement  of  the  posterior  extremities  of  the  turbinals,  hypertrophic 
rhinitis,  or  the  rarer  conditions  mentioned  at  p.  474  may  be  present  and 
require  attention.  All  such  conditions  should  have  been  detected  at  the 
time  of  the  first  anaesthetic,  and,  if  not  dealt  with  then,  the  patient's 
friends  should  have  been  made  aware  that  more  would  require  to  be  done. 


CHAPTER  XXIII 

OPERATIONS  ON  THE  LIPS.     HARE-LIP  AND  OTHER 
PLASTIC  OPERATIONS  ON  THE  LIPS 

HARE-LIP 

Best  time  for  Operation.  Any  time  after  the  second  or  third  month  is 
to  be  preferred.  For  most  cases  the  third  to  the  sixth  month  is  the  best. 
All  should  be  over  by  the  seventh  month  when  dentition  begins.  While 
the  rule  of  British  surgery  is  to  get  the  operation  over  before  dentition, 
many  German  surgeons  defer  taking  any  steps  till  the  child  has  entered 
on  the  second  year.  Thus,  Prof.  Billroth  ^  announced  his  practice  as 
follows  :  "  Unless  the  parents  urgently  demand  an  operation  as  early 
as  possible,  I  generally  prefer  to  operate  on  children  when  they  are 
more  than  one  year  old.  I  always  advise  this  in  strong  children  with 
complicated  hare-lips,  especially  when  the  intermaxillary  bones  are 
displaced  and  the  hare-lip  is  double.  I  have  been  particularly  satisfied 
with  the  results  of  operation,  as  far  as  appearance  is  concerned,  on  children 
at  rather  later  periods  of  life  and  in  adults." 

The  reasons  for  deferring  the  operation,  as  a  rule,  till  after  the  second 
month,  are  : 

(1)  The  difficulties  of  getting  children  with  hare-lip  to  take  sufficient 
food  are  exaggerated.  Very  often,  unless  the  palate  is  cleft  in  addition, 
these  children  can  suck  well,  and  are  in  good  condition.  When  the  palate, 
is  also  cleft,  a  serious  difficulty  may  arise  from  the  food  passing  into  the 
nose,  but  this  may  be  usually  met  by  careful  feeding  with  a  small  spoon 
put  well  back,  if  a  sucking-bottle  with  a  large  teat  and  a  good-sized  hole 
in  it  fails.  This  it  will  very  rarely  do,  if  slowly  raised  so  as  to  give  a  httle 
milk  each  time.  Sometimes  it  is  best  to  have  the  child  raised  when 
feeding.  The  mother's  milk  should  always  be  drawn  and  given  when 
possible.  When  the  child  really  cannot  get  sufficient  nourishment,  and 
is  marasmic  from  this  cause  only,  the  surgeon  may,  of  course,  operate 
before  three  or  even  two  months.  But  a  child  that  is  daily  wasting  is 
less  and  less  able  to  meet  the  strain  entailed  by  the  operation,  and  con- 
sequent repair.  This  should  be  clearly  understood  by  the  friends,  and 
also  the  following  fact  : 

(2)  It  is  not  uncommon  for  children  with  hare-lip  to  die  soon  after 

birth  from  causes  quite  apart  from  this  deformity,  viz.  diarrhoea,  lung 

trouble,  exhaustion.     In  such,  operation  is  unadvisable.     It  will  not 

mend  matters,  and  death  will  be  put  down  to  it,  and  not  to  the  above 

causes,  which  would  have  destroyed  the  child  in  any  case.     In  another, 

smaller,  class  of  cases  the  operation  itself,  chiefly  from  the  pain  it  causes 

in  a  weakly  child,  seems  to  start  a  process  of  fatal  wasting, 

1  Clin.  Surg.,  Syd.  Soc.  transl.,  p.  78. 
479 


480  OPERATIONS  ON  THE  HEAD  AND  NECK 

(3)  The  operation  can  be  done  much  more  perfectly  and  artistically 
on  a  young  child  than  on  a  new-born  infant,  the  parts  being  larger,  more 
fleshy,  and  more  easily  handled.     Sutures  also  cut  out  less  readily. 

(4)  For  the  first  few  weeks  of  life  the  child  has  scarcely  got  over  the 
change  from  intra-uterine  to  extra-uterine  life,  the  digestion  is  not  yet, 
so  to  speak,  in  full  swing,  and  a  very  slight  shock  may  be  too  much  for  the 
low  vitality  of  this  period. 

(5)  The  objection  that  early  closure  of  the  hare-lip  renders  access  to 
the  cleft  palate  more  difficult  is  dealt  with  at  p.  506. 

Condition  of  the  Hare-lip.  Before  operation  the  following  must 
be  inquired  into.  .  Is  the  cleft  single  or  double  ?  If  single,  is  it  simple, 
i.e.  without  involving  the  nose,  and  without  fissure  of  the  palate  ?  Are  the 
sides  ec^ual  and  acute-angled,  or  divergent  and  unequal  ?  Other  sources 
of  difficulty  are,  much  flattening  of  the  nose  from  the  septum  being  ad- 
herent and  dragged  over  to  the  superior  maxilla  on  one  side,  and  the  ala 
of  the  opposite  side  being  spread  out  and  stretched  over  the  upper  part 
of  the  fissure.  Or  the  edges  of  the  lip  are  widely  apart,  and  by  no  means 
to  be  approximated,  the  alse  being  so  widely  separated  that  lines  let 
fall  vertically  through  them  only  just  come  within  the  angles  of  the 
mouth. 

Other  more  general  points  will,  of  course,  be  remembered  as  influenc- 
ing the  result  of  the  operation.  Amongst  these  are,  the  digestive  and 
sleeping  power  of  the  infant ;  its  family  history  ;  the  existence  of  any 
weakening  condition,  such  as  otorrhoea  ;  if  it  is  in  a  children's  hospital, 
the  possible  presence  of  any  cases  of  infantile  diarrhoea,  and,  by  no  means 
least,  the  good  sense  and  patience  of  the  nurse. 

The  third  of  the  following  operations  is  the  one  which  is  most  generally 
indicated.  The  first  is  only  of  very  limited  use,  while  the  others  may  be 
employed  in  special  cases. 

(1)  The  Operation  for  those  Cases  where  the  Cleft  is  Narrow  and  the 
sides  of  the  Cleft  are  equal  (Fig.  183).  The  child  being  Avrapped  in  a 
towel,  mummy-wise,  to  ensure  the  hands  being  secured  if  it  "  come  to  " 
prematurely,  chloroform  or  C.E.  is  given  fully,  and  the  head  is  held 
suitably  presented  to  the  operator  by  an  assistant,  whose  hands,  at  the 
same  time,  make  pressure  upon  the  facial  arteries  as  they  cross  the  jaw. 
The  lips,  and,  generally,  the  alee  also,  are  now  freely  separated  from  the 
subjacent  bones  to  allow  of  the  margins  of  the  cleft  coming  together 
without  tension.  During  this  step  the  knife  should  be  kept  very  close  to 
the  bone,  otherwise  the  haemorrhage  will  be  free.  Some  advise  the  use 
of  a  blunt  instrument  here  after  the  mucous  membrane  has  been  incised. 
Unless  this  separation  of  lip  and  lower  nose  be  thoroughly  carried  out, 
the  tension  on  the  sutures  a  little  later  will  be  certain  to  interfere  with 
successful  union.  To  render  the  separation  efficient  the  knife  must  some- 
times be  carried  quite  up  to  the  infra-orbital  foramina,  while  the  alse 
nasi  must  also  be  thoroughly  separated,  so  that  any  flattening  and  dis- 
tortion of  the  nostril  may  be  remedied.  The  bleeding  is  met  by  keeping 
the  knife  very  close  to  the  bones,  and  after  the  soft  parts  are  freed, 
making  gentle  pressure. 

If  one  pre-maxilla  and  maxillary  bone  project  inconveniently  beyond 
its  fellow,  it  may  now  be  forced  back  into  place  with  the  finger  and  thumb,^ 
or  with  non-serrated  forceps  covered  with  thin  drainage-tube.     The  bone 

1  If  the  back  of  the  child's  head  is  firmly  supported,  the  thumb  of  the  surgeon  will, 
usually,  quickly  fracture  Ipack  thtj  bone  into  place. 


HARELIP 


481 


should  be  felt  to  crack  when  this  is  done  ;  otherwise,  if  merely  bent  back, 
it  sprin«:s  forward  again  and  causes  tension  on  the  flaps. 

The  edges  of  the  cleft  are  now  pared.  This,  the  most  important 
part  of  the  whole  operation,  must  be  done  carefully,  and  thoroughly  as 
well.  The  surgeon  seizes  the  lower  angle  of  each  flap  alternately,  either 
with  his  left  forefinger  and  thumb,  or.  if  the  parts  are  very  small  and 
slippery,  with  tenaculum-forceps.  which  should  not  hold  the  soft  parts 
too  near  the  edge,  or  they  will  tear  out  too  soon.  The  edges  being  thus 
made  tense,  the  surgeon,  with  a  narrow-bladed,  thin-backed,  small 
knife  (scissors  are  on  no  account  to  be  used),  pares  them  as  widely  as 
possible  by  two  incisions,  beginning  above  at  the  upper  angle  of  the  cleft, 
cur\nng  outwards  somewhat  as  they  descend,  quite  clear  of  the  edges  of 
the  fissure,  and  then,  in  the  lower  part,  curv- 
ing imvards  again,  through  the  red  prolabium. 
Beginners  nearly  always  make  the  mistake 
(Fig.  183)  of  removing  only  a  thin  paring  of 
red  surface.  The  pared  surface  should  be 
made  as  wide  as  possible,  especially  below,  in 
order  that  the  sutures  may  hold  better  and 
the  lip  be  deeper.  lu  Mr.  Owen's  words, ^ 
the  object  is  to  carve  out  as  massive  pieces 
as  possible,  not  httle  flaps.  If  one  margin 
of  the  flap  is  longer  than  the  other,  this  should 
be  pared  fii'st,  and  after  this  its  fellow,  that 
both  may  correspond.  The  haemorrhage  from 
the  coronary  arteries  is  met  by  seizing  them 
with  small  Spencer  -Wells  forceps,  which 
serve  to  approximate  the  lips  when  the  iii'st 
and  lowest  stitch  is  inserted. 

The  assistant,  who  steadies  the  head  and 
keeps  pressure  on  the  facial  arteries,  now, 
with  two  fijigers.  presses  the  cheeks  together, 
so  as  to  bring  the  flaps  into  apposition  while 
the  surgeon  introduces  his  sutures.  Two  or 
three  stout  steriHsed  salmon-gut  stitches 
should  fii'st  be  used,  the  lower  to  command 
the  coronary  arteries,  and  passed  close  to  the 
mucous  membrane.  This  first  stitch  being 
passed,  and  the  chief  fear  of  bleeding  removed,  three  or  four  others  of 
gossamer-gut  or  horsehair  are  inserted,  one  being  placed  in  the  free 
margin  of  the  lip  to  keep  the  wound  carefully  closed  here  against  the 
entrance  of  milk,  saHva,  &c.  In  adjusting  the  top  stitch  care  must  be 
taken  that  it  does  not  too  much  depress  the  tip  of  the  nose,  if  the  cleft 
has  been  one  rmming  up  into  the  nostril. 

Another  precaution  to  be  taken  with  the  nose  is  to  see  that  the 
alae  are  symmetrical,  and  that  neither  nostril  is  left  a  mere  chink.  The 
occasional  impoitance  of  this  is  shown  by  the  case  related  at  p.  482. 
All  the  chief  stitches  should  be  inserted  with  very  fine  needles,  one-quarter 
of  an  inch  from  either  side  of  the  cleft.  A  few  more  hints  may  be  given 
with  regard  to  the  sutures.  They  should  be  used  freely,  and,  in  addition 
to  the  lowest,  which  commands  the  coronary  arteries,  two  should  be 
passed  deeply  enough  to  bring  the  whole  thickness  of  the  orbicularis 

1  Cleft  Palnte  and  Hare-lip,  p.  96. 
SURGERY  I  31 


Fig.  1S3.  (After  Whitson, 
Edin.  Mtd.  Journ..  18S3,  p. 
7.)  The  dotted  line  shows 
the  cleft  widely  and  freely 
pared.  The  dark  one  .shows 
timid  paring  close  to  the  pro- 
labium. The  advantages  of 
the  ar^t  incision  are — (1)  A 
broader  lip.  (2)  Firmer  union, 
as  a  greater  number  of  vascu- 
lar points  are  cut  which  will 
throw  loops  across.  (3)  A 
better  grasp  for  the  sutures. 
(4)  A  more  veitical  depth  to 
the  lip.  the  two  points,  A  A. 
being  on  a  lower  level  than  B, 
B.  The  lower  ends  of  the 
dotted  lines  should  have  been 
shown  curved  downwards  and 
inwards  in  the  usual  wav. 


482  OPERATIONS  ON  THE  HEAD  AND  NECK 

together,  and  to  control  the  vessels.  In  tying  them  there  must  be  no 
strangling  of  the  tissues  ;  the  tension  required  is  to  hold  the  cut  surfaces 
together  with  allowance  for  some  swelling.  In  tying  them,  if  their  ends 
be  left  a  little  long,  their  removal  will  be  facilitated. 

Hare-hp  pins  are  now  practically  obsolete.  They  were  useful,  no 
doubt,  in  promoting  close  and  accurate  union  where  the  parts  came 
easily  together,  but  at  the  expense  of  the  risk  of  sloughing  and  scarring 
even  then  ;  with  much  tension  this  risk  was  increased.  The  sutures 
already  described,  and  the  prevention  of  tension  by  free  separation  of 
the  soft  parts  from  the  bone,  will  meet  every  need. 

The  sutures  being  tied,  the  nostrils  are  cleared  of  any  clots,  and  the 
following  dressing  applied  :  After  a  sealed  dressing  of  gauze  and  collodion 
has  been  used  to  cover  the  wound,  a  piece  of  cyanide  gauze  two  layers 
thick,  which  has  been  previously  cut  to  an  appropriate  size  of  "  butter- 
fly "  shape  so  that  one  wing  can  be  fixed  upon  each  cheek,  while  the 
uniting  portion,  cut  just  the  width  and  depth  of  the  lip,  passes  over  the 
wound.  This  dressing  is  secured  in  place  with  collodion,  and,  while  it  is 
being  adjusted,  an  assistant  holds  the  cheeks  forward,  a  position  which 
must  be  maintained  until  the  collodion  is  firm :  or,  instead  of  this,  a  piece 
of  adhesive  strapping  cut  in  a  similar  shape  may  be  employed. 

In  the  after-treatment,  the  wound  may  be  looked  at  on  the  second 
or  third  day,  the  stout  salmon-gut  stitches  removed  on  the  fourth  day, 
and  the  others  left  in  much  longer.  On  each  occasion  the  child  must  be 
firmly  held,  and  the  cheeks  most  carefully  supported,  while  a  similar 
dressing  to  that  described  above  is  applied. 

One  point  of  great  importance  is  scarcely  alluded  to  in  most  surgical 
works,  and  that  is,  that  in  some  cases  of  hare-lip  death  from  dyspnoea  may 
take  place  very  soon  after  the  operation.  Thus,  where  the  cleft  has  been 
a  large  one,  and  the  upper  lip  when  restored  is  tight,  when  it  overhangs 
the  lower,  if  the  nostrils  are  flattened  and  partially  closed  by  the  opera- 
tion, owing  to  the  tension  of  the  parts,  so  little  breathing-space  may  be 
left  that  temporary  interference  with  respiration  may  occur,  with  grave 
and  even  fatal  results,  before  the  breathing  can  be  accommodated  to  the 
altered  circumstances,  and  before  the  parts  dilate  and  stretch. 

The  first  case  that  drew  Mr.  Jacobson's  attention  to  tliis  accident  occurred  in 
the  early  part  of  1887,  at  Guy's  Hosiiital.  The  patient  was  an  infant,  aged  three 
months,  having  a  large  cleft  with  unequal  sides  and  going  through  the  alveolar 
margin,  the  two  ha^lves  of  these  being  on  different  levels.  The  projecting  alveolus 
was  broken  back  into  jiosition,  pared,  and  stitched  with  chromic  catgut  to  its  fellow. 
The  edges  of  the  cleft  were  then  pared  and  united.  They  came  together  excellently, 
the  wide  cleft  being  replaced  by  a  deep  upper  lip.  One  nostril  was  rather  chink-like. 
About  half  an  hour  after,  a  message  came  that  the  child  was  livid  and  dying.  The 
child  was  at  once  taken  to  the  theatre  ;  the  dressing  was  removed,  the  tongue  care- 
fully di-awn  forward,  and  artificial  respiration  performed.  The  childVpiickly  recovered 
and  began  to  cry,  though  not  very  vigorously.  Three  quarters  of  an  hour  later  its 
breathing  again  failed,  and,  though  the  house-surgeon  at  once  repeated  the  artificial 
respiration,  he  was  unable  to  resuscitate  the  child.  At  the  necropsy  no  clot  was 
found  in  the  fauces,  nor  anything  wrong  beyond  the  suddenly  occluded  oral  passage. 

Mr.  G.  A.  Wright  of  Manchester  has  also  recorded  two  such  cases. ^ 

The  children   here  were  aged   three   and  five  weeks  respectively,  the   hare-lips 

double ;    in  one,  after  the   operation,   the   lower   lip  was  drawn  in  so  much  as  to 

leave  but  a  small   openuig,  but   there  was  not  apparently  any  dyspncea.      In  one 

case  dyspnoea  came  on  suddenly,  and,  as  no  relief  followed  on  pulling  the  tongue 

'*  l^^  Abstracts  of  Cases  Treated  at  the  Pcndlebury  Hospital,  1885,  p.  146.  In  Ms  Abstracts 
for  1883,  Mr.  Wright  records  a  case  in  which,  after  an  operation  for  hare-lip,  there  was 
so  much  dyspnoea,  from  the  tongue  clinging  to  the  roof  of  the  mouth  at  each  inspiration 
"  that  it  had  to  be  pulled  out  and  fastened  by  a  ligature." 


HAKE-LIP 


483 


out,  triifliL'Otomy  and  aititicial  respiration  were  performed.  The  child  recovered, 
but  a  few  hours  later  the  breathing  failed  again,  and  death  ensued.  In  the  second 
case  the  child  was  found  dead  in  the  night.  "The  cause  of  death  was  probably 
valve-action  of  the  lower  lip." 

The  chief  objection  to  this  simple  operation  is,  that  when  cicatrisation 
is  completed  there  is  very  hkely  to  be  a  small,  but  disfiguring,  notch  in 
the  border  of  the  lip  at  the  site  of  the  original  cleft.      This  may  be  pre- 


Fic.  IS-t.     Operation  of  L'leiiiut.  or  Malgdigne. 

vented  by  the  (2)  Operation  of  Clemot  or  Malgaigne  (Fig.  184).  The 
edges  are  pared  down  to,  but  not  beyond,  the  red  line ;  the  flaps  thus 
detached  above  are  turned  downwards  and  kept  out  of  the  cleft  with  a 
probe.  The  upper  part  of  the  cleft  is  then  sewn  together  with  the  sutures 
already  advised,  while  the  projecting  is  shortened  as  required  with  a  pair 
of  sharp  scissors  and  united  with  one  or  two  stitches  of  gossamer-gut  or 
horsehair.  The  chief  objection  to  this  method  is,  that,  unless  great 
care  is  taken,  a  Httle  skin,  imperceptible  at  first,  but  sho'^'ing  white  after 
a  time,  may  remain  below  the  red  hue,  or  as  a  break  in  it. 

Frequently  however,  the  cleft  is  very  wide,  or  its  edges  are  markedly  un- 


^%     ^ 


Fig.  If^.j.     Upeiatiuii  of  Mirault. 


equal  or  asymmetrical.  Under  these  circumstances,  (3)  the  Operation  of 
Mirault  should  be  performed.  This  method,  which  is  most  generally 
applicable,  gives  the  best  residts  and  is  suitable  for  a  far  larger  group  of 
cases  than  that  fi.rst  described.  By  cutting  the  flaps  of  sufficient  size  any 
subsequent  notch  in  the  free  border  of  the  Up  can  be  avoided. 

The  patient  having  been  anaesthetised  and  placed  in  the  position 
recommended  above,  the  Hp  on  both  sides  of  the  cleft  and  the  alee  nasi 
are  freely  separated  from  the  bone  to  avoid  tension.     The  side  of  the  cleft 


484  OPERATIOXS  OX  THE  HEAD  AND  NECK 

which  is  the  more  vertical  is  then  selected  and  an  incision  is  made  down- 
wards and  outwards  from  the  apex  of  the  cleft  to  the  junction  of  the  skin 
and  mucous  membrane  so  as  to  leave  a  flap  on  this  side  free  above  but 
attached  below  (Fig.  185).  Care  must  be  taken  that  the  knife  transfixes 
the  whole  thickness  of  the  lip  so  as  to  give  a  good  broad  raw  surface. 
The  other,  more  sloping  side  is  then  freely  pared  throughout  its  extent 
from  the  apex  downwards  and  outwards.^  The  haemorrhage  is  controlled 
by  an  assistant  compressing  the  lip  on  each  side  by  the  thumb  and  fore- 
finger at  the  angle  of  the  mouth.  A  silkworm-gut  suture,  threaded  on 
a  small  curved  cutting  needle,  is  now  inserted,  passing  deeply  from  the 
skin  nearly  to  the  mucous  membrane  at  the  angle  of  the  raw  surface  of 
the  first  flap,  which  should  be  just  at  the  junction  of  the  red  prolabium 
with  the  skin.  The  suture  is  then  made  to  traverse  the  raw  surface  of  the 
opposite  side  of  the  cleft  at  the  corresponding  position,  i.e.  at  the  junction 


B. 

Edmund   Owen's  Modification. 

of  the  prolabium  and  skin.  This  suture  is  then  tied,  the  edges  of  the 
wound  being  accurately  adjusted.  The  upper  cutaneous  portion  of  the 
raw  surfaces  are  brought  together  by  means  of  a  few  sutures  of  gossamer- 
gut.  The  edges  of  the  red  mucous  portion  are  then  approximated  by  sutures 
of  the  same  material,  or  of  horsehair.  The  free  edge  of  the  lip  should, 
when  the  suturing  is  finished,  show  a  shght  prominence  at  the  side  of  the 
cleft.  If  this  is  so,  the  margin  of  the  lip  will  probably  be  level  when 
cicatrisation  is  completed.  If  quite  level  at  the  end  of  the  operation  the 
scarring  is  likely  to  leave  a  small  disfiguring  notch.  The  dressing  and 
after-treatment  are  similar  to  those  described  in  the  accomit  of  the  first 
method. 

Mr.  Edmund  Owen  has  suggested  the  follo^s'ing  modification  of  this 
operation  (Fig.  186).  The  more  sloping  side  is  first  widely  pared.  To 
free  the  flap  which  is  to  be  brought  across  from  the  other  side,  the  in- 
cision is  first  made,  as  u.sual,  from  A  to  C,  and  then  outwards.  The 
object  of  this  outward  prolongation  is  to  enable  the  flap  to  lie  level 
smoothly  when  it  is  brought  over,  i.e.  without  kinking,  to  which  there  is 
otherwise  a  tendency. 

(4)  Method  of  Nelaton  (Fig.  187).  This  is  adapted  to  those 
slight  cases  in  which  the  cleft  does  not  extend  through  the  whole  depth 
of  the  lip  but  terminates  at  some  distance  from  the  nostril.  It  may 
also  be  employed  to  remedy  the  unsightly  notch  left  after  one  of  the  other 
operations.  An  incision  resembhng  a  V  reversed  is  made  through  the 
whole  thickness  of  the  lip,  around  the  upper  angle  of  the  cleft.  By  this 
means  the  red  edge  of  the  cleft  is  separated  from  the  two  halves  of  the  hp, 
except  at  each  corner  below.     This  red  edge  is  next  turned  downwards, 

^  The  side.s,  especially  the  one  which  is  refreshed  throughout  its  whole  extent,  should 
be  pared  as  in  Fig.  185 — that  is,  somewhat  angularly — so  as  to  promote  the  adjustment 
of  the  flaps,  as  it  were  b}-  interlocking. 


HARE-LIP  485 

or  reversed  so  that  the  /\-shaped  wound  becomes  diamond-shaped.  The 
raw  surfaces  are  then  hrout^dit  together  by  the  means  aheady  described. 

(5)  Hagedorn  Operation.  This  is  sufficiently  explained  by  a  reference 
to  Fig.  ISS. 

(())  Konig's  Operation  is  shown  in  Fig.  189. 


Fig.  187.     Nelaton's  operation. 


Fig.  188.     HaL'cdorii'.s  operation. 


"^- 


Fxo.  180.     Konig's  operation. 

DOUBLE  HARE-LIP  (Figs.  190,  191) 

This  is  often  easier  of  cure  than  single  hare-lip  with  very  divergent 
sides  and  the  alveolar  margin  cleft  and  its  two  parts  on  imequal  levels. 
For  in  double  hare-lip  the  mischief  is  often  symmetrical,  and  the  sides  less 
divergent.     The  follo\\ang  varieties  may  be  recognised  : 

(a)  When  the  pre-maxillary  bone  is  in  situ,  and  the  two  clefts  are  simply 
and  fairly  bilateral. 


486  OPERATIONS  ON  THE  HEAD  AND  NECK 

(6)  When  the  pre-maxillary  bone  is  separated  from  the  rest  of  the 
jaw  and  projects  forwards,  in  some  cases  shghtly,  in  others  being  attached 
to  the  vomer  and  hanging  from  the  tip  of  the  nose. 

(c)  "When  the  pre-maxillary  bone  is  small  and  ill-developed,  and  when 
the  clefts  are  widely  gaping. 

The  first  two  of  these  require  notice. 

(a)  If  the  pre-maxillary  bone  is  in  position,  the  skin  over  it  is  freed 
from  its  attachments  behind  and  pared  to  a  point.  The  sides  of  the  cleft 
are  next  pared  from  above  downwards  (as  in  Fig.  190).  and  the  parts 
brought  together  by  transfixing  the  sides  and  the  central  flap  with  salmon- 
gut  sutures,  every  care  being  taken  to  keep  the  central  piece  well  down. 
Horsehair  and  gossamer-gut  sutures  are  also  used  as  well.  As  the  central 
piece  is  always  shorter  than  the  lip  itself,  the  resulting  wound  is  Y-shaped, 
and  it  is  the  side  flaps  which  meet  each  other  in  the  middle  line  below. 
Care  must  be  taken  to  free  the  central  flap  right  up  to  and  ^^^th  the  tip  of 
the  nose,  and  not  to  depress  the  latter  too  much  with  the  sutures,  otherwise 
the  nose  will  be  flattened.  As  in  single-hare-hp, 
where  one  side  is  larger  than  its  fellow,  a  flap 
may  be  freely  cut  from  it  to  form  the  prolabium 
and  lower  border  of  the  new  Up  by  the  method 
shown  in  Fig.  190.  When  both  clefts  are  wide 
the  centre  portion  may  be  pared  as  described 
above,  and  flaps  turned  downwards  from  the 
outer  side  of  each  cleft  as  described  for  Mirault's 
operation  (Fig.  185). 

(b)  Cases  in  which  the  pre-maxillary  bone 
is  separated  from  the  maxillae,  projecting  for- 
wards, sometimes  being  even  attached  to  the 
p-jp  J9Q  very  tip  of  the  nose. 

The  question  of  remo^^ng  or  lea\'ing  the 
pre-maxillary  bone  arises  here.  It  is  now  generally  agreed  that,  with  rare 
exceptions,  this  should  be  preserved  for  the  follo'U'ing  reasons  :(1)  if  the 
bone  be  removed  there  must  be  a  permanent  gap  through  the  hard  palate. 
(2)  There  must  also  be  a  flattening  and  malposition  of  the  upper  lip,  in 
consequence  of  its  having  lost  its  bony  support  ;  and  from  this  flattening 
of  the  upper  jaw  it  will  result  that  the  hp  will  be  very  short  and  tense, 
and  the  patient  extremely  "under-hung,"  a  very  unpleasing deformity. 
To  these  two  more  may  be  added — that  (3)  the  presence  of  this  bone 
is  needful  for  the  preservation  of  the  due  width  and  arch  of  the  bone, 
and  (-1)  that  such  an  arch  will  best  carry  artificial  teeth,  if  any  are 
needed  o\\'ing  to  the  unsatisfactory  eruption  of  the  natural  ones. 

If  the  following  points  be  attended  to,  the  pre-maxillary  bone,  however 
advanced  and  firmly  attached,  can  always  be  replaced  and  preserved  ; 
weakness  on  the  part  of  the  child,  which  is  undoubtedly  a  matter  of 
grave  consideration  in  cases  like  this  where  the  loss  of  blood  is  considerable, 
is  best  met  by  doing  the  operation  in  two  stages — in  other  words,  being 
content  to  first  get  this  bone  replaced,  and  leaving  the  uniting  of  the  soft 
parts  till  another  time. 

Where  the  stalk  of  attachment  of  the  pre-maxillary  bone  is  slender, 
and  where  there  is  plenty  of  room  between  the  two  maxillae,  it  may 
often  be  broken  back  into  place  by  the  operator  supporting  with  his  left 
hand  the  back  of  the  child's  head,  and  then  with  his  right  thumb  sharply 
fracturincr  back  the  bone.     This  should  be   done  thoroughlv.   and,  if 


IIAUE-LIP  487 

needful,  by  the  aid  of  non-serrated  forceps  coveretl  witli  drainage-tube, 
or  bone  forceps  may  be  applied  to  the  stalk  in  front  and  also  behind  till 
it  is  almost  completely  cut  throu<ih.  If  now  it  can  be  replaced,  but  tends 
to  come  forward  aii^ain,  it  slioukl  be  sutured,  on  one  side  at  least,  to  the 
maxilhe  with  sterilised  catjijut. 

If  the  maxillary  bones  on  one  side  or  both  are  in  the  way,  and  prevent 
the  replacing  of  the  pre-maxillary  bone  after  it  has  been  detached  suffi- 
ciently, or  if  this  is  too  voluminous,  its  sides  must  be  cut  away  and  the 
maxilhe  also  pared  till  the  central  piece  can  be  pushed  back  between  them 
and  retained  with  a  suture,  as  above  advised.  A  severer  method — one, 
therefore,  which  should  only  be  tried  when  all  other  means  of  replacing 
the  pre-maxillary  bone  have  failed — is  to  cut  a  wedge-shaped  gap  out  of 
the  septum  nasi  and  to  press  or  fracture  the  partially  detached  bone  into 
the  gap.  It  is  absolutely  necessary,  by  some  means  or  other,  to  get  the 
pre-maxillary  bone  quite  back  and  to  make  it  stay  there,  as  otherwise 


Fig.  191.     Hagedorn's  operation  for  double  hare-lip. 

the  soft  parts  over  the  projecting  bone,  or  the  line  of  union,  which  often 
comes  just  opposite  to  it,  will  be  pressed  upon  and  give  way. 

Hagedorn's  Operation  is  shown  in  Fig.  191. 

Causes  of  Failure  and  Death  after  Hare-lip  Operations.  Amongst 
the  commonest  of  these  are  :  (1)  Feeble  vitality.  Marasmus.  Many 
infants  die  after  hare-hp  operations,  but,  while  the  effect  of  loss  of  blood 
and  of  pain  must  not  be  lost  sight  of,  in  most  of  the  fatal  cases  death  is 
due,  not  to  the  operation,  but  to  feeble  vitality.  Whether  operated 
on  or  not,  the  majority  of  these  cases  would  have  died  in  infancy. 
(2)  Hcemorrhage.  This,  if  serious,  is  due  either  to  very  free  separation  of  the 
flaps  in  a  weakly  child,  or  (a  cause  much  less  excusable)  to  the  coronary 
arteries  not  having  been  properly  secured.  Loss  of  blood  may  lead  to  non- 
union, but  it  may  also  destroy  life  rapidly  by  a  clot  in  the  fauces  and  upper 
aperture  of  the  larynx.  One  case  has  been  reported  in  which,  after  opera- 
tion, this  untoward  result  would  have  happened,  the  child  getting  in- 
creasingly blue  and  breathless,  had  it  not  been  for  the  prompt  common 
sense  of  the  nurse  in  charge,  who  removed  a  large  clot  with  a  sponge 
on  a  holder.  (3)  Bronchitis  and  Broncho-Pneumofiia.  (4)  Diarrhoea. 
(5)  Asphyxia  (p.  482).  (6)  Infection,  especially  where  the  bone  has 
been  interfered  with  in  a  weakly  infant,  and  under  conditions  always 
adverse  to  aseptic  healing. 

Repetition  of  Operation.  In  the  rare  cases  where  primary  union  fails, 
all  sutures  are  to  be  removed  and  the  parts  fomented  \^ath  boracic  acid 
lotion.     As  soon  as  all  inflammation  has  subsided,  the  edges  will  rapidly 


488  OPERATIONS  ON  THE  HEAD  AND  NECK 

cover  themselves  with  healthy  granulations.  An  anaesthetic  should  now 
be  given  and  the  parts  thoroughly  cleansed  and  dried.  They  are  then 
carefully  approximated  \nth  gauze  and  collodion,  over  which  Meade's 
strapping  should  be  applied. 

A  good  result  will  often  be  obtained  in  apparently  hopeless  cases.  In 
many  cases  a  perfect  result  cannot  be  secured  by  one  operation.  Where 
parents  are  likely  to  be  unreasoning  and  unreasonable,  the  surgeon 
should  warn  them  of  this. 

In  cases  unfavourable  owing  to  the  malformation  or  to  the  general 
condition  (p.  -480).  hare-lips  which  have  been  ojaerated  on  often  cause 
disappointment,  however  much,  up  to  the  third  day,  they  resemble 
pictures  in  books.  Incomplete  closure,  below  or  above,  a  little  in- 
equaUty  in  the  levels  of  the  halves  of  the  new  lip,  some  flattening  and 
closures  of  the  nostrils — any  of  these  may  mar  the  first  operation.  The 
more  operations  a  surgeon  does,  the  more  difficult  and  trying  cases  will 
he  meet  with.  He  can  scarcely  do  better  than  remember  the  words  of  the 
great  surgeon  of  Vienna  :i  "  Operations  on  little  children  do  not  always 
succeed  as  well  as  could  be  wished,  on  account  of  the  diminutive  size  and 
softness  of  the  parts.  The  flaps  of  the  lips  cannot  always  be  adapted  as 
exactly  as  desired,  and,  even  if  this  be  satisfactorily  accomphshed,  the 
result  does  not  in  every  case  quite  come  up  to  expectation,  so  that,  some 
few  years  after,  further  slight  proceedings  become  desirable,  in  order  to 
improve  the  appearance."  And  again,  a  little  later,  the  same  surgeon, 
speaking  of  operations  on  "  quite  little  children,"  says  :  "  I  dechne  to 
give  any  absolute  guarantee  with  regard  to  the  result  in  such  cases." 

OTHER  PLASTIC  OPERATIONS  ON  THE  LIPS  AND  FACE 

(Figs.  192-213) 

These  are  very  numerous,  especially  for  the  restoration  of  the  lower 
lip  after  operations  for  epithelioma.  &c.,  injuries,  ulcerations,  and  burns. 
A  few  of  the  chief  will  be  described  here.  It  will  be  convenient  if,  at  this 
time,  some  general  principles  which  should  govern  every  operation  of 
plastic  surgery,  large  or  small,  are  considered. 

(1)  The  patient  should  be  in  the  best  possible  condition  as  to  general 
vitality,  healthy  performance  of  the  chief  functions,  appetite,  &c. 

(2)  If  the  deformity  has  resulted  from  tubercle  or  syphilis,  a  satisfac- 
tory condition,  both  constitutionally  and  locally,  must  have  been  secured 
by  previous  treatment. 

(3)  The  parts  to  be  operated  upon  must  be  rendered  as  aseptic  as 
possible.  Where  the  mouth  is  involved,  this  and  the  teeth  should  be 
thoroughly  cleansed  beforehand  (p.  532). 

(4)  Asepsis  should  be  maintained  as  thoroughly  as  possible  through- 
out the  operation.  The  knife  and  cutting  instruments  employed  must 
be  of  the  sharpest. 

(5)  The  flaps  should  be  taken  from  healthy  parts.  As  instances 
of  the  convenient  sites  for  flaps,  the  side  of  the  abdomen  or  region  of 
the  hip  may  be  given  where  the  ulcerated  surface,  e.g.  after  a  burn,  is  on 
the  forearm  or  back  of  the  hand.  Where,  in  a  child  especially,  the 
surface  is  about  the  knee,  the  thighs  may  be  crossed  in  order  that  the 
skin  may  be  taken  from  the  opposite  limb.^  Fixity  must  be  maintained 
by  the  use  of  plaster   of  Paris,  vAih  appropriate  windows .      "  Under 

1  Billroth,  Clin.  Surg.,  p.  79.  *  Keetley,  Lancet,  March  4,  1905. 


PLASTIC  OPERATIONS  489 

no  consideration  should  cicatricial  tissue  of  a  pale  glossy  surface  be  em- 
ployed, for  when  its  subcutaneous  connections  are  severed  it  is  almost 
certain  to  slough,  especially  when  the  result  of  a  burn.  If  cicatricial 
tissue  exist  at  the  base  of  a  flap,  sloughing  is  quite  likely  to  occur.  Cica- 
tricial tissue  at  the  border  of  a  flap  is  quite  certain  to  die,  and  its  presence 
there  must  not  be  estimated  in  computing  the  area  of  the  new  flap.  When 
the  flap  is  to  be  joined  on  three  sides  with  cicatricial  formation,  the  base 
must  be  made  large,  be  highly  vascular,  and  but  little  twisted,  as  the 
vascular  supply  at  the  sides  will  be  very  little  added  to  by  the  new 
association.''  ^ 

(0)  Each  flap  must  be  cut  thick  enough,  carrying  with  it  the  sub- 
cutaneous tissue,  and  large  enough  ;  "  as  a  rule,  one-sixth  larger  than 
the  space  it  has  to  fill."  -  "  Reparative  flaps  should  always  be  made 
large  enough  to  allow  of  at  least  three  lines  of  shrinkage  for  each  inch  of 
width  of  their  surface."  ^  As  an  instance  of  the  size  required,  Mr.  Keetley 
gives  the  case  of  a  child  with  a  large  hairy  mole  on  the  face.  After  this 
was  excised  and  the  arm  brought  up  to  the  head,  nearly  all  the  skin  on  the 
inner  aspect  from  the  shoulder  to  the  elbow  was  needed  for  the  peduncu- 


VI  n  n  n  i^ 


Fig.  192. 

lated  flap  employed.  The  same  authority  advises  the  use  of  a  pattern 
for  the  flap,  cut  out  of  boiled  india-rubber  sheeting. 

(7)  There  must  be  no  tension  whatever  on  the  flaps  when  they  are 
brought  into  apposition.  Tension  is  one  of  the  most  frequent  causes  of 
failure  after  a  plastic  operation.  The  chief  aids  in  securing  this  most 
important  end  are  :  (a)  Cutting  the  flaps  sufficiently  large.  (6)  Under- 
mining the  flap  or  flaps.  Julius  Wolfi  elaborated  this  method  of  closing 
large  gaps."* 

In  the  case  of  small  wounds  it  is  only  necessary  to  cut  between  the 
superficial  and  the  deep  fascia.  In  larger  woimds  the  knife  should  pass 
between  the  deep  fascia  and  the  muscles.  In  either  case  the  under- 
mining must  be  carried  out  freely  so  that  the  edges  of  the  womid  come 
together  without  tension.  Care  must  be  taken  to  avoid  scoring  or 
unduly  lacerating  the  deep  surfaces  of  the  flaps,  as  this  may  easily 
interfere  with  the  blood-supply  and  so  lead  to  sloughing. 

(c)  By  making  liberating  incisions  at  a  short  distance  from  the  womid, 
lateral  or  horizontal  as  required,  before  inserting  the  sutures  in  the  lips 
of  the  wound.  These  incisions  cause  slightly  gaping  wounds  after  the 
defect  has  been  closed,  but  these  usually  heal  rapidly  by  aseptic  granula- 
tion, (d)  By  use  of  flaps.  These  may  be  (a)  broad  and  capable  of 
being  glided  into  the  new  position,  (h)  pedmiculated  ;   (c)  granulating. 

(a)  Fig.  192  shows  how  a  triangular  gap  may  be  closed  by  ghding 
in  a  flap  raised  by  a  horizontal  incision.  But  in  these  cases  it  is  preferable 
to   convert   the  horizontal  incision,  cd,  into  one  curving  outwards  and 

1  J.  D.  Bryant,  Oper.  Surg.,  vol.  i,  p.  507.  ^  Treves,  Oper.  Surg.,  vol.  ii,  p.  3. 

2  J,  D.  Bryant,  loc.  supra  cit.  *  Berl,  Klin.  Woch.,  1890,  No-  6. 


490 


OPERATIONS  ON  THE  HEAD  AND  NECK 


downwards.  Such  an  incision  better  frees  the  flap,  acd,  whicli  is  to  be 
gUded,  and  is  likely  to  leave  a  less  conspicuous  scar,  as  it  can  often  be 
made  to  follow  a  natural  sulcus.  Where  the  gap  is  very  large,  two  such 
freely  curved  incisions  are  made,  one  on  each  side  of  the  gap.  In  the 
removal  of  extensive  epitheliomata  of  the  lower  lip,  where  a  very  large 
triangular  gap  is  left,  such  freely-made  curved  flaps  will  enable  the 

f  i 


Fig.  193. 


surgeon  to  close  the  gap  better  than  those  which  carry  authoritative 
names  and  which  are  shown  below. 

(6)  Flaps  with  Pedicles.  These  may  be  so  fashioned  (as  in  Fig.  193, 
where  a  quadrangular  gap  is  being  closed)  that  the  flaps  are  again  little 
more  than  glided.  In  other  cases  the  pedunculated  flap  must  be  cut 
in   accordance    with   the   principles   already   enunciated.     The   pedicle 

must  be  as  wide  as  possible.  The  flap 
itself  must  be  from  two  to  three  times 
as  large  as  the  area  which  it  has  to 
cover.  It  must  be  raised  as  thick  as 
possible,  its  apparent  bulkiness  being 
greatly  diminished  later.  In  many  cases 
it  will  have  to  be  "  jumped  "  over  inter- 
vening undetached  soft  parts.  The  di- 
rections given  above  as  to  a  pattern 
and  the  use  of  plaster  of  Paris  must  be 
remembered.  When  the  pedicle  is 
divided  the  parts  must  be  carefully 
steadied  and  approximated. 

(c)  One  more  class  of  flaps  must  be 
mentioned,  that  of  granulating  flaps. 

This  method  was  used  with  much  success, 
especially  in  cases  of  cicatrices  after  burns, 
by  Ml-.  J.  Croft.  ^  Where  the  gap  is  a  large 
one,  the  flaps  being  necessarily  long  and 
somewhat  narrow,  and  therefore  possessing  but  a  limited  blood-supply,  Mr. 
Croft  advised  that  the  flajjs  be  dissected  up  and  left  attached  at  each  end,  and 
allowed,  together  with  the  wound,  to  granulate  before  the  flap  is  moved.  Mr. 
Croft  claimed  the  following  advantages  for  this  method,  and  his  claims  were  made 
good  by  the  cases  which  he  showed:  (1)  The  risks  of  sloughing  of  any  part  are 
greatly  diminished.  Instead  of  being  transplanted  when  recently  drained  of 
blood  and  reduced  in  temperature,  it  is  removed  when  abundantly  vascular  and  full 
of  active,  living,  plastic  matter.  (2)  The  transplantation  being  made  two  or  three 
weeks  after  the  first  operation,  the  local  effects  of  shock  are  avoided  or  reduced  to  a 


Fig.  194. 


Patient  before  operation. 

(Croft.) 


mmmium. 


While  Mr.  Croft's  results  abundantly  justify  a  resort  to  this  method,  it 

is  a  tedious  one,  nine  to  twelve  months  being  sometimes  needed  in  a 

severe  case  ;    it  is  a  painful  one,  as  the  second  stage  may  have  to  be 

repeated  ;   and  it  draws  largely  on  the  reparative  powers  of  the  patient. 

1  Med.  Chir.  Trans.,  vol.  Lxxii,  1889,  p.  349. 


PLASTIC  OPKHATIONS  491 

For  these  reasons  most  surgeons  will  prefer  to  try,  first,  what  can  be 
etlVcted  by  a  very  free  division  of  the  scar  and  then  careful  Thiersch  s 

grafting  (p.  4;5). 


Fu;    195      The  same  patient  five  years  after  operation.     The  dotted  lines  show 
the'  site  and  extent  of  the  strap  of  skin  which  was  raised  and  transplanted. 

(Croft.) 

(8)  All   haemorrhage  must  be  thoroughly  arrested  ;    any  ligatures 
used  must  be  of  the  finest. 


Fig.  196.     The  patient  before  operation.     The  web  is  well  shown.     The  dotted 
lines  indicate  where  the  strap-like  flaps  of  skin  were  raised,  and  their  extent. 

(Croft.) 

(9)  Each  flap  '^  must  be  gently  handled,  carefully  adjusted,  and  most 
tenderly  and  precisely  sutured."  ^ 

(10)  The  sutures,  of  sterilised  silkworm-gut  and  horsehair,  must  be 
inserted  so  as  uniformly  to  distribute  the  slightest  remaining  tension. 

^  Treves,  Oper.  Surg.,  vol.  ii,  p.  3. 


492 


OPERATIONS  ON  THE  HEAD  AND  NECK 


(11)  Asepsis  must  be  carefully  maintained  during  the  healing  of  the 
wound. 

(12)  Where  restlessness  on  the  part  of  the  patient  is  to  be  expected, 
as  in  a  child  with  one  of  the  common  burn-scars  on  the  neck  or  upper 
extremity,  some  fixed  apparatus,  e.g.  plaster  of  Paris  applied  after  the 
method  used  in  Fig.  27,  should  be  kept  applied,  from  the  first,  to  the 
head  and  neck,  upper  trunk,  and  limb,  or  the  flap  will  begin  to  ulcerate 
and  irreparable  mischief  will  be  done. 

Removal  of  Epithelioma  of  Lower  Lip.  Restoration  of  Lip.  Figs, 
198-201    have   been  retained  partly  on  account  of  the  eminent  names 


Fig.  197.     After  operation.      The  greatly  improved   position  of  the  limb   is 
manifest.     The  dotted  lines  show  the  situation  into  which  the  flaps  have  settled. 

(Croft.) 


associated  with  these  methods  and  partly  because  they  are  still  occasion- 
ally of  service.  In  each  individual  case  the  situation,  extent,  and 
duration  of  the  growth  have  to  be  considered  as  well  as  the  question  of 
secondary  deposits  in  the  glands.  Hence  the  method  selected  will  be 
the  one  which  best  meets  the  necessity  of  the  case  in  question.  Carcinoma, 
in  this  situation,  is,  however,  best  removed  on  the  lines  shown  in  Fig. 
202.     There  are  two  dangerous  fallacies  with  regard  to  this  operation  : 

(1)  That  when  occurring  on  the  lip,  because  at  first  often  warty,  and  in  a  dry 
and  exposed  position,  it  is  a  slow  and  less  important  form  of  carcinoma  ; 

(2)  it  follows  that  the  operation  is  too  often  considered  a  trivial  one,  one 
for  which  the  classical  V-shaped  incision  suffices,  and,  as  it  is  followed  by 
rapid  healing,  that  removal  of  an  epithelioma  of  the  lower  lip  is,  in  fact, 
any  one's  operation.  The  simple  V-shaped  incision  is  only  justifiable  in 
the  very  straightforward  and  early  cases,  and  in  all  cases  the  limbs  of  the  V 
should  be  widely  separated  so  as  to  pass  through  healthy  tissues  well  away 
from  the  growth.  It  is  surprising  how  freely  the  lip  can  be  removed  in 
this  way  without  subsequent  inconvenience  or  deformity.  Where,  as  is 
most  frequent,  the  disease  occupies  the  neighbourhood  of  the  angle  of 
the  mouth,  two  V-shaped  incisions  should  be  employed  (Fig.  202) ;   where 


KESTOHATION  OF  LIPS 


493 


the  lip  is  exbeiuively  involved,  three  such  incisions  (Fig.  202)  are  called 
foi'.'  Further,  in  the  great  majority  of  cases,  owing  to  the  duration  of 
the  disease,  the  lymphatic  glands  in  the  submental  and    submaxillary 


Fifi.  198.     The  dotted  lines  show.the  operation  of  .Sene,  the  continuous  ones  that 

of  Syme.     The  central  part  of  each  runs  too  near  to  the  growth.     The  same 

remark  applies  toseveral  of  the  succeeding  figures. 


Fig.  199. 


Cf^ 


Fig.  200.     V.  Langenbeck's  method  of  Fig.   201.     Chciloplasty  by  the  method 

cheiloplasty.     (Tillmanns.)  of  Bruns.     (Tillmanns.) 

As  pointed  out  above  (Fig.    198),  the  incisions  in  many  of  these  illustrations 
are  drawn  much  too  near  to  the  growth. 

regions  should  be  investigated,  even  though  they  cannot  be  felt   to  be 
enlarged.^ 

^  Not  only  is  the  actual  epithelioma  to  be  remembered,  but  the  adjacent  area  should 
also  be  widely  removed  owing  to  the  degenerative  changes  here,  and  the  fact  that  they 
lie  on  the  borderland  of  carcinoma.  The  knife  should  pass  a  full  three-quarters  of  an  inch 
from  the  actual  disease. 

^  This  should  certainly  be  a  rule  in  hospital  patients  owing  to  their  carelessness  and 
the  difficulty  in  keeping  them  under  observation.  When  the  submaxillary  or  submental 
group  can  be  felt  to  be  enlarged  the  deep  cervical  group  should  also  be  removed.  See  the 
remarks  on  infection  of  the  glands  in  epithelioma  of  the  tongue,  and  those  on  removal  of 
epitheliomatous  glands  in  the  neck  (p.  539). 


494 


OPERATIONS  ON  THE  HEAD  AND  NECK 


X 


.,/>>. 


\ 
\ 


Restoration  o£  Lower  Lip.     Let  us  suppose  that  the  surgeon  has  oper- 
ated widely  on  an  epitheUoma  here,  removing  it  by  two  or  more  V-shaped 
incisions,  and  that  he  has  to  restore  the  lower  lip  and  cover  in  the  greater 
part  of  the  chin,  on  one  side  at  least.      The  method  of  taking  flaps  from 
^  the  neck  will  be  given  first  as  on  the  whole 

/    ^  preferable  for  reasons  given  below. 

I      ,^  ^,„,    /  V  From  the  apex  of  the  central  V-shaped 

incision   one   or   two   curved  incisions  are 
>  carried  as  in  Fig.  198,  only  on  freer  lines, 

down  to  the  level  of  the  hyoid  bone  and 
then  backwards  and  slightly  upwards  to 
the  angle  of  the  jaw.  The  following  points 
require  attention.  The  flaps  must  be  cut 
thick  enough  to  carry  the  facial  artery  in 
order  to  m3.intain  their  nutrition.  The 
bleeding  will  therefore  be  very  free  and 
abundance  of  Spencer- Wells  forceps  must 
be  at  hand.     Further,  as  the  deeper  cellular 

^--  tissue  will  be  opened  up  every  precaution 

^  -'  ^      must  be  taken  before,  during,  and  after  the 
operation  to  keep  the  wound  as  sterile  as 
possible.     The  flap  must  be  raised  evenly 
and  without  scoring.     The  lips  of  the  cen- 
tral V-shaped  incision  are  now  brought  to- 
gether in  the  horizontal  position  to  form 
the  new  lip,  the  cut  edge  of  the  mucous 
membrane  being  sufficiently  freed  to  enable 
it  to   be  united  to   the  edge  of  the  skin 
without  tension,   by  numerous  horsehair 
sutures  introduced  with  very  fine  needles. 
The  edges  of  the   flap  or  flaps  below  are 
then  united  vertically,  at  first  with  stout 
silkworm-gut  and  horsehair.     But  it  must 
be  understood  that  it  is  only  by  cutting  the 
flaps  on  very  free  lines  that  tension  will  be 
obviated.     Drainage  should  be  employed 
on  either  side  at  the  most  dependent  spots. 
If  tension  cannot  otherwise  be  met,^  the 
lower  edge  of  each  curved  incision  may  be 
undermined  to  admit  of  its  coming  up  to 
the  upper  edge.     Dry  dressings  of  sterile 
gauze  strips  kept  in  place  with  collodion 
for  all  the  upper  part  of  the  wound  may 
be  employed  ;  and  a  boracic-acid  fomentation  for  the  lower  part  where 
the  drainage-tubes  come  out. 

In  the  second  method  the  flaps  are  taken  again  by  freely  curved 
incisions,  but  here  not  from  the  neck  chiefly  but  mainly /rom  the  cheeks. 
The  two  incisions  now  start  not  from  the  apex  of  the  central  V-shaped 
incision  but  from  those  at  the  angles  of  the  mouth.  They  are  carried 
straight  outwards,  at  first,  to  the  masseter  muscle  ;  here  they  curve 
outwards  and  downwards  over  the  mandible  and  then  forwards  in  the  sub- 

'  Cutting  wedge-shaped  gaps  in  the  flaps  (Dowd,  Fig.  203)  may  relieve  tension  in 
and  facilitate  the  fitting  of  the  flaps  in  place. 


"'IT 


{ 


Fig.  202.  The  above  show  the 
way  in  which  an  epithelioma  of 
the  lower  lii^,  whether  involving 
the  centre  or  one  angle  of  the 
mouth,  should  be  dealt  with. 


RESTOl^VTION  OF  LIPS 


495 


maxillary  regions  nearly  as  far  as  the  hyoid  bone.  Wliere  the  defect  is 
unusually  large,  the  first  part  of  the  incision  must  go  beyond  the  masseter 
within  an  inch  or  so  of  the  auricle  before  it  is  curved  (h)\vnvvards.  It  is 
only  by  the  freest  operating  that  really  large  gaps  can  be  closed.  It  is 
well  to  make  this  part  of  the  incision  gradually  until  the  mucous  mem- 
brane is  reached.  This  must  be  divided  horizontally  with  one  cut  of 
sharp  scissors  on  a  level  higher  than  that  of  the  skin.  This  detail  prevents 
somewhat  the  retraction  of  the  nuicous  membrane.  As  the  lower  part 
of  the  flaps  are  being  raised  the  mucous  membrane  is  again  cut  first 
vertically  at  the  anterior  border  of  the  masseter,  and  again  horizontally 
at  the  line  of  its  reflection  on  to  the  gum.  Care  must  be  talvcn  in  raising 
the  first  part  of  the  flaps  not  to  injure  the  parotid  gland.  When  the 
flaps  have  been  sufficiently  raised  they  are  glided  and  pulled  inwards  so 


Fig.  203.  Operation  for  removal  of  epithelioma  and  restoration  of  lower  lip. 
The  objection  to  thi.s  method  is  that  it  opens  up  the  submaxillary  regions  only. 
In  order  to  remove  the  siibmental  glands  the  tissues  over  the  chin  must  bo 
turned  down.  The  after- difficulty  of  keejiing  these  up  in  place  may  be  met  in 
part  by  suturing  them  with  buried  chromic-gut  sutures  to  the  periosteum  of 
the  mandible.  The  wedge-shaped  incisions  (Dowd,  footnote  p.  494)  facilitate 
the  meeting  of  tension,  and  fitting  the  flaps  in  x^lace. 

that  the  edges  of  the  central  V-shaped  incision  meet  in  the  middle  line. 
The  same  details  with  regard  to  freeing  the  mucous  membrane  if  needful 
before  uniting  it  to  the  skin,  preserving  the  blood-supply  and  drainage, 
must  be  observed  as  in  the  method  first  described.  In  either  case  the  state 
of  the  submaxillary  and  submental  lymphatic  glands  must  be  cleared  up. 
In  both  small  triangular  gaps  may  be  left  at  the  outer  ends  of  the  incision. 
These  are  closed  by  skin-grafts.  While  in  the  second  method  it  is  easier 
to  provide  sufficient  mucous  membrane  for  completing  the  new  lip,  the 
first  method  given  is  preferable.  It  avoids  the  scars  on  the  face,  the 
damage  to  the  lower  branches  of  the  facial  nerve,  and  by  it,  it  is  easier 
to  keep  the  facial  artery  intact. 

Regnier's  Operation.     Here  the  incisions  are  fewer  and  the  scarring 
is  less,  as  a  large  flap,  having  its  nourishment  from  either  sids;  is  under- 


496  OPERATIONS  ON  THE  HEAD  AND  NECK 

mined  and  glided  up  over  the  chin  from  below.  The  epithelioma  is 
removed,  with  the  greater  part  of  the  lower  lip,  by  an  incision  curving 
downwards  somewhat  from  one  angle  of  the  mouth  to  the  other,  nearly 
to  the  chin.  All  bleeding  having  been  arrested,  the  cut  edge  of  mucous 
membrane  where  it  passes  at  its  reflection  on  to  the  mandible  is  freed  and 
stitched  carefully  to  the  skin  to  form  the  edge  of  the  new  lip.  A  free 
incision  about  five  inches  long  is  made  from  side  to  side  in  the  neck,  with 
its  centre  at  a  point  three  or  three  and  a  half  inches  below  the  middle 
of  the  wound  by  which  the  lip  has  been  removed.  The  tissues  between 
the  two  incisions  above  and  below  the  chin  are  now  undermined  and  the 
broad  strap-like  flap  with  its  double  pedicle,  one  on  either  side,  is  glided 
upwards  over  the  chin  to  keep  it  in  position  ;  its  lower  margin,  that  which 
corresponded  to  the  second  incision,  is  sutured  with  sterilised  catgut  to 
the  periosteum  over  the  lower  margin  of  the  mandible.  When  the  flap 
has  been  thus  raised  a  gap  is  left  in  the  submental  region  which  will,  in  part 
at  least,  require  skin-grafting  (p.  42). 

The  advantages  of  this  operation  have  been  mentioned  above.  On 
the  other  hand,  where  the  chin  is  prominent  it  is  not  an  easy  matter  to 
undermine  thoroughly  the  tissues  which  form  the  broad  collar-like  flap 
so  as  to  free  them  sufficiently,  at  the  same  time  using  the  knife  on  a  uniform 
plane  without  any  scoring.  Further,  in  cases  where  the  glands  required 
removal,  the  submental  and  submaxillary  regions  are  not  opened  up  as 
conveniently  as  by  the  other  methods. 

In  some  cases  where  the  gap  is  very  extensive,  where  the  patient  is 
young,  and  where  it  is  especially  desirable  to  avoid  scars,  it  may  be 
preferable  to  resort  to  the  skin  of  the  arm  for  the  flaps  required.  Figs. 
204  to  206  illustate  an  excellent  result  obtained  with  this  method  by 
Dr.  S.  Watts  of  the  John  Hopkins  Hospital.^ 

A  boy  aged  15  was  admitted  July  6,  1904,  having  had  his  lower  lip,  including 
the  periosteum  of  the  mandible  in  places,  bitten  off  two  days  before  by  a  circus 
pony  (Fig.  204).  The  wound  was  clean  and  free  from  infection.  A  flap,  including 
skin  and  fat,  12  cm.  wide  and  18  cm.  long,  was  dissected  up  from  the  right  upper 
arm  (Fig.  205).  Its  under-surface  and  the  raw  surface  of  the  arm  from  which  it  was 
taken  were  covered  with  grafts  from  the  thighs.  All  these  took  well,  and  in  ten 
days  the  flap  was  covered  with  skin  on  both  sides.  Some  of  the  skin  on  this  under- 
surface  was  intended  to  form  a  substitute  for  mucous  membrane,  and,  to  some 
extent,  prevent  contraction.  Severe  bronchitis  delayed  further  operative  pro- 
ceedings for  more  than  a  month.  Diu-ing  this  delay,  the  flap,  which  had  become 
much  shortened  by  the  sloughing  of  its  distal  extremity,  contracted  greatly.  On 
August  18  the  flap,  dissected  up  somewhat  further,  in  order  to  lengthen  it  as  much 
as  possible,  was  sutured  by  its  free  extremity  to  the  left  side  of  the  wound  in  the  lip. 
A  small  portion  of  the  vermilion  border,  which  had  been  preserved  on  this  side,  was 
sutm-ed  along  the  upper  edge  of  the  flap.  The  arm  was  held  in  place  by  a  plaster 
case  for  about  tlu-ee  weeks.  The  flap  was  then  severed  from  the  arm.  This  was 
done  under  local  antesthesia  in  several  stages,  to  allow  the  circulation  to  become 
more  perfectly  established.  At  two  subsequent  operations,  at  intervals  of  two  or 
three  weeks,  the  lower  and  right  borders  of  the  flap  were  trimmed  and  sutm-ed  in 
position.     The  admirable  final  result  is  shown  in  Fig.  206. 

Replacement  of  Lip.  Reference  may  here  be  made  to  those  cases 
occasionally  met  with  in  children  where,  after  burns  about  the  upper  neck 
the  lower  lip  and  chin  are  tied  downwards  by  scar  tissue.  This  is  another 
of  those  instances  where,  from  the  site  of  the  area  to  be  operated  upon 
and  the  age  of  the  patient,  a  resort  to  the  skin  of  the  arm  for  one  of  the 
flaps  required  is  indicated. 

^  Ann.  o/(S«rgr.,'' January  1905,  p.  118. 


RESTORATION  OF  LIPS 


497 


kiPH 

^^ 

jr^^^^B 

^^^^'^^^H 
% 

1 

1 

1 

Fig.  204. 


Fig.  205, 


SURGEKY  I 


32 


498 


OPERATIONS  ON  THE  HEAD  AND  NECK 


The  following  case,  under  the  care  of  Mi'.  W.  H.  Brown,  of  Leeds,^  indicates 
the  steps  that  may  be  resorted  to.  The  paper  is  accomjianied  by  photographs 
which  show  the  admirable  result  achieved.  The  child  was  aged  11.  To  stop  the 
dribbling  from  the  mouth,  a  cut  was  made  across  the  throat  from  angle  of  jaw  to 
angle,  and  the  head  pushed  up  into  the  erect  position.  To  close  the  wound,  about 
three  inches  wide,  which  resulted,  two  flaps  were  taken  from  the  shoulders  and 
turned  inwards  to  meet  beneath  the  point  of  the  chin.  The  result  of  this  operation 
was  to  rid  the  patient  of  all  di'ibbling.  To  remedy  the  eversion  of  the  lip,  "  as 
there  was  no  available  skin  on  the  neck  which  seemed  likely  to  be  of  use,  a  straight 
incision  was  made  just  below  the  red  border,  a  stitch  put  through  the  red  border, 
and  the  lip  drawn  up  into  a  natiu-al  position.  The  right  arm  was  then  l)rought 
across  the  face  and  fixed  so  as  to  allow  of  an  ample  flap  being  raised  from  over  the 


Fig.  206. 


middle  of  the  arm,  and  then  laid  into  the  space  below  the  lip.  This  flap  was  left 
attached  to  the  arm  and  stitched  with  silk  sutures  into  its  new  position.  A  fortnight 
later  the  arm  was  set  free  from  the  face,  and  the  flap  was  found  to  be  living  and 
healthy.  The  freed  edge  was  stitched  down  level  and  the  skin  cut."  The  following 
practical  points  in  the  after-treatment  of  such  cases  are  emphasised.  "  One  is  to 
keep  the  child  quiet  by  means  of  small  doses  of  opium  for  the  first  four  or  five  days, 
increasing  the  dose  about  half  an  hour  before  the  first  di-essing.  When  possible, 
it  is  best  to  change  the  dressing  for  the  first  time  under  an  anaesthetic.  Difficulty 
of  feeding  was  in  this  case  got  over  by  means  of  a  tube  and  funnel.  She  had  all  her 
nourishment  for  a  fortnight  by  this  method.  Absolute  fixation  of  the  head  was 
secured  by  using  large  sand-bags  on  either  side  of  the  head  with  a  strong  brow  band 
across  the  forehead." 

Restoration  of  Mouth.  This  is  sometimes  required  when  extreme 
narrowing  follows  on  an  operation  for  removal  of  the  lower  Hp,  in  which 
the  surgeon  has  been  compelled  to  trench  upon  the  upper,  or  on  cica- 
tricial healing  of  ulceration  due  to  burns,  lupus,  noma,   &c. 

In  cases  where  the  margin  of  the  lip  is  diseased  in  its  whole  extent, 
1  Brit.  Med,  Jovrn,,  January  7,  1905,  p.  20, 


UESTOHATION  OF  LIPS 


499 


and  wluM'e,  after  removal  of  the  disease,  the  mouth  may  become  too  small, 
a  part  of  the  red  mar<i;iii  of  the  upper  lip  may  be  utilised  iu  the  restoration 
of  the  orifice  of  the  mouth  (Fi<ij.  207).  Sufficient  of  the  vermilion  border 
is  detached  fioni  the  u|)per  lij)  to  allow  of  the  strip  thus  made  loose  being 


A.  B. 

Fin.  207.     Utilisation  of  red  margin  of  upper  lip  for  the  restoration    of    the 
orifice  of  the  mouth.     (Esmarch  and  Kowalzig.) 

drawn  around  the  orifice  of  the  mouth  and  forming  an  edge  for  the  lower 
lip  without  tension. 

In  other  instances  the  Method  of  Dieffenbach  may  be  employed  in 
these  cases  (Figs.  208). 

This  surgeon,  so  famous  for  his  plastic  skill,  proceeded  somewhat  thus  : 
Two  lateral  incisions  are  carried  from  the  opening  of  the  mouth  through 
the  whole  thickness  of  the  cheek,  sufficiently  far  to  ensure  the  new  mouth 
being  of  proper  size.  After  this  the  mucous  membrane  is  sufficiently 
detached  (a  matter  often  difficult  to  secure  without  causing  subsequent 


A.  B. 

Fig.  208.     Dieffenbach's  method  of  restoring  the  size  of  a  contracted  mouth. 
(Esmarch  and  Kowalzig.) 

sloughing,  owing  to  the  cicatricial  condition  of  the  parts)  from  the  skin 
to  allow  of  its  being  stitched  as  an  edging  all  round  the  opening  of  the 
new  mouth.  Very  sharp  knives  are  especially  needed  here.  The  surgeons 
must  particularly  aim  at  securing  that  the  skin  and  mucous  membrane 
meet  exactly  at  the  angles  of  the  new  mouth,  for  if  primary  union  of  the 
skin  and  mucous  membrane  be  not  secured  here,  recontraction  of  the 
new  opening  will  certainly  follow.  In  some  cases,  instead  of  dividing 
the  whole  thickness  of  the  cheeks  by  lateral  incisions,  it  is  better  to  dissect 
off  thick  triangular  flaps  of  skin  and  subcutaneous  tissue  with  their  bases 
placed  outwards  on  the  cheeks.  The  scar  tissue  is  next  freely  divided 
80  as  sufficiently  to  enlarge  the  mouth.    The  flaps  are  then  turned 


500 


OPERATIONS  ON  THE  HEAD  AND  NECK 


inwards  and  sutured  to  the  mucous  membrane  so  as  to  form  satisfactory 
new  angles,  and  prevent  any  recontraction. 

To  prevent  recontraction  Huter  has  advised  the  wearing  of  a  dilator 
made  of  ebony  or  hard  india-rubber,  of  the  shape  of  a  funnel,  with  two 
rims  to  maintain  it  in  place. 

Upper  Lip.  (i)  Operation  of  Sedillot  hy  Vertical  Flaps  (Fig.  209).  Flaps 
quadi'angular  in  shape  are  raised  by  the  following  incisions  :  (1)  the  internal  one, 
starting  from  a  point  midway  between  the  angle  of  the  mouth  and  the  lower  eyelid, 
and  ending  usually  at  a  point  on  a  level  with  the  i^rominence  of  the  chin  ;  (2)  a 
horizontal  one  passing  outwards  from  the  lower  end  of  the  first  for  half  an  inch  to 
two  inches  ;  and  (3)  a  second  vertical  incision  passing  upwards  from  the  outer 
end  of  the  horizontal  one  to  a  j^oint  on  a  level  with  the  ala  of  the  nose.  These 
flaps,  comprising  the  whole  thickness  of  the  cheeks,  are  moved  inwards  so  that 
their  lower  extremities  meet  vertically  in  the  middle  line. 

(ii)  Operation  of  Dieffenbach  and  Chauvel  by  Vertical  Flaps.  Here  the  flaps 
are  cut  in  the  reverse  direction  from  that  of  Sedillot.     This  method  is  to  be  preferred 


\ 


n 


ni 


Fig.  209.     The  dotted  lines  show  the 

operation  of  Sedillot,  the  continuous 

ones  that  of  Dieffenbach,  for  making  a 

new  upper  lip.     (After  Serre.) 


Fig.  210.     Restoration  of  one   angle 
of  the  mouth.     (After  Serre.) 


as,  owing  to  the  base  being  below,  there  is  less  tendency  for  the  new  lip  to  be  raised 
by  the  contraction  of  the  scar,  and  thus  to  expose  the  upper  teeth  (Fig.  209). 

(iii)  Operation  by  Lateral  Flaps.  Here  the  flaps  are  taken  laterally  from  the 
cheeks.  They  should  be  cut  of  the  full  depth  of  the  new  lip,  and  at  their  outer 
extremities  should  curve  downwards  so  as  to  diminish  the  tension.^ 

(iv)  Serre's  Operation  for  Restoring  One  Angle  of  the  Mouth.  Fig.  210  shows 
the  steps  which  would  be  adapted  for  restoring  one  angle  of  the  mouth,  which  has 
been  distorted  by  a  cicatricial  contraction  ;  a  similar  proceeding  being  available 
for  a  growth  in  this  situation. 

Restoration  of  Defects  on  the  Cheeks  (Figs.  211-213).  While 
surgical  interference  is  less  frequently  called  for  here  than  for  restoration 
of  the  lip,  greater  difficulties  are  present.  The  chief  of  these  are  the  less 
mobile  condition  of  the  part,  the  vicinity  of  the  facial  nerve  and  parotid 
duct,  and  in  many  cases  the  fact  that  morbid  conditions  causing  cicatricial 
contraction  and  fixity  are  often  met  with  here.  The  widely  different 
nature  of  the  operative  steps  required  now  will  be  seen  when  the  chief 
indications  for  restoration  of  the  cheek  are  considered,  viz.  those  arising 
after  removal  of  such  growths  as  epithelioma,  and  such  cases  as  those 
after  gunshot  injury  or  cancrum  oris.  In  these  two  last  not  only  is  there 
the  deficiency  to  remedy,  but  this  is  probably  hide-bound  at  its  periphery, 
and  a  varying  degree  of  ankylosis  of  the  jaw  is  often  present  as  well. 

Fortunately  these  cases  are  uncommon.  Space  will  only  permit 
mention  of  two  classes  of  cases.     (A)  Where  there  is  a  large  gap  and 

^  Dr.  Port,  of  New  York,  who  figures  this  operation  and  numerous  other  methods 
from  Szymanowski  {Handb.  d.  Chir.  Med..  Braunschweig,  1870),  lays  stress  upon  this 
precaution  {Inter.  Encyc.  Surg.,  vol.  i,  p.  489). 


RESTORATION  OF  CHEEK 


501 


little  or  nothing  to  bo  got  from  the  cheek.     Such  a  case  results  from 
extensive  removal  of  an  epithelioma  of  the  buccal  nmcous  membrane.  It  is 


Fig.  211.     One  method  of  closing  a  gap  in  the  cheek  by  a  gap  from  the  neck. 

useless  in  these  cases  to  slit  the  cheek  and  then  dissect  out  the  epithelioma, 
leaving  the  sldn.  Reappearance  of  the  disease  is  certain.  If  any  operation 
is  undertaken  the  whole  thickness  of  the  cheek  must  be  widely  removed. 


Fig.  212.  Israel's  method  of  closing  a  gap  in  the  cheek  by  a  flap  taken  from  the 
neck  :  this  flap  may  have  to  reach  almost  to  the  clavicle.  The  flap  is  reversed, 
and  its  outer  surface  skin-grafted  or  covered  in  by  a  second  flaj^.     (Esmarch  and 

Kowalzig. ) 

The  prognosis  is  always  grave,  and  the  gravity  increases  with  the  difficul- 
ties of  the  operation  the  farther  back  the  mucous  membrane  is  involved. 
The  surgeon  who  has  to  fill  a  large  ^  gap  in  the  cheek  where  the  only 
^  \\'here  the  gap  is  a  moderate  one  but  too  large  to  admit  of  being  closed    by  under- 


502 


OPERATIONS  ON  THE  HEAD  AND  NECK 


skin  left  is  that  fixed  above  to  the  malar  bone  and  infra-orbital  region  and 
below  to  the  mandible,  can  take  his  flap  from  the  forehead  or  neck.  The 
former  skin  has  the  advantage  of  being  hairless,  but  the  resulting  deformity 
is  greater.  The  pedicle  of  the  flap  lies  here  above  the  root  of  the  nose  or 
the  zygoma.  1  If  the  flap  is  taken  from  the  neck  (Figs.  211-213),  the 
scarring  is  much  less,  but  the  vascularity  is  not  so  good,  and  if  the  flap 
contain  hairs  it  must  either  not  be  inverted,  as  hairs  will  continue  to  grow 
into  the  mouth  indefinitely,  or,  if  this  is  necessary,  the  pedicle  must  start 
well  below  the  jaw  so  that  the  flap,  which  will  have  to  extend  nearly  to  the 
clavicle,  is  hairless.     A  considerable  area  will  thus  have  to  be  "  jumped  " 

when  the  flap  is  sutured  in  position.  At 
a  later  stage  the  pedicle  must  be  divided 
and  the  flap  trinnned  and  fitted  into  its 
place.  The  use  of  double  flaps  is  not 
recommended,  owing  to  the  great  inter- 
ference with  soft  parts  which  is  entailed 
in  patients  whose  vitality  is  often  by  no 
means  good,  and  who  are  not  well 
adapted  for  prolonged  anesthesia.  The 
surface  of  the  inverted  flap  should  be 
grafted  by  Thiersch's  method  at  the 
time.  The  wound  in  the  neck  will  be 
mainly  closed  after  the  edges  are  under- 
mined, the  rest  being  effected  by  skin- 
grafting.  As  in  the  case  of  the  lower 
lip,  the  question  of  taking  the  flap 
from  the  arm  in  suitable  cases  (p.  498) 
must  be  considered. 

(B)  In  cases  where  the  chief  con- 
dition calling  for  repair  is  not  so  much 
a  deficiency  of  skin  as  cicatricial  con- 
traction of  the  mucous  membrane  and 
fixity  of  the  jaw,  Gussenbauer's  method 
in  two  stages  should  be  employed.  All 
cicatricial  tissue  having  been  removed 
and  divided  and  the  mouth  opened  as  far  as  possible,  a  flap  of  skin  and 
subcutaneous  tissue  with  its  base  situated  over  the  masseter,  or,  if  needful, 
still  far  back  in  front  of  the  lobule,  is  dissected  up  between  this  muscle  and 
the  gap.  It  is  then  turned  into  the  mouth  round  the  anterior  edge  of  the 
masseter  and  sutured  to  the  mucous  membrane  over  the  internal  pterygoid 
with  sterilised  catgut  on  fine  curved  needles.  In  about  four  weeks,  when 
the  vascularity  of  the  flap  around  its  edges  is  assured,  the  base  and  j)osterior 
part  of  the  flap  are  dissected  up  and  turned  forwards  into  the  remaining 
part  of  the  gap  to  form  a  new  angle.  It  is  then  grafted  or  covered  with  a 
second  flap  taken  from  below  the  mandible.     The  objections  to  double 

mining  and  gliding  the  edges  of  the  tissues  left,  a  flap  may  sometimes  be  taken  from  the 
masseteric  region  with  its  base  near  the  gap.  The  flap  is  turned  forwards  so  that  its 
skin  surface  looks  into  the  mouth,  the  raw  surface  being  grafted.  This  is  only  applicable 
to  cases  where  the  skin  is  without  hairs.  Care  must  be  taken  not  to  injure  the  parotid 
gland  and  duct,  and  as  far  as  possible,  the  branches  of  the  facial  nerve. 

1  Senn,  in  a  case  in  which  the  entire  cheek  had  been  removed  for  epithelioma,  turned 
down  a  frontal-parietal  flap — the  patient  was  the  subject  of  extensive  alopecia — so  that 
the  skin  svirface  replaced  the  mucous  membrane.  A  flap  from  the  neck  and  an  additional 
one  from  the  scalp  covered  the  raw  surface  and  maintained  the  blood-supply  (Ann.  of 
Surg.,  October  1904,  p.  (JOl). 


Fig.  213.  To  show,  diagrammati- 
eally,  one  method  of  closing  a  defect 
in  the  cheek.  A,  Area  involving  entire 
thickness  of  cheek  excised.  B,  Flap 
carried  up  from  the  neck  and  inverted 
so  that  its  cutaneous  surface  replaced 
the  mucous  membrane  of  the  cheek. 
It  was  sutured  to  the  gum  above  and 
))elow  and  adhered  readily.  C,  Flajj 
glided  u)>  from  the  neck  to  cover  the 
raw  suriface  of  B.  D,  Flap  glided 
-downwards  for  the  same  purpose. 
(Haynes.) 


RESTOKATION  OF  CIIEKIv 


508 


flaps  ill  those  cases  liave  been  mentioned  above.  The  same  assidiujus 
attention  will  be  required  as  in  other  cases  of  fixity  of  the  jaws  (p.  442), 
and  P]smarch's  modified  operation  (p.  441)  may  be  required. 

In  extensive  gaps  in  cliiUlrcn,  where  the  confined  position  is  better 
borne,  the  flap  may  be  taken  from  the  inner  side  of  the  arm,  the  parts 


Fig.  214. 


Fig.  216. 

being  secured  by  plaster  of  Paris  (p.  497).  In  those  very  rare  cases 
where,  after  injury  or  sloughing,  the  nose,  upper  lip,  lower  lids  and  cheeks 
have  disappeared,  a  paper  by  Senn  ^  may  be  consulted.  Here  a  huge 
flap  was  taken  from  the  scalp.  The  operative  procedure  was  divided 
into  about  ten  stages. 

Defects  of  the  EyeUds.     Figs.  214,  215  show  different  methods  of  curing 
that  troublesome  condition  known  as  ectropion.     Fig.  216  explains  how 
a  growth  around  the  inner  canthus  may  be  removed  without  deformity. 
1  New  York  Med.  Journ.,  June  20,  1903. 


CHAPTER  XXIV 

OPERATIONS  ON  THE  PALATE 

OPERATIONS  FOR  CLEFT  PALATE.     REMOVAL  OF 
GROWTHS  FROM  THE  PALATE 

OPERATIONS  FOR  CLEFT  PALATE 

(])  Varieties.  The  extent  of  the  cleft  may  vary  immensely.  Every 
intermediate  stage  may  be  found  between  a  bifid  uvula  and  a  complete 
cleft  of  both  the  hard  and  the  soft  palate  associated  with  a  single  or 
double  hare-lip.  A  cleft  of  the  hard  palate  without  any  cleft  of  the  soft 
palate  is  rare.  The  cleft  may  be  narrow  or  so  wide  that  the  palatal 
processes  appear  to  have  developed  but  slightly.  The  nasal  septum  may 
end  freely  below  or  be  attached  to  the  palate  at  one  side  of  the  cleft.  The 
results  of  the  deformity  are  the  well-known,  nasal,  indistinct  speech, 
difficulty  in  swallowing,  and  regurgitation  of  food  through  the  nose. 
With  a  complete  cleft  of  the  palate  and  lip  an  infant  is  unable  to  take  the 
breast,^  a  difficulty  which,  however,  can  usually  be  overcome  by  perse- 
vering care  and  attention.  With  regard  to  the  voice  it  may  at  once  be 
stated  that,  even  when  the  cleft  is  neatly  closed,  the  operation  is  often 
most  disappointing  as  regards  speech.  This  is  due  to  the  fact  that  the 
repaired  soft  palate  has  lost  much  of  its  mobility  and  hence  cannot 
shut  off  the  naso-pharynx  from  the  buccal  cavity.  Much  depends  upon 
systematic  training  in  improving  the  speech,  which  essential  part  of  the 
after-treatment  cannot  well  be  undertaken  before  the  fifth  year. 

(2)Age  of  the  patient.^  The  best  age  for  the  operation  is  still  a  matter 
of  controversy.  Until  some  fifteen  years  ago  practically  all  surgeons  were 
agreed  that  the  best  time  for  the  operation  was  about  the  beginning  of  the 
third  year.  About  that  date  Sir  W.  Arbuthnot  Lane  advocated  operation 
in  extreme  infancy  and  many  surgeons  have  now  adopted  his  views.  Thus 
Sir  W.  A.  Lane  ^  writes  :  "  The  best  time  is  the  day  after  birth,  or  as  soon 

^  Cases  are  very  rare  in  which  sufficient  food  cannot  be  given  by  one  of  the  following 
methods  (especially  after  any  coexisting  hare-lip  has  been  closed),  if  only  they  are  per- 
severingly  tried,  viz.  a  small  spoon  passed  well  into  the  back  of  the  mouth  ;  a  feeding- 
bottle  with  a  teat  big  enough  to  fill  the  gap,  the  teat  being  perforated  underneath  for  the 
escape  of  the  milk,  only  a  little  being  given  at  a  time  ;  an  ordinary  feeding-bottle  with 
a  leaf-like  piece  of  india-rubber  attached  above  the  teat,  so  as  to  fill  up  the  gap.  It  is  often 
advisable  to  take  these  cases  into  hospital  or  a  home  and  put  them  under  the  care  of  a 
specially  trained  nurse.  The  nutrition  is  usually  at  once  improved,  and  the  mother  can 
be  taught  to  maintain  the  improvement  until  the  child  is  about  two  years  old. 

^  The  reader  should  certainly  refer  to  a  discussion  before  the  Surgical  Section  of  the 
Royal  Society  of  Medicine,  opened  by  Sir  W.  Arbuthnot  Lane  {see  Proc.  Boy.  Soc.  Med., 
June  1911).  The  arguments  for  and  against  early  operation  will  here  be  found  fully  dis- 
cussed as  well  as  many  interesting  points  about  the  actual  operations  and  their  results.  A 
jiaperbyMr.  r.  W.  Goyder  {Biit.Joitrn.  Su>g.,\o].  i.  p.  259  may  also  be  consulted.  Here 
the  advantages  and  disadvantages  of  the  flap  opei  ation  and  I.angenbeck's  operation,  and  of 
the  early  and  late  operations  are  carefully  and  impaTtiallv  discussed. 

3  Cleft  Palate  and  Hare-lip,  1905,  p.  42. 

504 


CLEFT  TALATE  rA):^ 

alter  that  as  possible/'  Again  when  opening  the  discussion  on  this 
subject  before  the  surgical  section  of  the  Royal  Society  of  Medicine  {see 
footnote),  "  The  earliest  I  have  done  has  been  within  seven  hours  of 
birth.  .  .  .  Putting  the  matter  as  briefly  as  possible,  early  operation 
saves  a  large  number  of  lives  which  would  otherwise  be  lost.  Many  of  the 
clefts  present  in  those  cases  can  only  be  closed  before  the  gums  are  en- 
croached on  by  the  teeth.  The  sooner  the  nose  is  separated  ofE  from  the 
mouth  the  earlier  the  naso-pharynx  is  exposed  to  the  influence  of  the 
mechanical  factors  which  normally  determine  the  developments  of  this 
passage,  and  of  the  structures  which  surround  it."  The  following  are, 
on  the  other  hand,  the  opinions  of  other  surgeons  who  have  had  large 
experience  of  operating  for  this  deformity.  The  late  Mr.  J.  N.  Davies 
Colley  ^  stated  that  when  he  had  the  opportunity  of  choosing  the  age  he 
preferred  fourteen  months.  Mr.  E.  Owen  ^  gave  his  opinion  that  "  For 
a  soft  palate,  the  child  being  in  good  health,  the  time  for  operating  is 
somewhere  in  the  first  six  months,  I  think.  For  a  hard  and  soft  palate 
together  it  is,  I  think,  in  the  second  year."  Mr.  G.  A.  Wright,  of  Man- 
chester, states  :  ^  "  We  are  not  inclined  to  attempt  closure  of  a  severe 
case  of  cleft  of  both  hard  and  soft  palates  earlier  than  the  third  year  at 
soonest."  Mr.  R.  W.  Murray,  of  Liverpool,  prefers,  as  a  general  rule,  to 
postpone  operating  upon  the  palate  until  the  child  is  between  two  and 
three  years  of  age,  and  then  at  one  operation  to  completely  close  the 
cleft."  ^  American  surgeons  whose  eagerness  to  make  trial  of  new 
methods  is  well  known,  are  not,  as  a  rule,  in  favour  of  very  early  operations, 
preferring  the  age  of  three  or  four  years  or  later.^  Finally  the  opinion  of 
Mr.  James  Berry  in  the  above-mentioned  discussion  may  be  quoted  : 
"  The  period  of  choice  for  the  operation  he  regarded  as  about  two  years 
ef  age,  though  there  were  many  cases  with  narrow  clefts  which  could 
be  advantageously  operated  upon  earlier,  some  even  in  the  first  year  of 
life.  It  was  impossible  to  mention  any  age  that  was  suitable  for  all 
cleft  palate  operations  ;  but  the  difficult  ones  should  be  done  at  about 
two  years  of  age."  The  question  of  the  best  age  for  the  operation  is 
rendered  more  difficult  owing  to  the  fact  that  the  operation  which 
admittedly  gives  the  best  results  at  the  age  of  two  or  three  years  (Langen- 
beck's  operation)  is  unsuitable,  owing  to  the  width  of  the  cleft,  in  infants, 
in  whom  some  form  of  flap  operation  is  necessary. 

The  arguments  in  favour  of  the  very  early  operation  are  : 

(1)  That  a  considerable  proportion  of  the  infants  born  with  a  cleft 
palate  die  before  reaching  the  age  of  two  years,  chiefly  owing  to  difficulties 
connected  with  nutrition.  Surgeons  who  do  not  operate  until  two  or 
three  years  thus  do  not  operate  on  the  worst  cases.  On  these  grounds 
the  early  operation  is  claimed  to  be  a  life-saving  one. 

(2)  That  in  many  cases,'  where  the  cleft  is  very  wide,  an  early  flap 
operation  affords  the  only  means  of  closing  the  cleft. 

(3)  That  an  early  operation  is  of  importance  in  the  development  of  the 
nose,  naso-pharynx,  and  surrounding  structures. 

Of  these  arguments  the  first  is  by  far  the  most  important.  The  advo- 
cates of  the  late  operation,  however,  deny  that  difficulty  in  nutrition 

1  Tmns.  Med.  Soc,  vol.  xlx,  p.  70.  1806.  ~  Ibid.,  p.  68. 

^  Af-hby  and  Wright's  Diseases  of  Children,  p.  171. 
*  Brit.^Med.  Journ.,  vol.  i.  1906,  p.  24.1. 

5  Trans.  Phil.  Acad,  of  Sitr(j..  February  1,  1904  ;  Ann.  of  Surg.,  June  1904.  p.  1029  ; 
Trans.  New  York  Surg.  Soc,  October  25,  1905  ;  Ann.  Stirg.,  January  1906,  p.  136. 


506  OPERATIONS  ON  THE  HEAD  AND  NECK 

is  a  frequent  cause  of  death.  Thus  Mr.  Berry  ^  says,  "  With  regard  to  the 
question  of  the  early  flap  operation  being  a  '  life-saving  '  one,  that  was 
a  very  difficult  matter  to  settle  without  very  careful  statistics,  which 
hitherto  had  never  been  produced.  His  strong  belief  was  that  the  early 
operation  was  the  very  reverse  of  life-saving.  When  he  saw  a  young  child 
with  a  very  wide  cleft  palate  and  much  emaciated,  he  usually  instructed 
the  nurse  or  mother  to  feed  it  carefully  and  properly  until  it  was  better 
nourished,  and  then  he  operated  upon  it  at  his  own  time.  If  those 
children  were  nursed  properly  he  did  not  find  that  many  of  them  died. 
He  would  be  glad  to  havefromthose  who  advocated  very  early  operation 
some  definite  statistics  as  to  how  many  they  had  done,  and  how  many  of 
the  children  were  alive,  not  when  they  left  the  hospital,  but  say  one  year 
afterwards."  Some  statistics  produced  by  Mr.  C.  H.  Fagge,  who  spoke  in 
favour  of  the  early  operation,  appear  to  support  Mr.  Berry's  point.  Mr. 
Fagge  had  operated  on  thirty-eight  infants  mider  one  year  of  age.  "  One 
of  the  thirty-eight  died  during  the  palate  operation,  and  two  died  in  the 
hospital,  but  the  remote  mortality  was  much  more  alarming,  for  an  effort 
to  trace  these  patients  by  correspondence  for  this  meetiiig  showed  that 
fourteen  others  had  died  from  various  causes,  of  which  six  were  directly  or 
indirectly  due  to  subsequent  operations  for  hare-lip." 

The  question  of  the  width  of  the  cleft  is  discussed  below,  and  the 
possible  causes  of  a  fatal  resillt  on  p.  527. 

As  is  the  case  in  many  such  controversies  the  truth  is  probably  inter- 
mediate between  the  two  extreme  views.  It  may  be  granted  that  a  narrow 
incomplete  cleft,  involving  the  soft  palate  alone,  should  be  closed  during 
infancy.  When  the  cleft  is  very  wide  or  is  complete,  the  best  result  will 
probably  be  obtained  by  postponing  the  operation  mitil  the  completion 
of  the  first  dentition,  i.e.  about  two  years.  Should,  however,  a  thorough 
trial  of  the  methods  of  feeding  mentioned  in  the  footnote  on  p.  504  not 
be  successful,  even  after  closure  of  the  hare-lip,  then  the  cleft  in  the 
palate  should  certainly  be  operated  upon.  Careful  observation  by  the 
surgeon,  and  unremitting  attention  and  care  by  the  mother  or  nurse, 
are  essential  in  all  cases  of  cleft  palate. 

(3)  Order  of  Operation  on  Lip  and  Palate.  Another  question  that 
has  been  raised  with  regard  to  operations  on  cases  of  cleft  plate  in  infants 
is  whether  the  cleft  palate  or  the  hare-hp,  which  usually  complicates  the 
cases,  should  be  taken  in  hand  first.  Sir  W.  Arbuthnot  Lane  and  the 
other  advocates  of  the  early  operation  on  the  palate  either  complete  both 
operations  under  the  same  anaesthesia,  or  leave  the  hare-lip  until  the  cleft 
palate  is  closed.  An  important  argument  in  favour  of  this  procedure  is, 
that  the  gap  in  the  lip  facilitates  the  operation  for  closing  the  cleft  in 
the  palate.  If,  on  the  other  hand,  it  is  decided  not  to  operate  on  the 
palate  until  the  child  is  two  or  three  years  old,  the  operation  on  the  lip 
should  take  place  at  about  the  age  of  two  months.  If  the  operation  on 
the  palate  is  postponed  for  two  years  the  cleft  narrows  considerably,- 
especially  if  the  hare-lip  is  operated  upon  in  infancy.  These  facts  are 
used  as  arguments  in  favour  of  the  early  and  late  operations  respectively. 

(4)  Severity  of  the  Case  and  Kind  of  Patient.  It  is  not  so  much  the 
extent  of  the  fissure — whether  the  soft  is  alone  affected,  partially  or 
completely,  whether  that  common  form  in  which  the  cleft  involves  the 

^  Loc.  siiprn  cit 

^  Incomplete  clefts,  i.e.  those  involving  the  soft  palate  and,  say,  the  posterior  two- 
thirds  of  the  hard,  do  not  show  this  spontaneous  narrowing  to  such  an  extent  as  complete 
clefts,  i.e.  those  in  which  the  alveolar  process  is  involved. 


CLEFT  PALATE  507 

soft  and  a  portion  of  tlie  hard  is  })resent,  or  whether  the  whole  pahite  is 
spht — that  is  of  importance,  as  the  width  of  the  cleft  and  the  thickness 
of  the  tissues  which  hound  it.  Sir  W.  Fergusson  was  the  first  who  pointed 
out  the  influence  which  the  heiglit  of  the  vault  of  the  hard  palate  has 
upon  an  o})eration  for  closing  a  cleft  of  it.  He  showed  that  the  hif^her 
the  vault  the  more  easy  is  it  to  dissect  down  flaps  of  nnico-periosteum  ; 
while,  on  the  other  hand,  the  less  arched  the  vault,  the  greater  is  the 
difficulty  in  getting  sufficient  flaps.  Other  points  of  importance  are  the 
size  of  the  mouth,  a  very  narrow  or  small  one  interfering  with  the  use 
of  the  needful  instruments  ;  and,  finally  (a  point  always  to  be  noted),  the 
length  of  the  i)alate,  for  the  shorter  this  is,  the  more  impossible  will  it  be 
for  this  to  touch  the  pharynx  later  on,  however  perfectly  it  has  been  united, 
and  the  more  marked,  consequently,  will  be  the  nasal  tone  of  the  voice. 

Other  points  of  importance,  but  not  connected  especially  with  the 
cleft,  are  those  which  bear  upon  the  general  health  of  the  patient — viz. 
fretfulness,  or  a  sunny  temper  ;  coexisting  ear  disease,  or  congenital 
syphilis  ;  whether  the  child  has  had  the  usual  illnesses  and  exanthemata 
■ — an  attack  of  whooping  cough,  scarlet  fever,  mumps,  or  measles  being 
likely  to  interfere  with  the  success  of  an  operation. 

(5)  Amount  to  be  Closed  at  one  Sitting.  It  is  now  universally  agreed, 
that  unless  there  are  circumstances  of  peculiar  difficulty  in  the  case,  the 
whole  cleft  should  be  closed  at  one  operation.  When,  however,  the 
bringing  together  of  the  whole  cleft  in  one  operation  would  necessitate  so 
free  a  division  of  the  soft  parts  as  to  endanger  the  vitality  of  the  flaps, 
it  is  advisable  to  close  first  that  part  of  the  cleft  that  can  be  most  easily 
approximated,  whether  it  be  the  hard  or  the  soft  palate.  Thus,  if  there 
has  been  much  difficulty  in  getting  the  edges  of  the  soft  palate  together, 
it  is  better  to  leave  the  anterior  part  of  the  hard  palate  to  be  closed  by  a 
subsequent  operation — which  can  always  be  done  if  the  posterior  part 
has  been  closed — rather  than  to  run  the  risk  of  spoiling  the  whole  opera- 
tion by  endangering  the  vitahty  of  the  flap.  It  is  far  better  to  make  at 
the  first  operation  a  good  soft  palate  than  a  good  hard  palate.  A  hole  in 
the  hard  palate  can  always  be  closed  unless  extensive  sloughing  has 
occurred.  It  may,  on  the  other  hand,  be  extremely  difficult  to  make 
a  good  and  efficient  soft  palate,  if  the  first  operation  has  been  followed 
by  a  faulty  union  of  this  part. 

(6)  Preliminary  Preparation.  The  child  should  be  in  the  best  of 
health.  It  is  best  to  keep  the  patient  for  some  days  in  the  home  or 
hospital  before  operating,  in  order  that  he  may  become  accustomed  to  the 
surroundings.  Adenoids  or  enlarged  tonsils  should  be  removed  several 
weeks  before,  any  muco-puruleut  nasal  discharge  as  thoroughly  dealt 
with  as  possible,  and  any  carious  teeth  must  be  attended  to  as  possible 
sources  of  infection,  and  to  ensure  stability  for  the  gag.  • 

Operation.  Langenbeck's  operation  for  a  cleft  involving  both  the 
soft  and  hard  palate  is  most  frequently  performed,  and  thus  will  be 
described  first. 

Langenbecks  Operation.  The  following  special  instruments  will 
be  required,  (a)  A  gag.  Smith's  gag  or  some  modification  of  it  is  very 
commonly  used.  It  has  the  disadvantage  that  the  tongue  plate  is  apt  to 
force  the  tongue  back  and  thus  embarrass  the  breathing.  Lane's  gag 
(Fig.  217)  is  simpler,  is  easily  adjusted  and  does  not  slip.  If  it  is  used  a 
stout  suture  should  be  put  through  the  anterior  part  of  the  tongue  so  that 
its  position  is  under  the  control  of  the  operator  and  the  anaesthetist. 


508  OPERATIONS  ON  THE  HEAD  AND  NECK 

(6)  Cleft  palate  knives,  both  double-edged  and  blunt-pointed,      (c)  Several 
cleft  palate  elevators  of  varying  curve  and  strength,      (d)  Long  dissecting 

forceps,  one   of   which  has  fine  tenaculum  or 
mouse-tooth   ends.       (e)    Durham's,    or    some 
similar  form  of  cleft  palate  needle,  one  curved  so 
77rilft\  .-"'      -'     ^^  ^^  P^^^  horn  left  to  right,  and  one  in  the  re- 

w/^^^^i:\  ;  '- '"  '  verse  direction  :  or  Lane's  small  needles  with 
his  most  ingenious  needle-holder  may  be  used. 
(/)  Sutures  of  silkworm-gut,  gossamer-gut,  and 
horsehair.  Wire  sutures  are  now  but  rarely 
employed. 

The  patient's  stomach  being  just  empty,  so 

that  he  shall  not  vomit  during  the  operation, 

nor  want  food  immediately  after,  he  is  placed 

on  a  suitable  operating  table  in  a   good  light. 

^''''  ^miate  T''  ''^''^*       Chloroform  or    the  C.E.  mixture   is  the  best 

*    "  anesthetic.     The  head  is  allowed  to  hang  over 

the  end  of  the  table  so  that  it  is  fully  extended  on  the  spine,  or  the  same 

\ 


Fig.  218.     Durham's  cleft  palate  needles. 

position  may  be  secured  by  a  sandbag  placed  beneath  the    shoulders. 
Two  points  require  attention  at  this  stage  :   (1)  The  gag  should  be  satis- 


CLKFT  PALATK 


509 


factorily  adjusted  once  for  all.  If  Smith's  gag  be  used  care  must  be  taken, 
in  fitting  the  tongue  piece,  that  tlie  base  of  the  tongue  is  not  janmied  over 
the  entrance  of  the  larynx.  (2)  J5efore  connnencing  the  operation  the 
surgeon  should  assure  himself  not  only  that  the  breathing  is  regular,  but 
also  that  the  patient  is  deeply  under  the  influence  of  the  anaesthetic, 
without  abolition  of  the  laryngeal  reflex.  If  this  point  be  secured,  without 
any  hurrying  at  this  stage,  the  subsequent  interruptions  for  the  adminis- 
tration of  further  anaesthetic  will  be  few  and  brief.  The  operation  may 
be  described  in  the  following  stages. 

A.  Raising  the  Muco-periosteum  (Fig.  219).  An  incision  is  made, 
on  one  side,  down  to  the  bone,  commencing  just  behind  and  internal  to  the 
last  molar  tooth,  and  is  carried  forwards, 
parallel  to  the  alveolar  arch,  for  a  dis- 
tance depending  upon  the  length  and 
width  of  the  cleft.  In  a  short  or  narrow 
cleft  the  incision  need  not  exceed  half 
or  three-quarters  of  an  inch,  but  with  a 
long  or  wide  cleft  it  may  be  necessary 
to  extend  it  as  far  forwards  as  the 
lateral  incisor.  Care  must  always  be 
taken  to  leave  a  sufficient  bridge  of 
tissue  in  front,  or  the  vitality  of  tli' 
flap  may  be  endangered.  Through  thi.s 
incision  an  elevator,  of  suitable  length 
and  curve,  is  introduced  between  the 
soft  parts  and  the  bone,  and  worked  in- 
wards until  the  extremity  appears  in  the 
cleft.  By  movements  from  without  in- 
wards and  from  before  backwards,  the 
muco-periosteum  is  separated  from  the 
"bone  for  the  whole  length  of  the  cleft ; 
every  possible  care  must  be  taken  to 

raise  the  soft  tissues  evenly  and  without  laceration  or  button-holing. 
The  chief  difficulty  will  be  met  with  at  the  anterior  end  of  the  bony 
cleft.  If  the  anterior  extremity  of  the  gap  reaches  as  far  as  a  point  just 
behind  the  incisions,  much  difficulty  may  be  met  with  in  separating  the 
muco-periosteum  here,  and  the  surgeon  will  do  well  to  be  provided  with 
several  elevators  of  different  curves.  Indeed,  it  may,  in  these  cases,  be 
better  to  leave  the  anterior  part  of  the  palate  to  be  closed  by  a  subsequent 
operation.  Again,  at  the  junction  of  the  hard  and  soft  palates,  the  soft 
parts  are  firmly  bound  down  to  the  former  by  fibrous  tissue.  They  may 
best  be  freed  by  a  pair  of  curved  scissors,  one  blade  being  placed  under 
the  muco-periosteum,  between  it  and  the  bone,  and  the  other  passed 
through  the  cleft,  above  the  soft  palate  into  the  naso-pharynx  ;  the  fibrous 
aponeurosis  is  thus  divided  close  to  the  bony  palate.  A  third  but  less 
important  spot  where  difficulty  may  be  experienced  is  the  attachment 
of  the  soft  parts  in  the  neighbourhood  of  the  hamular  process.  Here  a 
curved  elevator,  a  blunt-pointed,  narrow,  curved  knife,  or  curved  scissors 
■ — each  being  kept  close  to  the  bone — must  be  thoroughly  used.  The 
thorough  separation  of  the  soft  farts,  especially  at  the  jimction  of  the  hard 
and  soft  palate,  by  relieving  all  tension  on  the  sutures,  and  by  doing  away, 
probably,  ivith  the  need  of  prolofiging  bachicards  the  lateral  incisions,  is 
the  key  of  the  operation.     The  muco-periosteum  having  been  freed  on 


Fig.  219.     Showing  the  lateral  in- 
cisions, and  the  raising  of  the  muco- 
periosteum. 


510 


OPERATIONS  ON  THE  HEAD  AND  NECK 


one  side,  that  on  the  opposite  side  of  the  cleft  is  treated  in  exactly 
the  same  manner.  While  the  soft  parts  are  thus  separated  the  haemor- 
rhage will  be  free.  It,  however,  can  always  be  controlled  and  eventually 
arrested  by  pressure  carefully  and  firmly  applied  on  the  right  spot  with 
small  sterilised  sponges  on  suitable  holders.  There  must  be  no  unneces- 
sary manipulation  of  the  flaps,  and,  above  all,  no  bruising  of  them. 
Dabbing  sponges  about  needlessly  does  no  good  as  regards  the  hsemor- 
rhage,  while  it  is  harmful  in  exciting  exudation  of  mucous  and  injuring  the 
soft  parts.  The  more  the  surgeon  himself  does  the  sponging  the  better. 
He  knows  how  to  do  it ;  he  sees  best  where  it  is  required,  and  his  looking 
to  it  himself  will  save  additional  hands  in  an  already  confined  space. 

Sponges  on  holders  should  be  handed  to 
him,  singly,  by  an  assistant,  who  is  kept 
supplied  with  them  by  a  nurse.  If  the 
blood,  in  spite  of  the  above  precautions, 
collect  in  the  pharynx,  and  in  spite  of 
careful  sponging  threaten  to  obstruct  the 
breathing,  the  child  should  be  turned  right 
over,  and  the  blood  allowed  to  run  out  into 
a  basin  on  the  floor.  If  much  blood  get 
into  the  stomach,  it  is  a  certain  emetic. 

B.  Paring  the  Edges.  The  edges  of  the 
cleft  are  then  pared  in  the  following 
manner.  The  tip  of  one  half  of  the  uvula  is 
firmly  grasped  by  a  pair  of  long  dissecting 
forceps  with  tenaculum  ends.  The  soft 
palate  is  thus  made  tense  and  is  then 
transfixed  by  a  sharp  double-edged  cleft 
palate  knife  immediately  in  front  of  the 
forceps,  and  about  one-eighth  of  an  inch 
from  the  margin  of  the  cleft.  The  knife 
is  then  made  to  cut  forwards  as  far  as 
the  anterior  end  of  the  cleft  at  the  same  distance  from  the  edge  of  the 
flap.  The  posterior  part  of  the  uvula  is  then  pared  by  cutting  just 
external  to  the  forceps.  The  other  side  of  the  cleft  is  next  pared  in 
the  same  manner.  I'he  strips  which  have  been  cut  from  the  edges 
of  the  flaps  are  now  connected  alone  at  the  anterior  V-shaped  end  of 
the  cleft.  These  strips  are  seized  and  made  tense  by  the  dissecting 
forceps  and  the  paring  of  the  anterior  extremity  is  complete.  It  is 
important  that  long  continuous  strips  should  be  removed,  as  otherwise 
the  paring  is  likely  to  be  uneven  or  imperfect.  A  uniform  broad  raw  edge 
is  essential  for  success.  There  will  not  be  much  haemorrhage  during 
the  process  of  paring,  and  during  this  and  the  process  of  suturing  care 
must  be  taken  to  avoid  all  bnnsing  or  crushing  of  the  raw  edges,  as  this 
will  seriously  interfere  with  the  subsequent  union.  The  two  raised  flaps  of 
muco-periosteum  should  now  hang  down  in  the  mouth,  so  that  they  can  be 
brought  together  without  tension. 

Some  surgeons  prefer  to  pare  the  edges  before  making  the  lateral 
incisions  and  raising  the  soft  parts,  but  this  is  largely  a  matter  of  indi- 
vidual practice  and  opinion. 

C.  Closure  of  the  Cleft.  The  raw  edges  must  now  be  brought  into 
accurate  apposition  by  sutures  of  silkwonn-gut  or  of  fine  gossamer-gut  : 
some  surgeons  recommend  horsehair  for  the  uvula  and  soft  palate.     The 


Fic.  220. 


Paring  the  cdgc- 
thc  cleft. 


of 


CLEFT  PALATE 


511 


Fig.  221.      Closing  the  cleft,  show- 
ing the  sutures  in  position  and  the 
gaping  of  the  lateral  incisions. 


Hist  suturo  sliould  be  passed  at  the  junction  of  the  hard  and  soft  pahites. 
The  flap  to  the  operator's  rij^ht  hand  is  made  tense  by  securing  the  uvula, 
avoiding  the  pared  surface,  with  the  tenaculum  toothed  dissecting  forceps, 
and  drawing  it  backwards.  A  sharp  needle,  suitably  curved,  is  then  by  a 
sudden  stab  made  to  transfix  the  whole 
thickness  of  the  flap  a  short  distance  ^  '  ^ 

from  its  edge.  The  opposite  flap  is  then 
made  tense  in  the  same  manner,  and  is 
transfi.xed  by  the  same  needle  from 
the  nasal  to  the  buccal  surface.  A 
silkworm-gut  suture  is  then  threaded 
and  the  needle  withdrawn,  the  suture 
being  thus  drawn  across  the  cleft.  The 
edge  of  the  flaps  should  not  be  held  by 
the  forceps  for  fear  of  bruising  ;  the 
needle  should  always  be  threaded  after 
the  flaps  have  been  transfixed.  The 
sutm'e  is  not  tied  at  once,  but  the  ends 
are  secured  with  a  pair  of  clip  forceps 
which  may  be  used  instead  of  the  dis- 
secting forceps,  for  making  the  anterior 
part  of  the  flaps  tense  during  the  inser- 
tion of  the  sutures  in  this  situation. 

A  second  sutm-e  is  then  inserted  in 
the  same  manner  about  the  middle  of 

the  hard  palate,  and  a  third  about  the  nuddle  of  the  soft  palate. 
Other  sutures  are  inserted  as  required.  When  three  or  four  are  in 
position  they  may  be  tied,  care  being  taken  that  the  edges  are  everted 
so  that  the  raw  surfaces  are  brought  accurately  together.  At  the  anterior 
end  of  the  hard  palate  it  is  usually  found,  as  is  sometimes  the  case  through 

the  whole  length  of  the  cleft,  that  the  needle 
cannot  be  passed  in  the  way  described  above, 
without  undue  tension  and  pulling  on  the 
flaps.  When  this  is  so  the  sutures  may  be 
passed  in  one  of  the  following  ways  :  (a)  The 
loop  method  (Fig.  222).  A  threaded  needle 
is  made  to  transfix  one  side  of  the  cleft  in  the 
way  described  above.  The  loop,  which  ap- 
pears in  the  cleft,  is  then  grasped  by  a  pair  of 
forceps  and  the  needle  is  withdrawn,  leaving 
the  loop  of  the  suture  projecting  from  the 
nasal  aspect  of  the  flap.  A  second  needle, 
curved  in  the  reverse  direction,  is  then  made 
to  transfijx  the  opposite  flap  from  the  buccal 
to  the  nasal  surface.  This  is  also  grasped  by 
a  pair  of  forceps  and  the  loop  is  drawn  through 
the  loop  of  the  first  suture.  The  first  suture 
is  then  withdrawn,  bringing  the  second  suture  into  position  across 
the  cleft,  (b)  A  curved  needle  is  passed  through  the  edge  on  one 
side  into  the  cleft  ;  it  is  then  threaded  and  withdi-awn,  and  the 
suture  disengaged.  A  needle  with  a  reverse  curve  is  then} passed 
similarly  through  the  other  side  and  threaded  with  the  end  already 
passed  ;    this  is  then  drawn  through  the  second  side  by  remo^■ing  the 


Fig.    222.     Loop-method   of 
passing  sutures,     (ilason. ) 


512 


OPERATIONS  ON  THE  HEAD  AND  NECK 


needle,  the  suture  being  thus  brought  across  the  gap.  (c)  The  sutures 
may  be  passed  with  Lane's  small  cleft  palate  needles  and  needle-holder. 
The  tip  of  the  right  half  of  the  uvula  is  lightly  held  with  forceps,  and  the 
fine  needle,  threaded  with  the  finest  silkworm-gut,  is  passed  from  below 
upwards  and  brought  out  into  the  cleft ;  the  needle  is  released  from  the 
holder  and  drawn  through.  It  is  then  readjusted  in  the  holder,  the  tip  of 
the  left  half  of  the  uvula  is  similarly  held  on  the  stretch,  and  the  needle 
passed  again  into  the  cleft  and  brought  out  from  above  downwards, 
transfixing  the  left  half  of  the  uvula. 

Attention  should  be  paid  to  inserting  the  sutures  at  a  sufficient  dis- 
tance from  the  edge  and  a  due  distance  from  each  other  so  as  to  equally 
distribute  amongst  themselves  any  tension  that  may  be  present.  In 
passing  a  suture,  the  needle-point  should  be  quickly  stabbed  through  at  the 


Fig.  223.  The  chief  parts  concerned  in  the  operation  for  cleft  palate,  the  lateral 
incision  b,  c  through  the  mucous  membrane,  and  that  for  division  of  the  muscles, 
a,  are  shown  (v.  Esmarch  and  Kowalzig).  The  last  incision  is  largely  replaced 
on  the  Continent  by  detaching  the  hamular  process  after  Billroth's  method. 
The  chisel  is  introduced  upwards  and  inwards,  and  the  dislocation  of  the  process 
completed  with  an  elevator. 

intended  spot.  The  surgeon  must  make  sure  that  in  all  cases  the  edges 
are  everted  so  that  the  raw  surfaces  are  brought  together. 

D.  Relief  of  Tension,  Should  there  be  any  tension  when  the  suturing 
is  completed,  the  lateral  incisions  should  be  prolonged.  It  will  generally 
be  found  necessary  to  continue  them  backwards  just  internal  to  the 
hamular  process.    Any  hgemorrhage  is  arrested  by  firm  but  gentle  pressure. 

Operation  on  the  Soft  Palate.  When  the  cleft  involves  the  soft 
palate  alone  it  is  usually  narrow,  and  the  operation  is  much  simplified. 
It  is  carried  out  on  the  lines  described  above  in  the  following  stages. 
(a)  Paring  of  the  cleft,  (b)  Suture  of  the  raw  edges,  (c)  An  incision 
on  each  side  just  internal  to  the  hamular  process  to  divide  the  muscles  and 
to  relieve  tension. 

Operation  on  the  Hard  Palate  alone.  This  will  be  called  for  in  those 
rare  cases  where  the  cleft  involves  the  hard  palate  only,  and  in  those  where 


CLEFT  PALATE 


51 3 


the  cleft  in  the  posterior  part  of  the  palate  has  been  successfully  closed, 
while  the  anterior  ])art  oi  the  cleft  has  broken  down  or  its  closure  not 
atteni])ted.  The  ojx'ration  needs  no  special  description,  as  it  is  cai'ried 
out  in  the  way  described  above.  J^ateral  incisions  will  always  be  required 
to  raise  the  muco-periostcuni  from  the  bone. 

The  after-treatment  and  the  causes  of  failure  are  considered  on  p.  525. 

Davies-Colley's  Flap  Method  Jor  Hard  Palate  (B'igs.  224-22(5).  This 
was  fiist  published  by  its  inventor  in  the  Brit,  Med.  Journ.,  October  25, 


.r- 


X 


y 


Fig.  224.  The  shading  indicates,  in  the  hard  palate,  stripped-up_  periosteum  ; 
in  the  .soft  palate,  the  stripping  into  two  planes.  The  lower  figure  represents 
diagrammaticaUy  a  transverse  vertical  section  through  the  hard  palate    along 

the  line  x  y. 

1890,  and  recommended  as  appUcable  (1)  in  infants  ;  (2)  in  cases  where 
the  ordinary  operation  had  failed  ;  and  (3)  in  cases  in  w^hich  the  cleft  of  the 
hard  palate  was  too  wade  to  be  bridged  over  by  the  ordinary  operation. 
The  late  Mr.  Davies-Colley  afterwards  published  his  method  in  a  modified 
and  extended  form.^     It  may  be  divided  into  the  three  following  stages  : 

"  First  Stage  :  that  of  Incision  and  Separatio7i  of  the  Muco-periosteum 
(Fig.  224).  The  patient  being  under  an  anaesthetic,  and  the  jaws  held 
open  by  a  Smith's  gag — (a)  an  incision,  ah,  is  made  from  before  back- 
wards, about  an  inch  long,  with  its  centre  just  internal  to  the  last  molar 

1  Trans.  Med.-Chir.  Soc,  1894,  vol.  Ixxvii,  p.  236. 
SURGERY  I  33 


514 


OPERATIONS  ON  THE  HEAD  AND  NECK 


tooth.  It  should  go  down  to  the  bone  in  front,  and  behind  it  should 
pierce  the  soft  palate.  Through  this  incision  a  raspatory  is  introduced, 
and  the  soft  parts  separated  inwards  from  the  posterior  half  of  the  hard 
palate,  much  as  in  the  ordinary  operation,  but  not  to  such  an  extent. 

"  (B)  An  incision,  cd,  is  carried  on  the  same  side  from  just  in  front 
of  the  cleft,  and  at  a  distance  of  about  a  quarter  of  an  inch  from  its  margin, 
backwards  to  the  junction  of  the  hard  and  soft  palate.  As  it  approaches 
the  soft  palate  the  incision  should  converge  to  the  edge  of  the  cleft,  and  it 


9     d 


X 


^ 


If 


<^^ 


\ 


Fig.  225.     The  lower  part  of  the  diagram  represents  a  similar  section  to  that 

shown  in  the  preceding  figure.     The  arrows  indicate  the  direction  in  which 

the  muco-periosteum  of  the  margins  of  the  cleft  is  reflected  inwards. 

should  be  continued  along  the  edge  of  the  soft  palate  in  such  a  way  as  to 
split  that  structure  to  the  depth  of  about  three-eighths  of  an  inch.  For 
this  purpose  the  knife  should  be  lateralised,  and  as  the  knife  approaches 
the  uvula  a  forceps  wtII  be  required  to  hold  the  uvula  steady  while  it  is 
being  divided.  At  this  part  the  incision  must  not  be  quite  so  deep,  in 
order  to  avoid  the  complete  division  of  the  lateral  half  of  the  uvula.  The 
soft  palate  near  the  cleft  will  now  consist  of  two  planes — a  lower  one 
which  is  continuous  with  the  band  of  muco-periosteum  between  the  two 
incisions,  ah  and  cd,  and  an  upper  one  attached  to  the  back  of  the  hard 
palate.  The  muco-periosteum  internal  to  the  incision,  cd,  should  be 
separated  inwards  from  the  bone  until  it  is  left  attached  by  the  soft 
tissue  which  covers  the  margin  of  the  cleft  of  the  hard  palate. 


CLEFT  PALATE 


51 


"  (B)  A  lai-fjo  flap,  rfg,  of  somewhat  trianf,nilar  shape,  but  with  the 
front  angle  rouiulcd.  siiould  be  taken  from  the  other  side  of  the  palate. 
One  side  of  the  flaj).  (;/',  runs  parallel  to  and  a  sixth  of  an  inch  from  the 
insertions  of  the  teeth  from  the  last  molar  to  the  median  incisor  ;  the 
other,  /j/,  runs  backwards  at  a  distance  of  a  sixth  of  an  inch  from  the  margin 
of  the  cleft  of  the  hard  palate,  and  continuous  with  a  splitting  of  the  .soft 
palate  similar  to  that  upon  the  other  side,  and  reaching  as  far  back  as  the 
tip  of  the  uvula.     The  muco-periosteum  of  the  triangular  flap  should 


y    ^ 


Fig.  226. 


also  be  separated  from  the  hard  palate  by  means  of  the  raspatory,  and, 
finally,  that  which  lies  internal  io  fg  should  be  separated  inwards,  until  it 
is  only  attached  to  the  margin  of  the  cleft. 

"  Second  Stage  :  the  Union  of  the  Mesial  Flaps  and  the  Upper  Planes 
of  the  Soft  Palate  (Fig.  225).  By  means  of  an  ordinary  palate-needle, 
with  the  curve  at  the  end  in  a  plane  at  right  angles  to  the  stem  five 
sutures  of  silk  or  catgut  are  passed  through  the  edges  of  the  flaps  in- 
ternal to  ed  and/^,  care  being  taken  to  turn  the  flaps  inwards  so  that  their 
mucous  covering  looks  upwards  and  their  raw  surface  downwards. 
Continuously  with  this  union  the  edges  of  the  upper  plane  of  the  soft 
palate  on  either  side  must  be  brought  together  in  the  same  way.     From 


516  OPERATIONS  ON  THE  HEAD  AND  NECK 

four  to  six  sutures  are  necessary  for  this  stage.  When  it  is  completed 
the  whole  cleft  of  the  hard  and  soft  palate  should  be  bridged  over  by  a 
layer  of  muco-periosteum  and  soft  palate  tissue,  with  the  raw  surface 
looking  downwards. 

"  Third  Stage  :  Union  of  the  Triangular  Flap  and  the  Lower  Planes 
of  the  Soft  Palate  (Fig.  226).  With  the  same  needle  sutures  of  soft  silver 
wire  are  now  passed  in  the  ordinary  way  so  as  to  draw  over  the  margin 
fg  of  the  triangular  flap  to  the  outer  edge  of  the  incision  cd,  on  the  other 
side.  At  the  same  time  the  margins  of  the  lower  planes  of  the  split  soft 
palate  are  brought  together  in  the  same  way.  About  six  wire  sutures  are 
necessary,  and  two  silk  or  horsehair  sutures  may  be  used  for  the  approxi- 
mation of  the  uvula  and  the  adjacent  parts  of  the  soft  palate.  There  will 
now  be  a  second  complete  bridge  across  the  cleft,  but  in  this  bridge  the 
mucous  surface  will  look  downwards,  while  the  raw  surface  will  look  up- 
wards and  be  in  contact  with  the  raw  surface  of  the  first  bridge. 

"The  incision  ab  gapes  widely,  and  may  have  to  be  increased  in  size, 
especially  at  the  expense  of  the  muscular  tissue  of  the  soft  palate,  in 
order  to  allow  the  edges  to  come  together  without  tension. 

"  The  after-treatment  is  similar  to  that  which  is  usual  after  the 
ordinary  operation.  An  interval  of  at  least  three  weeks,  and  some- 
times as  many  as  six  weeks,  should  be  allowed  before  removing  the 
sutures  of  the  third  stage,  while  those  of  the  second  stage  have  to  be  left 
to  come  away  as  they  can  or  to  be  absorbed. 

"  There  is  so  little  tension,  that  if  primary  union  should  fail,  secondary 
union  would  probably  take  its  place.  For  a  short  time  a  raw  surface  is 
left  in  the  opening  made  by  the  gaping  of  the  incision  ab,  and  on  the 
other  side  over  the  space  previously  covered  by  the  triangular  flap  ;  but 
these  surfaces  soon  get  covered  with  granulations,  and  give  rise  to  no 
trouble  or  deformity." 

Flap  Method  of  Sir  W.  Arbuthnot  Lane.  Sir  W.  Arbuthnot  Lane  ^ 
considers  that  "  The  best  time  for  operation  is  the  day  after  birth,  or  as 
soon  after  that  as  possible.  The  newly  born  child  is  always  healthy,  the 
capacity  of  its  tissues  for  repair  being  at  the  very  best,  its  digestion  has  not 
been  impaired  by  experimental  and  usually  most  unsatisfactory  feeding, 
and  its  resisting  power  reduced  correspondingly  ;  it  is  apparently  unin- 
fluenced by  the  operation  in  that  it  does  not  cry  or  show  evidences  of  being 
in  pain  ;  it  is  never  or  hardly  ever  sick  after  the  anaesthetic,  but  takes 
its  food  within  an  hour  or  two  of  the  completion  of  the  operation  with 
apparent  enjoyment ;  the  loss  of  blood  is  very  slight,  being  usually 
much  less  than  in  the  case  of  a  circumcision,  and  the  risk  to  life  is  under 
ordinary  conditions  very  trivial  indeed." 

"  The  general  principle  on  which  most  of  the  operations  are  based  is 
that  of  raising  from  the  roof  of  the  mouth  on  one  side  of  the  cleft,  a  flap, 
which  consists  of  the  mucous  membrane,  submucous  tissue  and  periosteum 
of  the  roof  of  the  mouth,  and  when  this  flap  extends  over  the  alveolus, 
care  is  taken  to  avoid  unnecessary  damage  to  the  subjacent  teeth.  This 
can  only  be  done  efficiently  very  soon  after  birth.  In  early  infancy  it  is 
possible  to  provide  a  well  vascularised  thick  flap,  which  is  practically  three 
times  as  broad  as  can  be  obtained  when  the  teeth  have  begun  to  en- 
croach materially  on  the  mucous  membrane  or  to  perforate  it,  since  the 
muco-periosteum  covering  the  under  and  outer  surface  of  the  alveolus 
can  be  made  to  form  the  outer  two-thirds  of  the  flap. 

1  Cleft  Palate  and  Hare-lip,  1905,  p.  42  ;  Clin.  Led.,  p.  15. 


CLEFT  PALATE 


517 


"  III  pcMfonniii",'  the  operation  the  eliild  is  placed  iiiider  an  anocsthctic, 
a  thread  is  i)assed  thi()Ujj;h  tlie  tip  of  the  toiijijue  by  wliich  traction  can 
be  efficiently  exerted."  Sir  W.  Arbuthnot  Lane  uses  his  toothed  o;a<rs 
made  in  pairs.  Sevei'al  sizes  should  be  at  hand.  His  needles  and  needle- 
holder  are  shown  in  Fig.  227. 

"  The  manner  in  which  the  flap  is  formed  from  the  muco-periosteiini 
on  one  side  and  is  fixed  beneath  the  sej)arated  muco-periosteum  lining 


3 


Fig.  227.     Lane's  needle- holder  and  needles. 


the  roof  of  the  mouth  on  the  opposite  side  is  of  the  cleft  in  an  edentulous 
infant  represented  in  Figs.  228,  229. 

"  In  the  soft  palate,  the  flap  which  is  raised  comprises  all  the  soft 
parts  down  to  the  tensor  palati,  and  may  be  made  as  extensive  as  neces- 
sary by  encroaching  on  the  cheek  if  there  is  not  enough  material  in  the 
remains  of  the  soft  palate.  On  the  other  side  of  the  cleft,  the  muco- 
periosteum  is  divided  along  its  free  margin 
till  the  soft  palate  is  approached.  The  ex- 
tremity of  the  uvula  or  its  relic  is  picked 
up  with  forceps,  and  an  incision  made  out- 
wards from  it  along  the  free  margin  of  the 
palate  for  some  distance,  and  from  its  outer 
limit  another  is  carried  forwards  and  in-, 
wards  along  the  upper  part  of  the  soft 
palate  to  reach  the  posterior  limit  of  the 
incision  running  along  the  free  margin  of 

the  hard  palate.  The  triangular  flap  of  mucous  membrane  and  submucous 
tissue  intervening  between  the  two  incisions  described  and  the  margin  of 
the  cleft  in  the  soft  palate  is  raised  off  the  subjacent  muscles  and  turned 
inwards,  and  the  raw  surface  left  by  doing  so  is  increased  in  area  by  turning 
outwards  a  further  portion  of  the  mucous  membrane  covering  the  soft 
palate  externally.  By  this  means  the  area  of  the  upper  surface  of  the 
soft  palate,  rendered  bare  by  the  removal  of  its  mucous  covering,  is 
rendered  much  greater  than  before.  By  means  of  a  stout  steel  elevator  in- 
troduced between  the  muco-periosteum  and  the  bone  through  the  incision 
made  along  the  margin  of  the  cleft,  the  muco-periosteum  is  raised  from 
the  bone  up  to  the  inner  margin  of  the  alveolus.  The  flap  whose  edge 
is  attached  along  the  margin  of  the  cleft  is  placed  beneath  the  flap  wliich 
has  been  raised  from  and  for  a  considerable  distance  beyond  the  margin  of 
the  cleft,  and  is  pinned  down  by  fine  curved  needles  and  0000  Chinese 


Fig.  228.  Showing  the  flap 
raised  and  fixed  in  position.  In 
this  case  the  cleft  is  not  of  suf- 
ficient breadth  to  render  it 
necessary  to  strip  the  alveolus 
of  its  covering  of  mucous  mem- 
brane.    (Lane.) 


518 


OPERATIONS  ON  THE  HEAD  AND  NECK 


twist  silk  in  this  position  by  a  number  of  sutures  which  perforate  the 
free  margin  of  the  reflected  iflap  and  the  outer  part  of  the  elevated  flap, 
the  knots  being  tied  on  the  under  surface  of  the  latter,  whence  they  can 
be  removed  with  facility  when  the  opposing  surfaces  have  united  firmly, 
which  they  do  in  about  ten  days.     Then  the  free  margin  of  the  raised 


A.  B. 

Fig.  220.  A,  A  cleft  of  a  breadth  sufficient  to  require  the  employment  of  a 
flap  from  the  entire  alveolus.  The  dotted  lines  indicate  the  incisions,  that  to 
the  left  of  the  cleft  being  on  th(!  nasal  surface  of  the  palate,  while  that  on  the 
right  is  on  the  buccal  aspect.  (Lane.)  "B,  The  flaps  sutured  in  position.  The 
shaded  area  represents  the  surface  laid  bare  by  the  removal  of  the  flap.      (Lane.) 

flap  is  attached  by  separate  sutures  to  the  raw  surface  of  the  reflected 
flap.  Finally,  the  opposing  edges  of  the  free  margin  of  the  soft  palate 
are  united  in  a  similar  manner. 

"  In  Fig.  230  I  have  attempted  to  indicate  diagrammatically  the 
details  of  the  method  I  have  described.  It  is  intended  to  represent  the 
mouth  of  an  infant,  showing  a  broad  cleft  involving  almost  the  entire 
palate.  The  position  of  the  alveolus  is  indicated  by  the  three  crosses,  xxx. 
]  represents  the  incision  which  extends  forwards  and  outwards  through 
the  muco-periosteum  from  the  anterior  limit  of  the  cleft,  and  which  passes 
over  and  beyond  the  alveolus  to  its  outer  surface,  while  2  commences  at 

its  outer  limit  and  runs  back  along  the 
outer  surface  of  the  gums  about  the  junc- 
tion of  the  cheeks  and  alveolus.  An  in- 
cision, 3,  is  then  made  from  its  posterior 
extremity  along  the  free  margin  of  the 
palate  to  the  uvula.  The  flap  included 
between  these  incisions  is  raised  from  the 
subjacent  structures,  a  specially  designed 
small  knife  or  a  carefully  constructed  pair 
of  sharp-pointed  scissors  being  used  for 
the  purpose.  As  the  posterior  palatine 
foramen  is  approached,  an  elevator  pressed 
in  between  the  flap  and  the  bony  palate 
causes  the  posterior  palatine  vessels  and 
nerves  to  protrude  for  a  considerable 
length  in  a  tube  of  periosteum.  This  is 
readily  grasped  by  a  pair  of  efficient  compression  forceps  and  divided 

beyond.  ,       -n 

"  It  happens  not  uncommonly  in  the  type  of  cleft  palate  illustrated  by 
Fig.  230  that  the  septum  presents  a  free  margin  which  extends  almost,  if 


Fig.  230. 


CLEFT  PALATE 


519 


not  quite,  to  the  level  of  the  cleft.  In  these  cases  I  make  an  incision,  4, 
through  tlie  nuicous  membrane  and  periosteum  or  perichondrium  along 
the  middle  line  of  the  septum  with  two  small  traverse  incisions,  5,  at 
either  end,  and  turn  down  laterally  the  narrow  flaps  so  formed,  leaving  the 
cartilage  or  bone  bared  or  exposed.  By  placing  the  flap  which  has  been 
raised,  in  position,  the  line  along  which  it  will  rest  on  the  septal  margin 
can  be  readily  defined.  AVith  a  sharp  knife  the  surface  of  the  reflected 
flap  is  denuded  of  its  covering  mucous  membrane  along  the  area  of  impact. 
By  a  series  of  sutures  perforating  the  superjacently  imposed  flap  and  the 
margin  of  the  septum  if  it  be  not  too  hard,  or  the  flaps  of  muco-periosteum 
if  the  edge  be  bony,  the  reflected  flap  is  pinned  to  the  septum  ;  G  in  Fig.  230 
shows  the  incision  along  the  free  margin  of  the  cleft  continued  as  7, 
obliquely  outwards  and  backwards  along  the  upper  surface  of  the  soft 
palate.  The  incision  8  extends  from  the  posterior  limit  of  7  along  the 
lower  free  margin  of  the  soft  palate  to  the  tip  of  the  uvula,  and  the 
incision  10  forwards  and  outwards  from  the  anterior  limit  of  6  on  to  the 


Fio.  231.     Flaps  in  position. 
( Lane. ) 


Fig. 


232.     Flaps  for  a  common  type 
of  cleft  palate. .     (Lane.) 


alveolus.  This  last  incision  facilitates  the  raising  of  the  flap  on  this  side, 
and  of  the  introduction  beneath  it  of  the  reflected  flap  from  the  opposite 
side.  After  the  muco-periosteum  external  to  the  incision  6  has  been 
raised  from  the  bone,  the  soft  palate  is  freed  from  the  posterior  margin  of 
the  hard  palate,  and  the  mucous  membrane  on  its  upper  surface  turned 
outwards  to  the  position  of  9. 

"  In  Fig.  231  the  flaps  are  shown  in  position.  The  sutures  along  the 
line  1  represent  those  attaching  the  septum  to  the  reflected  flap.  Those 
along  2  show  the  sutures  which  unite  the  free  edge  of  the  raised  flap  to  the 
under  surface  of  the  reflected  flap  ;  those  along  the  line  3  anchor  the  edge 
of  the  reflected  flap,  and  those  along  the  line  -l  connect  the  flaps  where 
they  form  the  free  margin  of  the  new  soft  palate. 

"  Another  common  type  of  cleft  palate  is  that  illustrated  in  Fig.  232, 
the  cleft  in  front  being  to  one  side  of  the  middle  line  extending  from 
between  the  septum  and  a  portion  of  the  roof  of  the  mouth,  while  pos- 
teriorly the  cleft  in  the  soft  palate  is  fairly  symmetrical.  As  the  mucous 
membrane  is  always  very  thin  where  it  covers  the  septum  and  the  adjacent 
portion  of  the  roof,  the  flap  must  be  reflected  inwards  from  the  narrow  or 
less  developed  side  and  raised  outwards  from  the  septum,  the  narrower 


520 


OPERATIONS  ON  THE  HEAD  AND  NECK 


flap  being  fixed  beneath  the  muco-periosteum  covering  the  broader  side 
of  the  roof  of  the  mouth. 


A.  B. 

Fig.  233.     A,  A  complete  cleft  of  the  palate.     The  dotted  lines  indicate  the 
incisions,  and  the  shaded  area  the  portion  of  muco-periosteum  elevated  from 
the  subjacent  bone.     (Lane.)     B,  The  flap  fixed  in  position  by  a  double  row  of 
sutures.     The  shaded  ]}art  shows  the  surface  of  hard  palate  stripped  of  muco- 
periosteum.     (Lane.) 


A.  B. 

Fig.  234.     A,  A  common  form  of  cleft.     The  dotted  lines  on  the  nasal  aspect  to 

the  right  of  the  cleft  and  on  the  buccal  aspect  to  the  left  of  the  cleft  indicate 

useful  incisions.     (Lane.)     B,  The  flaps  in  position  and  sutured.     (Lane.) 


A.  B. 

Fig.  23.5.     A,  The  dotted  line  to  the  right  of  the  cleft  represents  the  incision 

along  the  buccal  aspect  of  the  palate,  and  that  to  the  left  the  incision    along 

the  pharj'ngeal  aspect.     (Lane.)     B,  The  flap  sutured  in  position. 

"  Figs.  233,  234  show  the  forms  of  flap  when  the  teeth  have  come 
through  the  gum,  or  when  a  sufiicient  flap  can  be  obtained  without  en- 
croaching on   the  gum,  and  Fig.  235,  the  manner  in  which   the  cleft 


CLEFT  PALATE 


521 


in  the  soft  palate  is  closed.  Associated  with  a  complete  cleft  of  the 
palate  there  is  often  a  displacement  forwards  of  the  pre-maxilla,  which  is 
attached  to  the  under  sm-face  of  the  septum  beneath  the  tip  of  the  nose. 
I  have  found  it  best  to  divide  the  mucous  membrane  along  the  limits 
of  the  pre-maxilla,  laterally  and  posteriorly  avoiding  any  interference 
^\ith  the  soft  parts  in  front.  The  muco-periosteum  is  separated  from  the 
subjacent  pre-maxilla  and  is  reflected  forwards.  The  pre-maxilla  is  cut 
away  from  the  septum  by  means  of  biting  forceps,  the  edge  of  the  septum 
being  nicely  trimmed  and  rounded.  This  flap,  which  consists  of  a  mesial 
relic  of  lip  and  muco-periosteum,  is  opened  out  when  it  covers  a  consider- 
able area.  Its  margin  is  attached  by  sutures  to  the  raw  under  surface  of  the 
reflected  flap  and  to  the  raised  flap,  which  is  rendered  raw  where  the  pre- 
maxillary  flap  covers  it  by  the  removal  of  its  epithelial  covering  by  means 


A. 
Fig.   236.     A,  Flaps  for  a  very  wide  cleft. 

(Lane.) 


B. 

(Lane.)      B,  Flaps  in  position. 


of  a  sharp  knife.  In  this  way  the  gap  between  the  alveolar  segments 
is  filled  up  very  advantageously,  and  later,  when  the  cleft  in  the  Up  is 
closed,  the  mesial  relic  of  the  lip  serves  to  complete  the  septum  and  to 
afford  attachment  to  the  lateral  margins  of  the  cleft. 

"  It  happens  not  infrequently  that  it  is  impossible  to  close  the  whole 
length  of  the  cleft  by  one  single  operation. 

"  Fig.  236  illustrates  such  a  condition.  The  cleft  is  a  very  vn.de  one, 
and  it  is  impossible  to  close  it  by  the  reflection  of  the  flaps  in  the  manner 
described.  An  incision  is  made  along  the  entire  aspect  of  the  gum  along 
the  line  indicated  by  1.  Two  are  made  along  the  direction  of  2,  and  two 
others  along  the  free  inner  margins  of  the  cleft.  The  flap  included  be- 
tween 1  and  2  on  either  side  is  turned  back,  great  care  being  taken  of  its 
attachment,  which  is  usually  very  thin.  The  flaps  comprised  between 
1,  2  and  3  are  raised  from  before  backward,  care  being  taken  to  avoid  any 
damage  to  the  descending  palatine  vessels.  These  flaps  are  then  dis- 
placed inwards,  as  in  Fig.  236b,  their  opposing  margins  being  sutured 
together  and  to  the  subjacent  flap,  and  if  possible  to  the  septum  also. 

"  At  a  later  period  the  posterior  portion  of  the  cleft  may  be  closed  in 
one  of  two  ways,  the  method  varying  with  the  breadth  of  the  cleft  and 
the  extent  of  material  at  disposal.  The  first  and  more  generally  applicable 
method  is  by  reflecting  a  flap  inwards  on  one  side,  leaving  it  attached  by 
its  inner  margin,  the  other  flap  being  rendered  raw  on  its  posterior  surface 


522 


OPERATIONS  ON  THE  HEAD  AND  NECK 


and  its  area  extended  as  in  Fig  235.  The  second  method  is  to 
reflect  a  flap  inward  as  before,  while  the  flap  from  the  opposite  side  is 
raised  from  the  subjacent  parts  by  an  incision  extending  along  its  inner, 
posterior,  and  outer  margins,  so  that  it  pivots  anteriorly  as  in  Fig.  237 
and  can  be  made  to  cover  the  flap  reflected  from  the  opposite  side.  Or, 
both  flaps  may  be  made  to  pivot  upon  their  anterior  attachments,  their 
internal  edges  are  sutured  carefully  together,  the  outer  free  margins  being 
anchored  wherever  a  suitable  attachment  can  be  found.  The  free 
inner  margins  of  the  cleft  are  also  pinned  down  to  the  subjacent  flaps  by 
sutures. 

"  In  Fig.  237  I  have  indicated  the  mode  of  closure  of  the  back  of  the 
cleft  by  raised  flaps,  the  outlines  of  which  are  represented  as  dotted 
lines,  and  in  Fig.  237b  the  suturing  of  the  raised  flaps  on  both  sides  in 


A. 

Fig.  237.     A,  Flaj)s  for  closure  of  back  of  cleft. 

(Lane.) 


(Lane.)     B,  Flaps  in  position. 


position.  In  order  to  avoid  confusion,  the  knots  of  the  sutures  which 
attach  the  inner  margins  of  the  cleft  to  the  superjacent  flaps  are  not 
indicated  in  this  diagram. 

"  In  this  diagram  the  outlines  of  the  flaps  are  represented  as  firm  lines, 
the  dotted  lines  representing  the  position  of  the  incisions,  and  show 
portions  of  the  area  deprived  of  mucous  membrane,  and  uncovered  by 
the  flaps,  which  have  been  brought  inwards  so  as  to  oppose  their  inner 
margins. 

"  As  regards  the  treatment  of  the  infant  after  the  operation,  no 
change  whatever  in  diet  is  adopted,  nor  is  any  attempt  made  to  sponge 
or  spray  the  interior  of  the  mouth.  Means  are  taken  to  ensure  that  the 
hands  cannot  be  introduced  into  the  mouth.  At  the  end  of  about  eight 
or  ten  days  the  stitches  are  removed.  Should  a  cleft  in  the  lip  complicate 
that  of  the  palate,  the  former  is  closed  as  soon  as  the  palate  has  been  dealt 
with,  never  before.  In  most  cases  I  perform  both  operations  under  a 
single  ana3sthesia." 

The  Flap  Operation  and  Langenbeck's  Operation  compared.^  The 
chief  advantages  claimed  for  the  flap  operation  are  :  (1)  It  can  be  used 
for  closing  very  wide  clefts  in  infancy.  (2)  No  tissue  has  to  be  pared 
away.     (3)  A  much  larger  extent  of  raw  surface  is  brought  into  close 

^  See  also  the  remarks  on  p.  505. 


CLEFT  PALATE 


523 


contact  than  by  Langenbeck's  operation.  (4)  The  tension,  at  any  rate 
in  the  lower  bridge  uniting  the  sides  of  the  hard  palate,  is  much  less. 
(5)  Whereas,  in  Langenbeck's  operation,  the  pressure  of  the  tongue  tends 
to  tear  apart  the  slender  line  of  raw  surface  which  has  to  unite,  in  the  flap 
operation  the  pressure  is  beneficial,  as  it  keeps  the  raw  surfaces  of  the 
two  bridges  in  close  contact.  (6)  The  early  flap  operation  is  needful  for 
the  proper  development  of  the  nasal  passages  and  the  naso-pharynx. 
The  following  are  the  chief  disadvantages  of  the  early  flap  operation  : 

(1)  The  mortality,  as  might  be  expected  from  the  greater  severity  of 
the  operation  and  the  age  of  the  patient,  is  greater.  In  Sir  W.  Arbuthnot 
Lane's  series  of  cases  ^  it  was  5-8  per  cent.  The  question  of  the  early 
operation  being  a  life-saving  one,  and  of  the  late  mortahty,  have  already 
been  touched  upon. 

(2)  The  resulting  palate  is  thinner,  less  symmetrical,  and  more 
fibroid  ;    hence  the  soft  palate  is  less  mobile  than  after  Langenbeck's 


Fig.  238.     One  of  Sir  A.  Lane's 


B. 

methods  for  closing  a  residual  cleft  in  the  soft 
palate. 


operation.  As  the  result  of  this  the  defective  speech  is  less  likely  to  be 
improved. 

(3)  Mr.  James  Berry  ^  has  pointed  out  another  disadvantage,  viz.  that 
the  flaps  may  undergo  atrophy,  even  to  the  reappearance  of  a  perforation, 
sometimes  after  the  operation. 

(4)  The  flaps  taken  from  the  gums  may  injure  the  tooth  follicles. 
Brophy's  Operation  (Figs.  239,  240).     Dr.  Brophy,  surgeon-dentist, 

of  Chicago,  operates  on  the  palate  first,  and  deals  with  the  cleft  by  thrust- 
ing the  maxillary  and  palate  bones  together.  As  it  has  not  been  received 
with  favour  in  this  country  it  will  only  be  briefly  described  here.  It  is  a 
much  more  serious  operation  than  those  already  described,  one  of  %vhich 
will  be  suitable  for  cleft  palate  of  any  degree  or  extent.  There  is  a  very 
heavy  mortality,  and,  in  addition,  there  is  a  considerable  possibihty  of 
necrosis  of  the  jaws — a  very  grave  complication  in  young  infants.  It 
was  first  introduced  into  this  country  by  Mr.  Owen.  The  following 
description  of  the  operation  is  taken  from  his  "  Cleft  Palate  and  Hare-lip," 
p.  47.  The  child  operated  on  by  Mr.  Owen  by  this  method  was  three 
months  old,  the  cleft  a  broad  one  extending  into  the  right  nostril.  The 
vomer  was  adherent  to  the  palatal  process  of  the  left  maxilla. 

"  The  operation  was  begun  by  paring  the  edges  of  the  cleft,  and  after  this  I 
tried,  but  ineffectually,  to  thrust  the  maxillae  towards  each  other  by  firm  pressure 
with  the  fingers  and  thumb.     Xext  I  raised  the  cheek,  and,  well  back,  towards  the 

^  Loc.  supra  cit. 


524 


OPERATIONS  ON  THE  HEAD  AND  NECK 


posterior  extremity  of  the  hard  palate,  just  behind  the  malar  ])rocesR,  and  above 
the  level  of  the  horizontal  process  of  the  palate  bone,  drove  the  end  of  a  strong 
needle  on  a  handle  through  the  substance  of  the  maxilla.     This  needle  carried   a 


Fig.  239.  Vertical  section  of  the  superior  maxillary  bones  of  a  child  five  weeks 
of  age,  showing  congenital  cleft  palate.  A  A,  Silver  wire  tension-sutures.  B  B, 
Lead  plates.     C  C,  Germs  of  tlie  first  temporary  molar  teeth.     D,  Cleft  palate. 

(Brophy.) 

thick  silk  pilot-suture  through  to  the  cleft,  where  its  loop  was  pulled  down  towards 
the  mouth.  Then  the  needle  was  similarly  passed  through  the  opposite  maxilla, 
the  loop  being  brought  down  as  before.     The  second  loop  was  passed  through  the 


Fig.  240.  Vertical  section  similar  to  that  in  Fig.  239,  showing  method  of 
closing  cleft  of  hard  palate.  A  A,  Silver  wire  tension-sutures.  B  B,  Lead 
plates.  C  C,  Germs  of  first  temporary  molar  teeth.  D,  Cleft  closed.  E  E, 
Muco-XDcriosteum,  forming  external  wall  of  the  triangular  space  made  by  forcing 
the  lower  fragments  of  the  bone  inward.  F  F,  Lines  of  fracture  made  by 
ai)proximation  of  the  palatal  processes.  G  G,  Triangular  space  on  nasal  surface 
of  bone  made  by  approximation  of  the  palatal  processes.     (Brophy.) 

first,  which,  being  drawn  upon,  was  made  to  bring  the  second  loop  through  both 
of  the  maxillae  and  across  the  nasal  fossa,  above  the  level  of  the  hinder  part  of  the 
alveolar  processes.     The  sharply-bent  end  of  a  silver  wire  was  then  hooked  on  to 


CLEFT  PALATE  525 

this  looi),  and  by  jMilling  back  tlio  latter,  the  wire  was  made  to  take  its  place.  The 
wir(>  suture  thus  lay  above  tlie  horizontal  processes  of  the  palate-bones,  where  it 
could  be  se(>n  through  the  cleft.  Similarly,  a  wire  sutm-e  was  taken  through  the 
maxilhv  above  the  front  i)art  of  the  cleft.  Two  small,  oblong,  leaden  ])lates,  with 
a  hole  drilled  near  each  end,  had  already  been  ijrepared,  and  one  of  them  was  then 
laid  along  the  outside  of  the  right  maxilla,  under  the  cheek,  the  end  of  the  hinder 
wir(^  being  passed  through  the  jjosterior  and  the  end  of  the  front  wire  through  the 
anterior  hole.  The  right  ends  of  the  wire  were  then  twisted  together  from  left  to  right, 
the  plate  being  closely  applied  against  the  maxilla%  after  which  the  ends  of  the 
wire  were  ^n-essed  down  tlat.  The  ends  of  the  wire  under  the  left  cheek  were  then 
similarly  treated,  and,  as  they  were  being  twisted  up,  the  maxilla?  were  squeezed 
together,  or,  rather,  another  vigorous  attempt  was  made  to  squeeze  them  together. 
But  I  could  not  move  them.  So,  in  accordance  with  Dr.  Brophy's  method,i  I  then 
incised  the  mucous  membrane  over  each  malar  process,  and,  introducing  a  scalpel, 
divided  the  maxilUe  suificicntly  to  enable  me  to  thrust  their  palatine  processes 
into  the  middle  line.  After  this  it  was  at  once  seen  that  the  width  of  the  gap  in  the 
lip  had  been  greatly  reduced,  and  that  the  lateral  halves  of  the  palate  were  brought 
closer  together.  Fine  wire  sutures  were  then  passed  tlu-ough  the  freshened  borders 
of  the  entire  cleft. 

"  When  the  maxilLne  have  been  thus  thrust  together,  the  wires  extending  between 
the  leaden  plates  have  to  be  tightened  up  and  again  twisted.  These  wires  and 
plates  are  not  disturbed  for  three  or  four  weeks.  Some  superficial  ulceration  some- 
times takes  place  beneath  the  borders  of  the  plates,  but  it  is  of  no  importance.  The 
wu-es  and  plates  may  be  removed  after  about  the  third  week.  The  infant  was  very 
ill  for  two  or  thi-ee  days,  and  the  union  of  the  sutured  borders  was  only  partial,  but 
the  front  of  the  cleft  was  solidly  closed,  and  a  useful  bridge  held  securely  at  the 
junction  of  the  hard  and  soft  palate.  Ultimately  the  cleft  was  completely  closed 
by  four  supplementary  operations.  The  lip  was  dealt  with  about  two  months  later. 
The  whole  result  was  admirable." 

After- Treatment.  When  the  child  is  put  back  to  bed,  warmth  should 
be  applied  by  hot  bottles.  The  side  position  is  best  at  first,  that  blood 
may  trickle  out  of  the  mouth.  When  the  risk  of  vomiting  has  passed  a 
little  ice  may  be  given.  The  hands  should  be  secured  for  the  first  few 
days.  For  the  first  forty-eight  hours  milk  with  ice  or  barley-water  only 
should  be  allowed.  After  this,  yolks  of  eggs,  arrowroot,  broths,  soups,  and 
(in  about  ten  days)  light  puddings,  jelhes,  may  be  allowed.  If  the 
patient's  temper  and  intelUgence  allow  of  it,  the  mouth  may  be  regularly 
syringed  or  washed  with  Condy's  fluid  or  boracic-acid  lotion.  In  other 
cases  it  is  best  to  leave  the  wound  quite  alone.  The  nurse  should  devote 
herself  to  preventing  the  child  from  crying,  and  to  keeping  the  patient 
amused.  Whenever  it  is  possible  the  child  should  be  taken  into  the  fresh 
air  after  the  first  two  or  three  days  (Owen).  There  should  be  no  hurry 
to  remove  the  sutures,  which,  if  not  of  silk  may  remain  for  seven 
or  ten  days  in  the  soft  and  an  almost  indefinite  time  in  the  hard  palate. 
No  one  should  be  allowed  to  look  at  them  either  early  or  often.  To 
prevent  the  child  getting  the  fingers  into  the  mouth  it  is  well  to  mould 
felt  sphnts  in  front  of  the  elbow-joints.  These  will  allow  of  movements 
of  the  hands  and  use  of  toys. 

To  make  this  subject  of  after-treatment  at  all  complete  a  few  words 
must  be  said  about  the  improvement  of  speech  after  the  cleft  has  been 
surgically  cured,  and  the  occasional  need  of  an  obturator.  Even  after  a 
complete  closure  of  the  cleft  much  awkwardness  of  speech  is  liable  to 
remain,  this  being,  of  course,  the  more  marked  the  older  the  patient  is. 

1  Dr.  Brophy's  words  on  the  point  are  :  "  If  we  are  unable  to  close  the  fissure  with  these 
wires,  if  from  lack  of  tissue  or  from  firm  resistance  of  the  parts  it  cannot  be  done,  there 
is  a  further  method  to  be  employed  which  will  obviate  these  difficulties.  With  your  knife, 
after  the  cheek  is  well  raised,  divide  the  mucous  membrane  just  over  the  malar  process, 
Here  insert  a  knife  in  the  horizontal  direction  dividing  the  bone  freely,  but  damaging  the 
mucous  membrane  as  little  as  possible." 


526  OPERATIONS  ON  THE  HEAD  AND  NECK 

Parents  are  often  to  blame  for  the  little  trouble  they  will  take  to  further 
the  success  of  the  surgeon's  efforts,  and  this  refers  in  many  cases  to  those 
who  have  not  the  excuse  of  the  ignorance  and  toilsome  life  of  the  poorer 
classes.  They  too  often  act  as  if,  because  the  cleft  is  closed,  no  further 
responsibility  rests  with  them.  Again,  the  patients,  being  usually  children, 
without  a  thought  as  to  the  future,  and  satisfied  with  the  improvement  in 
their  deglutition,  present  many  difficulties.  Not  only  has  the  child  to  be 
taught  the  right  way  of  using  its  organs  of  speech,  but  wrong  habits, 
especially  nasal  and  guttural  tones,  have  to  be  unlearnt.  This  is  only 
to  be  brought  about  by  means  of  systematic  lessons  and  practice  gone 
through  regularly  day  by  day  for  months  and  even  years.  No  plan  will 
be  fomid  better  than  that  recommended  by  Mr.  W.  Haward,  Clin.  Lect., 
"  On  Some  Forms  of  Defective  Speech  "  :  i  "  The  instructor  should  sit 
directly  facing  the  pupil  ;  the  pupil  is  made  to  fix  his  attention  thoroughly 
upon  the  face  of  the  teacher,  and  to  copy  slowly  his  method  of  articulation. 
This  should  be  displayed  by  the  teacher  in  an  exaggerated  degree,  every 
movement  of  the  lips  and  tongue  being  made  as  obvious  as  possible  to  the 
pupil,  and  the  more  difficult  sounds  or  movements  prolonged  for  the 
purpose.  Thus,  for  instance,  suppose  the  word  '  sister  '  were  to  be 
practised,  the  teacher,  having  filled  his  chest  with  a  long  inspiration, 
would  open  his  lips  and  draw  back  the  angles  of  his  mouth,  so  that  the 
pupil  could  see  well  the  position  of  the  tongue  against  the  teeth  ;  he 
could  then  prolong  the  hissing  sound  of  the  '  s,'  and,  finally,  separating  the 
teeth  as  the  sound  of  the  '  t  '  in  the  second  syllable  issues,  allow  the  pupil 
again  to  see  the  position  of  the  tongue  as  the  word  is  ended.  Or,  for 
another  example,  take  the  word  '  lily.'  Here  the  teacher  would  separate 
the  lips  and  teeth,  so  that  the  tongue  would  be  seen  curved  upwards, 
with  the  tip  touching  the  hard  palate  ;  the  word  would  then  be  pronounced 
with  a  prolongation  of  each  syllable,  the  teeth  and  lips  being  kept  open,  so 
that  the  uncurling  of  the  tongue  and  its  downward  movement  are  clearly 
seen.  So,  again,  in  teaching  the  proper  method  of  sounding  such  words 
as  '  wing  '  or  '  youth,'  much  aid  is  given  by  keeping  the  lips  some- 
what separated,  so  that  the  relation  of  the  tongue  and  palate  can  be  made 
manifest.  The  pupil  must  be  made  to  fill  his  chest, ^  and  then  to  imitate 
as  closely  as  possible  every  movement  and  sound  of  the  teacher  ;  and  this 
may  sometimes  be  assisted  by  making  the  pupil  feel  with  the  finger  as  well 
as  observe  with  the  eye  the  relative  movement  and  position  of  the  teacher's 
tongue  and  palate.  There  should  be  no  other  person  in  the  room  to  dis- 
tract the  pupil's  attention.  It  is  best  to  continue  the  exercise  for  a  short 
time  only,  and  to  repeat  it  frequently,  rather  than  fatigue  the  child  by  a 
long  lesson  ;  and  it  is  a  good  plan  to  take  an  ordinary  elementary  spelling- 
book  and  to  mark  the  words  which  the  pupil  finds  most  difficult  to  pro- 
nounce,^ so  that  these  may  be  especially  practised." 

With  regard  to  the  question  of  obturators  and  vela  ;*  in  cases  where 
it  has  been  found  impossible  to  close  a  very  wide  cleft,  or  where  it  is 
evident  that  even  after  a  successful  operation  the  palate  will  be  so  tense 
and  short  as  to  be  quite  unable  to  touch  the  pharynx,  and  so  shut  oft'  the 

1  Lancet,  1883,  vol.  i,  p.  111. 

^  Opening  the  mouth  widely  and  learning  to  keep  the  tongue  down  on  the  floor  of 
the  mouth  are  two  points  to  be  early  and  strenuously  insisted  upon.  The  patient  should 
practise  them  before  a  looking-glass. 

*  Especially  those  containing  the  letters  t,  b,  d,  k,  g,  s,  z,  and  i  (Rose). 

*  Acquired  clefts,  due  to  syphilitic  disease,  or  necrosis,  in  adult  patients,  are  usually 
best  treated  by  obturators. 


CLEFT  PALATE  527 

nose  from  tlio  mouth,  an  obturator  may  bo  icMjuired.  A  very  useful  foiin, 
tliat  of  Dr.  Suerseu,  of  Berlin,'  and  several  others,  are  described  by  Mr. 
Newland  Pedley.'^  The  whole  question  is  very  fairly  dealt  with,  and 
many  useful  hints  are  here  given  as  to  the  improvement  of  speech  in  these 
cases.  The  chief  disadvantages  of  instrumental  aids  are  that  if  fitted  early 
they  will  recjuire  fre([uent  alteration  ;  on  the  other  hand,  unless  worn  early 
they  will  be  of  little  service.  Moreover,  the  expenses  of  the  necessary 
repairs  and  renewals  can  rarely  be  met  by  hos])ital  patients.  -Just  the  same 
care  in  overcoming  faulty  habits  of  speaking  and  in  teaching  correct  ones 
is  required  now  as  after  a  successful  operation. 

Causes  of  Failure.  (I)  Vomiting.  (2)  Premature  cutting  of  sutures 
from  tension.  (.3)  IhvmorrJutge.  Serious  haemorrhage  in  children, 
either  at  the  time  or  later,  is  very  rarely  met  with.  In  cases  of  severe 
lucmorrhage  duri)ig  the  operation  Mr.  Berry's  advice  is  worth  remember- 
ing. "  If  a  smart  haemorrhage  occurs,  the  knife  should  not  be  at  once 
withdrawn,  but  made  to  cut  a  httle  further,  so  as  to  ensure  that  the 
vessel,  whether  artery  or  vein,  is  completely  divided." 

Mr.  H.  Marsh, ^  in  the  case  of  a  patient  aged  21,  was  compelled  to 
plug  the  posterior  palatine  canal  owing  to  severe  haemorrhage  on  the  sixth 
day. 

The  hocmorrhage  recurred  twice,  the  last  time  being  as  late  as  the  fourteenth 
day,  and  was  arrested  on  each  occasion  by  the  following  means  :  "  Searching  with  a 
sharii-pointed  probe,  passed  through  the  lateral  cut,  about  one-third  of  an  inch  in 
front  of  the  hamular  process,  which  can  be  easily  felt  through  the  soft  palate,  and 
about  the  same  distance  directly  inwards  from  the  wisdom  tooth,  I  felt,  after  two 
or  tlu-ee  attempts,  that  I  had  tixed  the  probe  in  the  orifice  of  the  canal,  and  at  the 
same  time  the  patient  screamed  with  pain  when  the  large  posterior  palatine  was 
touched.  A  wooden  plug,  made  by  sharpening  a  piece  of  firewood,  was  then  pressed 
firmly  into  the  canal,  by  holding  it  in  a  pair  of  strong  forceps  with  its  point  looking 
upwards,  and  a  little  backwards  in  relation  to  the  roof  of  the  mouth.  Directly  the 
plug  was  introduced  the  bleeding  ceased."  The  recurrence  was  due  to  the  plug 
slipping  out. 

(4)  Whooping  Cough.  (5)  Exanthemata.  (6)  The  child  futting  a 
finger  into  the  wound.  (7)  Swallowing  of  solid  food.  (8)  Feeble  condition 
of  the  child,  with  congenital  syphilis,  &c.  Children  of  defective  mind 
always  cause  additional  anxiety  in  the  after-treatment.  (9)  Acute  in- 
fantile Diarrhoea.  Though  mentioned  last,  this  baffling  pest  of  surgery 
is  too  well  known  to  those  who  have  to  operate,  in  the  summer  on  little 
children  in  hospitals. 

With  reference  to  the  above  causes  of  failure,  while,  very  occasionally, 
haemorrhage  at  the  time  of  the  operation  in  a  weakly  child,  prolonged 
vomiting  or  want  of  supervision  after  the  operation,  may  be  the  cause,  in 
the  very  great  majority  of  cases  the  failure  is  due  to  some  neglect  of  the 
precautions  which  are  recognised  as  essential.  They  are,  (a)  insufficient 
relief  of  tension  on  the  sutures  by  inadequate  use  of  the  raspatories  in 
freeing  the  muco-periosteum  flaps  when  the  lateral  incisions  are  made, 
or  in  separating  the  soft  parts  at  the  junction  of  the  hard  and  soft  palates  ; 
(b)  unskilful  paring  of  the  edges,  by  which  either  not  enough  is  done,  the 
cleft  not  being  completely  pared,  or  too  much  is  removed  and  the  tension 
thereby  increased  ;  (c)  bruising  of  the  edges  from  unskilful  manipulation 
with  instruments  or  sponges,  difficulty  in  passing  the  sutures,  &c.  In 
some  cases  where,  in  spite  of  free  separation  of  the  parts,  the  operation 

1  Brit.  Med.  Jonrn.,  1882,  vol.  ii,  p.  875. 

2  Gm/s  Hospital  Rcporls,  1894. 

^  Clin.  Soc.  Trans.,  vol.  xi,  p.  71. 


528  OPERATIONS  ON  THE  HEAD  AND  NECK 

occasionally  fails,  perhaps  from  the  presence  of  much  scar  tissue,  union 
may  still  be  secured,  much  as  in  the  case  of  a  hare-lip  (p.  488),  if  about  the 
tenth  day  the  edges  are  carefully  pared,  and  drawn  together  with  sutures 
of  silkworm-gut  or  silver  wire,  sufficiently  stout  not  to  cut  through 
readily,  and  not  drawn  too  tight.  The  explanation  of  this  happy  result 
is  probably  found  in  the  abundance  of  vascular  loops  now  present  on 
either  side  of  the  cleft.  In  the  case  of  a  partial  union,  where  one  or 
more  holes  persist,  there  should  be  no  hurry  to  interfere,  and  the  child 
should  be  got  into  the  best  possible  condition  beforehand,  by  a  stay  at  the 
seaside,  if  possible  Where  a  gap  remains  in  the  soft  palate,  the  course 
to  be  taken  will  be,  according  to  its  width,  either  a  fresh  operation  on  the 
former  lines,  or  one  in  which  a  flap  is  employed  by  Lane's  method 
(Fig.  235). 

REMOVAL  OF  GROWTHS  OF  THE  PALATE 

Growths  here,  though  rare,  have  a  special  interest,  from  their 
position,  and  may  thus  be  briefly  noticed.  For  a  good  account  of 
them  reference  should  be  made  to  a  paper  by  Mr.  Stephen  Paget, ^ 
in  which  the  following  points  are  brought  out  :  (1)  The  chief  groups 
are  the  polypoid  and  warty,  the  adenomatous,  the  sarcomatous,  and 
the  carcinomatous  ;  this  last  including  the  encephaloid,  which  are 
very  rare,  and  the  epitheliomatous,  commencing  in  irritation  here  as 
elsewhere.  (2)  That  it  is  hardly  possible  to  tell  beforehand  to  which 
group  the  growth  belongs.  (3)  Most  of  them,  especially  the  adeno- 
mata, can  be  shelled  out  with  surprising  ease.  (4)  That  the  growth 
itself  should  not  be  cut  into. 

The  commonest  growths  which  the  surgeon  has  to  deal  with  here  are 
sarcomata  and  epitheliomata.  In  either  case,  where  the  growth  is 
large  and  vascular,  we  would  strongly  urge  the  advisability  of  making  use 
of  such  aids  as  intratracheal  anaesthesia  or  a  preliminary  laryngotomy  and 
plugging  the  fauces,  slitting  the  cheek  and  ligaturing  the  external  carotid 
on  the  side  in  which  the  growth  extends  farthest  back.  Tying  the  above 
vessel  not  only  renders  the  operation  much  more  bloodless,  and  so  enables 
it  to  be  more  thoroughly  done,  but  diminishes  also  the  risk  of  secondary 
haemorrhage,  a  risk  that  in  a  part  like  this,  which  cannot  be  kept  aseptic, 
is  always  present.  Mr.  Jacobson  followed  the  above  course  in  two  cases, 
in  each  of  which  the  disease  implicated  the  pterygoid  region  on  one  side. 
One  was  an  epithelioma  of  the  hard  and  soft  palate  involving  the  alveolar 
process  and  the  pterygoid  region  on  the  left  side.  In  the  other  case,  one 
of  sarcoma  of  the  right  pterygoid  region  and  the  soft  palate,  an  opera- 
tion had  already  been  attempted  by  a  surgeon  at  Johannesburg.  Liga- 
ture of  the  right  external  carotid  allowed  of  the  removal  of  some  enlarged 
glands  at  the  angle  of  the  jaw,  and  prevented  any  severe  haemorrhage 
when  the  growth  was  shelled  out  of  the  palate  and  right  pterygoid  region. 
In  1905,  five  years  after  the  operation,  this  patient  was  married  and  fruit- 
farming  in  Cahfornia.     The  parts  were  perfectly  sound. 

In  the  case  of  a  growth  of  the  hard  palate,  peehng  it  off  with  a  blunt 
dissector  and  scraping  the  bone  will  be  quite  insufficient.  The  bone 
around  should  be  freely  removed  with  a  chisel  or  gouge  and  mallet,  or  a 
partial  removal  of  the  upper  jaw  {e.g.  its  palate  and  one  alveolar  process) 
performed,  if  needful. 

^  St.  Bartholomew's  Hospital  Reports,  vol.  xxii. 


CHAPTER  XXV 

REMOVAL  OF  THE  TONGUE— OPERATIONS  FOR 
EPITHELIOMA  OF  THE  TONGUE 

REMOVAL  OF  THE  TONGUE 

(Figs.  241-245) 

The  day  when  the  belief  is  accepted,  and  acted  upon,  that  cancer  of  the 
tongue,  Kke  other  epithehomata,^  has  a  pre-cancerous  stage,  and  that  this 
is  the  stage  in  which  we  ought  to  operate,  will  be  a  happy  one  for  hundreds 
of  patients  and  for  the  results  of  surgery.  Of  all  the  painful  deaths  by 
which  men  leave  this  world  there  are  few  more  miserable  and  distressing 
than  that  which  closes  life  by  cancer  of  the  mouth.  And  yet,  though  in 
the  case  of  the  tongue  this  most  important  stage  is,  from  the  position  of 
the  organ  which  it  attacks,  peculiarly  under  our  eyes  and  lies  open  to 
our  examination  and  detection,  how  frequently  it  is  overlooked !  ^ 

Before  describing  the  different  operations  it  will  be  well  to  say  some- 
thing with  reference  to  two  or  three  very  practical  points  which  arise 
with  every  case  of  tongue  cancer,  a  form  of  cancer  which,  it  must  be 
remembered,  is  very  frequent  and  increasing  in  frequency  ;  ^  which  attacks 
all  ranks  of  life  ;  which,  after  its  early  stage,  is  especially  malignant,'*  and, 
finally,  for  the  relief  of  which  an  operation  is  as  much  dreaded  and 
deferred  by  men  as  that  for  carcinoma  mammge  is  by  women. 

A  Pre-Cancerous  Stage.  However  tongue  cancer  begins,  it  usually 
passes  through  the  above  stages,  i.e.  a  stage  (the  duration  of  which  is 
unknown,  and  varies  extremely)  in  which  inflammatory  changes  only 
are  present,  viz.  ulceration  and  other  changes  in  the  epithelium,  not 
amounting,  as  yet,  to  epithelioma,  but  on  which  epithelioma  inevitably 
supervenes.  The  boundary"  line  between  this  pre-cancerous  stage  and 
cancer  is  extremely  narrow  ;  the  duration  of  this  stage  may  be,  and  often 
is,  extremely  brief. ^ 

The  common  pre-cancerous  lesions  are  dental  or  traumatic  ulcers 
and  chronic  superficial  glossitis — usually  of  syphilitic  origin. 

Aids  in  recognising  this  stage  are  :    (1)  The  duration  of  the  ulcer. 

^  The  rare  sarcoma  of  the  tongue  is  alluded  to  at  p.  548. 

^  See  Papers  by  Mr.  Jacobson,  (rz/y's  Hospital  Reports,  1889,  ]).  245;  Practitioner, 
May  1903. 

^  Amongst  common  cancers,  e.g.  of  breast,  rectum,  uterus,  &c.,  cancer  of  the 
tongue  stands  about  tliird,  although  so  rare  in  women.  Mr.  Barker,  in  his  carefully 
worked-out  article  on  "  Diseases  of  the  Tongue  "  (Syst.  of  Surg.,  vol.  ii,  p.  578),  gives  a 
series  of  tables  showing  that  in  the  previous  thirty  years  there  had  been  a  steady  increase 
from  2"6  to  11 '5  per  cent. 

*  This  is  shown  in  the  following  facts  :  (a)  The  rapidity  here  is  quite  different  from  that 
in  other  epitheliomata.  Epithelioma,  usually  thought  a  slow  cancer,  here,  in  a  moist 
warm  cavity,  much  irritated,  and  never  dry  and  warty,  is  terribly  rapid.  (6)  Gland 
invasion  is  here  not  only  certain,  but  inevitably  early  as  well, 

5  See  a  paper  by  Sir  H.  T.  Butlin  on  "  The  Early  Diagnosis  of  Cancer  of  the  Tongue  and 
the  Results  of  Operation  in  such  Cases,"  {Proc.Roy.  Sac.  Med.,  Clin.  Sec,  March  1912,  p.  99.) 
SURGERY  I  529  34 


530  OPERATIONS  ON  THE  HEAD  AND  NECK 

(2)  Its  obstinacy  to  treatment.  (3)  The  age  of  the  patient.  (4)  Absence 
of  any  induration  or  fixity. 

Questions  arising  before  operation.  The  operating  surgeon  will  often 
be  called  upon  to  give  an  answer  to  the  two  following  questions  :  Will  the 
disease  be  permanently  cured  ?  If  a  permanent  cure  is  impossible,  will 
life  be  bettered  and  prolonged  ? 

A.  Will  the  disease  be  permanently  cured  ?  Really  permanent  cures, 
i.e.  cases  in  which  no  reappearance  of  the  disease  has  shown  itself  five 
years  after  the  operation  on  the  tongue,  are  as  a  matter  of  common  know- 
ledge, still  very  rare.  From  Mr.  Jacobson's  experience — and  it  has  been 
a  large  one,  chiefly  of  advanced  cases — the  proportion  of  permanent 
recoveries  carefully  watched  would  not  be  above  12  per  cent.^  Reappear- 
ance in  the  tongue  after  a  well-performed  operation  is  rare,  but  as  the 
glands  are  invaded  in  the  great  majority  of  patients  by  the  time  they 
come  to  us,  a  permanent  recovery  is  in  these  cases  exceptional,  however 
thoroughly  repeated  operations  are  performed.^ 

Sir  J.  Hutchinson  ^  drew  attention  to  the  following  facts  which  cannot 
be  emphasised  too  strongly.  Gland  infection  here  begins  almost  from  the 
very  day  that  the  sore  assumes  suspicious  features.  Again,  lymphatic 
glands  may  become  involved  through  ulcers  of  the  most  insignificant  size 
and  of  the  briefest  duration.  Lastly,  the  same  authority  points  out  that 
cancer  germs  may  remain  latent  in  the  lymphatic  glands  for  several  years 
and  then  show  signs  of  disease.  Before  leaving  this  subject  it  may  be 
pointed  out  that  invasion  of  the  glands  is  here  not  only  certain,  usually 
early,  but  also  peculiarly  baneful,  owing  to  (1)  the  way  in  which  epithe- 
lioma infects  the  glands — inflammatory  cells,  as  well  as  those  of  cancer, 
passing  from  the  primary  growth,  if  ulcerated,  as  it  usually  is,  into  the 
glands  ;  and  (2)  the  great  importance  of  the  structures  amongst  which 
the  cervical  lymphatic  glands  lie.  When  epitheliomatous  glands  are 
operated  upon,  the  following  conditions  interfere  with  a  thorough  extir- 
pation of  the  disease  :  (a)  The  number  of  the  glands  and  the  abundant 
communication  between  the  different  groups,  the  importance  of  the 
structures  closely  adjacent  to  the  deeper  ones,  and  the  fact  that  the  glands 
may  be  affected  and  yet  so  minute  as  to  escape  the  most  careful  operator. 
(h)  The  presence  only  too  often  of  septic  cells  (the  original  trouble  being, 
usually,  an  ulcer)  as  well  as  of  malignant  deposit  in  the  glands  so  mats 
them  to  adjacent  parts  as  to  make  extirpation  quite  impossible.     In- 

^  Kocher  {Op.  Surg.,  Eng.  Trans.,  p.  415)  gives  the  following  statistics  :  "  Between 
1890  and  1903  our  operations  numbered  sixty-two.  In  only  ten  could  the  ojDeration  be 
performed  from  the  mouth  without  a  preliminary  operation,  while  in  thirteen  the  cheek 
had  to  be  split ;  in  twenty-three  the  jaw  was  divided  in  the  mid-line,  in  four  laterally, 
while  in  three  cases  it  was  partially  resected.  In  seven  cases  complete  excision  of  the 
tongue  from  its  root  was  undertaken."  The  total  operation  mortality  was  only  6'6 
per  cent,  in  uncomi^licated  cases  and  14"51  per  cent,  in  those  in  which  the  jaw  was  divided. 
"  We  were  able  to  obtain  the  subsequent  history  in  fifty-seven  of  the  sixty-two  patients. 
Only  five  may  be  regarded  as  radical  cures,  a  sufficiently  long  interval  having  elapsed.  In 
one  case  a  recurrence  took  place  after  three  years,  in  another  after  ten  years.  Six  patients 
who  have  been  under  observation  for  less  than  three  years  are  in  perfect  health  up  to  the 
present  time,  so  that  if  we  regard  all  these  six  cases  as  cured,  our  statistics  as  regards 
radical  cure  would  be  22'8  per  cent.,  but  in  absolutely  certain  cases,  i.e.  up  to  seven 
years,  16"2  per  cent,  have  remained  free  from  recurrence."  The  results  of  197  cases 
operated  upon  by  the  late  Sir  H.  T.  Butlin  will  be  found  recorded  in  the  Brit.  Med.  Journ., 
Jan.  2,  1909,  p."l. 

-  If  a  sore  has  been  persistent  for  more  than  three  months,  permanent  recovery  is  very 
doubtful.  If  it  has  persisted  for  over  six  months,  if  more  than  one-third  of  the  tongue 
is  invaded,  if  the  floor  of  the  mouth  is  involved,  permanent  recovery  is  well-nigh  certainly 
hopeless. 

3  Brit.  Med.  Journ.,  1891,  vol.  ii,  p.  1190. 


REMOVAL  OF  THE  TONGUE  531 

flaniinatory  soitening  having  set  in  leads  to  their  breaking  down  during 
attempts  at  their  removal,  with  the  result  that  shells,  still  the  seat  of 
cancerous  foci,  are  left  behind.  These  relics,  owing  to  the  vascularity 
of  the  surrounding  parts,  do  not  die,  but  preserve  sufficient  vitality  to 
act,  a  little  later,  as  centres  of  recurrent  disease. 

The  explanation  of  the  small  number  of  permanent  recoveries  after 
removal  of  cancer  of  the  tongue  is  not  altogether  to  the  credit  of  our 
profession.  Patients  and  we,  alike,  are  too  often  both  to  blame.  The 
gravity  of  the  disease  is  overlooked,  the  time  of  the  "  pre-cancerous 
stage  "  is  lost.  Because  cancer  of  the  tongue  is  so  often  preceded  by 
syphilis,  or  local  irritation,  the  practitioner  diagnoses  the  above,  and 
suggests  them  as  the  essential  part  of  the^mischief  :  "  gives  drugs  another 
chance,"  e.g.  potassium  iodide,  mercury,  caustics.^  To  these  there 
are,  in  nearly  every  case,  the  strongest  objections  in  the  pre-cancerous 
stage.  Time  is  lost,  strength  is  lost,  and  the  patient  is  lulled  and  befooled, 
while  all  the  time  the  vascularity  and  irritation  around  the  ulcer  are 
increased.  Furthermore,  the  patient  is  in  part  responsible  for  the  delay, 
as  he  very  naturally  dreads  the  operation,  exaggerating  its  danger,  pain- 
fulness,  and  the  supposed  inevitable  loss  of  speech.  We  shall  never  be  able 
successfully  to  combat  the  above  till  (I)  the  importance  and  value  of  the 
pre-cancerous  stage  are  recognised  and  thus  limited  operations  are  j  ustified ; 
(2)  when  medical  men  will  assure  their  patients  that  even  after  more 
extensive  operations,  sufficient  power  of  speech  will  remain. 

B.  If  a  permanent  cure  is  impossible,  will  life  be  bettered  and  pro- 
longed ?  Cases  which  are  not  operated  on  die  within  eighteen  months, 
many  in  twelve  months.  An  operation  wisely  planned  and  well  carried 
out  often  gives  a  gain  of  six  or  eight  months.  This  is  a  gain  not  only  of 
time,  but  also  of  comfort.  Death  by  glandular  recurrence  in  the  neck  is 
less  painful  and  noisome  than  death  by  mouth  cancer.  No  one  who  has 
seen  much  of  tongue  cancer  will  have  any  difficulty  in  answering  the  ques- 
tion which  of  the  two  is  the  more  painful  to  the  patient  and  distressing 
to  those  around  him — tongue  cancer  with  its  terrible  foetor,  profuse  and 
foul  salivation,  its  pitiless,  incessant,  weary,  racking  aching  of  tongue, 
ear,  face,  and  teeth  ;  or  recurrence  in  the  cervical  glands,  an  alternative 
in  which  the  patient  is  often  able  to  work  up  till  near  the  last  and,  till 
towards  the  close,  is  free  from  the  agonising  tenderness,  the  stinking 
foetor,  the  dribbhng  of  foul  sahva  (not  only  half  poisoning  the  patient,  but 
rendering  him  noisome  to  others),  and  the  slow  starvation  day  by  day 
of  tongue  cancer.  Where  an  operation  is  certainly  attended  with  risk, 
the  patient  in  facing  it  may  be  relieved  by  the  assurance  that  a  life 
prolonged  in  hideous  misery  and  constant  agony  is  worse  than  death 
following  close  on  an  operation.  "  When  a  man  has  only,  suppose,  two 
or  three  years  to  live,  it  is  no  small  advantage  if  at  least  half  the  time  can 
be  spent  in  comfort  rather  than  in  misery,  and  in  profitable  work  rather 
than  in  painful  idleness  "  (Paget). 

If  a  patient  cannot  make  up  his  mind  to  an  operation  and  is  losing 
precious  time,  he  should  be  warned,  without  being  unduly  frightened,  of 
the  state  of  things,  alluded  to  in  the  few  fines  above,  which  will  inevitably 
follow.  Usually,  as  soon  as  this  sets  in,  i.e.  when  the  condition  of  the 
tongue  renders  him  a  nuisance  to  himself  and  others,  the  patient  becomes 

^  A  word  of  warning  may  be  given  hero  with  regard  to  the  use  of  X-rays  or  radium 
in  the  early  stages  of  this  disease.  An  epithelioma  of  the  tongue  will  not  be  cured  by 
these  meaas  and  much  precious  time  may  easily  be  wasted. 


532  OPERATIONS  ON  THE  HEAD  AND  NECK 

willing  to  run  any  risk.  But,  too  often,  by  this  time,  the  glands  have  for 
some  time  been  enlarged,  and  the  mischief  has  reached  the  floor  of  the 
mouth  or  the  alveolar  mucous  membrane  by  extension,  though  not  yet 
perhaps  with  ulceration. 

Operations.     The  following  four  will  be  described,  viz.  : 

(1)  Whitehead's. 

(2)  Kocher's  modification  of  Syme's  operation. 

(3)  Kocher's  former  operation. 

(4)  Trans-hyoid  pharyngotomy. 

Preliminary  Treatment.  Whichever  method  is  chosen  the  following 
details  are  to  be  attended  to  carefully.  For  as  many  days  as  possible 
before  the  operation  every  effort  should  be  made  to  get  the  mouth  clean. 
All  loose  teeth  or  stum.ps  and  all  tartar  should  be  removed.  The  patient 
should  brush  his  teeth  two  or  three  times  in  the  day  thoroughly,  and  make 
himself  handy  in  washing  out  his  mouth,  and  in  the  use  of  a  feeder  and 
tube.  Much  too  often  these  most  important  steps  are  left  till  after 
the  operation,  and  to  a  nurse.  If  practised  beforehand  they  occupy  the 
patient's  thoughts,  and  after  the  operation  they  are  not  a  new  thing  to  him, 
and  no  one,  however  much  in  earnest,  can  carry  it  out  as  well  and  as  pain- 
lessly as  the  patient  himself.  As  to  the  mouth-wash,  from  its  unirritating 
nature,  Condy's  fluid  is  excellent.  Solutions  of  chinosol  or  of  carbolic  acid 
are  also  admirable.  Before  the  operation  the  surgeon  should  take  note  of 
the  teeth,  as  to  their  cleanness,  and  whether  sufficient  molars  are  present 
to  take  the  leverage  of  the  ordinary  gag.  If  this  is  not  the  case,  Hewitt's 
wheel-gag  may  be  used.  Some  surgeons  recommend  that,  when  the 
patient  is  anaesthetised,  the  sui"face  of  the  ulcer  should  be  treated  with 
pure  carbolic  acid,  strong  formalin,  or  even  the  actual  cautery,  with  the 
view  of  rendering  the  surface  as  aseptic  as  possible.  The  surgeon  should 
also  ascertain  beforehand  the  exact  situation  and  extent  of  the  growth. 
The  transverse  incision  behind  the  growth  should  always  lie  a  full  inch 
posterior  to  the  cancer.  Only  in  some  cases  involving  the  posterior 
third  is  this  occasionally  impracticable.  Even  in  doubtful  cases  it  will 
be  wiser  to  make  a  rule  to  adopt  the  above  margin.  If  he  leaves  any 
examination  to  be  made  at  the  time  of  the  operation,  his  finger  may  not 
only  become  infected  if  he  be  dealing  with  an  ulcer,  as  is  usually  the  case, 
but  he  will  very  likely  start  bleeding,  which  is  needless,  and  may  be 
embarrassing  if  the  anaesthetic  at  that  moment  be  causing  difficulties. 

(1)  Whitehead's  Operation  (Fig.  241).  By  this  method  the  tongue 
is  removed  through  the  mouth  by  scissors,  the  glands  being  also  removed 
either  at  the  same  or  another  operation.  The  advantages  of  this  method 
are  very  great.  They  are  :  (a)  The  transverse  section  of  the  body  of  the 
tongue  can  be  placed,  deliberately,  well  behind  the  growth.  (6)  The 
resulting  wound  is  very  clean,  there  being  very  little  laceration.  The 
infection  which  would  take  place  from  an  extensive  operation,  even  with 
scissors,  is  readily  checked  by  the  use  of  the  lotions  mentioned  above. 
The  advantage  of  those  in  saving  a  patient  whose  vitahty  is  very  often 
lowered,  from  the  depressing  effects  of  being  liable  for  days  to  breathe  and 
swallow  with  a  foetid  sore  in  his  mouth,  in  securing  rapid  granulation  and 
healing,  and  thus  enabhng  the  patient  to  be  early  propped  up,  and  soon 
to  leave  his  bed,  must  be  obvious  to  every  surgeon  who  knows  how  great 
the  risk  is  of  fatal  broncho-pneumonia.  For  the  same  reason  secondary 
haemorrhage,  where  ordinary  care  is  taken,  is  unknown,  (c)  The  instru- 
ments required  are  extremely  simple  and  few,  as  will  be  seen  from  the 


REMOVAL  OF  TUK  TONGUE 


533 


accounts  of  the  operation.^  The  cliiel'  disadvantage  of  Whitehead's 
method  is  that  it  does  not  permit  of  the  surgeon  cutting  deeply  in  cases 
where  the  growth  has  extended  along  the  muscles  to waVds  the  hyoid  bone. 
To  such  cases  it  is  unsuited  and  Kocher's  modification  of  Syme's  method 
is  always  then  to  be  preferred. 

Before  tU>scribing  the  operation  certain  preliminary  points  of  it  nuist 
be  discussed. 

A.  The  Anaesthetic.  It  is  most  essential  that  the  anaesthetic  should  be 
in  the  hands  of  a  man  who  can  be  thoroughly  trusted.  It  is  often  taken 
badly  in  these  cases,   with  nmch  dyspnoea  and  restlessness  at  first ; 


Fig.  241. 


and,  during  the  operation,  owing  to  the  open  mouth  admitting  much  air, 
and  the  fear  of  interfering  with  the  operator,  the  patients  often  "  come  to  " 
prematurely.  The  only  thing  is  to  get  them  well  under  at  first  ;  later 
on  it  will  be  best  not  to  keep  them  too  much  under  the  influence  of  the 
anaesthetic,  in  order  that,  the  sensibility  of  the  larynx  not  being  lost, 
the  blood  may  not  enter  the  air  passages.  The  administrator  must  watch 
the  tint  of  the  lips,  the  veins  in  the  cheeks,  and  know  when  a  little  blood 
is  only  safely,  though  noisily,  bubbhng  at  the  back  of  the  fauces,  and  when 
it  is  getting  into  the  trachea.  If  the  tint  of  the  parts  mentioned  above  is 
sufficiently  red  or  pink  all  is  well  ;  they  quickly  show  a  tendency  to  lividity 
on  the  one  hand,  and  pallor  on  the  other, 

1  On  the  value  of  Mr.  Whitehead's  method  Sir  H.  Butlin  writes  (Oper.  Surg,  of  Malig. 
Dis.,  p.  154)  :  "  Whitehead's  operation  for  removal  of  one  part  or  the  whole  of.the  tongue 
haa  been  my  stock  operation  for  the  past  ten  years  or  more.'" 


534  OPERATIONS  ON  THE  HEAD  AND  NECK 

The  question  of  the  advisabiUty  of  a  prehminary  laryngotomy  now 
arises.  It  forms  no  part  of  a  Whitehead's  operation  proper.  The 
operator  who  introduced  the  scissors  method,  and  whose  success  with  it 
is  so  well  known,  never  at  any  rate,  at  first,  made  use  of  a  preliminary 
laryngotomy.  After  the  laryngotomy  has  been  performed  the  pharynx 
is  plugged  with  sterilised  gauze  and  the  anaesthetic  is  administered  through 
the  laryngotomy  tube. 

The  anaesthetist  and  his  apparatus  are  thus  much  more  out  of  the 
way  of  the  surgeon,  there  is  no  chance  of  blood  being  drawn  down  into  the 
larynx  or  trachea,  and,  on  this  account,  there  is  a  diminished  likelihood 
of  septic  pneumonia.  With  the  fauces  plugged,  and  the  patient  breathing 
through  a  laryngotomy  tube,  the  surgeon  can  neglect  the  haemorrhage 
more,  can  so  operate  with  greater  deliberation,  and  consequently  is  enabled 
throughout  to  keep  more  surely  wide  of  the  disease.  For  these  reasons 
a  preliminary  laryngotomy,  with  plugging  of  the  fauces,  may  be  recom- 
mended in  these  cases  :  (1)  When  the  growth  extends  beyond  the  middle 
of  the  tongue  into  the  posterior  third.  (2)  When  the  floor  of  the  mouth 
is  at  all  involved.  (3)  When  the  tongue  is  so  fixed  that  the  diseased 
portion  cannot  be  drawn  out  of  the  mouth.  In  growths  limited  to 
the  anterior  half  of  the  tongue,  unless  there  is  much  fixity,  laryngotomy 
is  not  needed,  for,  as  will  be  seen  below,  sufficient  of  the  tongue  in  such 
cases,  after  very  little  use  of  the  scissors,  comes  right  out  of  the  mouth. 

If  it  be  decided  to  perform  laryngotomy,  this  operation  is  done  as 
described  on  p.  562,  and  sterilised  gauze,  secured  by  a  loop  of  silk,  is 
packed  into  the  pharynx  behind  the  fauces.  The  gauze  must  be  pressed 
well  back,  and  care  taken  that  it  does  not  force  backwards  the  base  of  the 
tongue,  or  it  may  cause  some  difficulty  in  securing  the  lingual  artery 
when  the  transverse  section  of  the  tongue  is  made  far  back.  In  a  pro- 
longed operation,  where  the  sponge  becomes  soaked  with  blood,  it  must 
be  removed  and  renewed.  So  little  sloughing  and  swelling  follows 
Whitehead's  operation  that,  as  a  rule,  the  laryngotomy  tube  may  be 
removed  before  the  patient  has  left  the  operating  table  or  as  soon  as  he 
is  back  in  bed. 

The  anaesthetic  may  also  be  administered  by  Crile's  method,  in  which 
tubes  are  passed  along  the  floor  of  the  nasal  fossae  to  the  superior  aperture 
of  the  larynx,  the  pharynx  being  plugged  with  sterilised  gauze  when  these 
are  in  place.  The  intratracheal  method  of  anaesthesia  {q.v.,  p.  781)  is 
admirable  for  the  removal  of  the  enlarged  glands,  and  also  for  the  operation 
on  the  tongue  :  the  tube  in  the  mouth  does  not  get  in  the  way  of  the 
operator.  The  sole  disadvantage  is  that  the  somewhat  complicated 
apparatus  may  not  be  at  hand,  or  the  services  of  an  anaesthetist  sufficiently 
skilled  in  its  use  available. 

B.  Should  the  tongue  and  the  enlarged  glands  be  both  dealt  with  at 
one  operation  ?  There  is  much  to  be  said  in  favour  of  both  sides  of  this 
question.  Removal  of  the  tongue  itself  is  a  serious  operation,  and  removal 
of  the  enlarged  glands  requires  always  a  long  and  careful  dissection  calling 
for  much  care  and  deliberation  on  the  part  of  the  operator.  For  thorough 
extirpation  of  malignant  glands  the  operator  should  not  be  hurried.  On 
the  other  hand,  many  patients,  after  undergoing  one  operation  of  such 
severity  as  removal  of  the  tongue,  are  unwilling  to  consent  to  any  further 
operation.  The  surgeon  should  therefore  be  guided  by  the  extent  of  the 
disease  jind  the  number  and  fixity  of  the  enlarged  glands,  and  also  the 
temperament  and  condition  of  the  patient. 


RKMOVAI.  OF  THE  TONGUE 


535 


In  ail  elderly  patient  of  iin])aired  vitality  with  extensive  disease  and 
many  enlarged  glands,  operation  in  two  stages  will  certainly  be  desirable. 
In  a  younger  and  more  healthy  patient  with  less  extensive  disease  the 
whole  may  be  safely  completed  under  one  anaesthesia.  When  the 
operation  is  done  in  two  stages  some  surgeons  remove  the  tongue  first 
and  the  glands  about  ten  days  later  ;  other  remove  the  glands  first,  leaving 
the  tongue  to  be  dealt  with  hiter.  One  disadvantage  of  the  first  of  the 
plans  is  that  owing  to  septic  absorption  the  diseased  glands  may  enlarge, 
break  down  and  suppurate,  thus  increasing  the  difficulty  of  their  removal. 
Against  the  second  plan  it  is  argued  that  the  primary  growth  is  still  left 
and  may  continue  in  the  interval  to  disseminate  epitheliomatoiLS  cells. 
An  advantage  of  first  operating  upon  the  glands  is  that  the  lingual  artery 
may  be  tied  tluring  the  operation. 

C.  Splitting  the  Cheek  (Fig.  242).  This  step  is  an  excellent  one.  It 
may  be  made  use  of,  in  men  especially,  in  cases 

where  the  disease  is  situated  very  far  back, 
extending  close  to,  or  on  to,  the  anterior  pillar 
of  the  fauces,  where  the  haemorrhage  is  expected 
to  be  especially  free,  where  the  light  is  unavoid- 
ably very  bad,  or  where  there  is  unusual  diffi- 
culty in  getting  the  jaws  well  apart.  The 
improved  view  is  a  very  great  aid  in  these 
cases.  The  cheek  is  divided  as  far  back  as  the 
anterior  border  of  the  masseter,  below  Stenson's 
duct  and  parallel  to  the  branches  of  the  facial 
nerve  which  thus  are  not  injured  :  the  facial 
artery  is  divided  and  the  ends  of  this  and 
several  small  branches  are  secured  at  once.  The 
parts  require  most  careful  adjusting  afterwards, 
especially  at  the  corner  of  the  mouth,  where, 
from  the  dribbling  of  saliva,  primary  and  exact 
union  is  not  always  secured.  As  the  branches  of 
the  facial  nerve  are  not  divided,  there  is  no 
resulting  muscular  atrophy. 

D.  Preliminary  Ligature  of  the  Linguals.  When  the  tongue  and  the 
enlarged  glands  are  removed  at  the  same  operation  the  removal  of  the  glands 
should  be  first  effected  and  the  lingual  artery  ligatured  in  the  course  of  this 
part  of  the  operation.  Otherwise  this  precaution  is  not  recommended 
for  the  following  reasons  :  (1)  The  haemorrhage  may  be  as  free  as  in  the 
usual  operation  with  scissors,  performed  without  any  such  prehminary.^ 
(2)  If  the  operation  with  scissors  be  performed  with  attention  to  the 
details  given  below,  the  haemorrhage  is  not  so  difficult  to  deal  with  as  to 
require  this  precaution.  (3)  The  operation  of  ligature  of  one,  or  possibly 
both,  linguals  is  by  no  means  an  operation  that  can  always  be  done 
quickly,  and  may  be  a  matter  of  considerable  difficulty. 

The  Operation.  A  good  light  is  absolutely  essential.  Dayhght 
close  to  a  window  is  far  the  best.  If  it  is  needful  to  operate  when  the  above 
cannot  be  obtained,  as  on  a  foggy  November  afternoon,  a  good  head-lamp 
will  be  useful.  But  no  tongue  sihould,  if  it  can  be  avoided,  be  removed  on 
a  foggy  day,  not  so  much  on  account  of  the  light,  but  because  of  subse- 
quent respiratory  trouble. 

^  When  this  happens  the  vessel  has  been  probably  seotired  in  front  of  a  large  dorsalis 
linguae,  subsequently  divided. 


Fig.  242.     A,  Incision  for 
splitting  the  cheek.    B,  In- 
cision    for    removing    the 
enlarged  glands. 


536 


OPERATIONS  ON  THE  HEAD  AND  NECK 


In  making  arrangements  for  a  good  light,  the  surgeon  will  remember 
that,  while  the  removal  itself  takes  but  a  short  time,  getting  the 
patient  under  the  ansesthetic,  and  keeping  him  under  its  influence,  often 
prolong  the  operation.  It  may  not  be  superfluous  to  add  here  that 
this  is  an  operation  which  calls  for  coolness  and  decision  on  the  part 
of  the  operator,  and  for  promptness  with  their  help  on  the  part  of  all  those 
who  assist.  The  surgeon  must  be  cool  and  deliberate  at  three  periods 
especially  :  (1)  In  taking  up  all  bleeding-points  which  are  not  checked  by 
pressure  and  by  pulling  on  the  tongue  ;  there  must  be  no  hurried  and  often 


Fig.  243.     Condition  of  mouth  a  year  after  complete  removal  of  the  tongue  in 
a  patient  aged  67.     The  absolutely  edentulous  jaws  are  to  be  noted. 


futile  snapping  at  such  spirting  vessels.  (2)  In  making  the  transverse 
incision,  the  operator's  mind  must  be  absolutely  decided  where  he  is  going 
to  cut,  and  he  must  not  forget  the  fact  that  it  is  no  good  cutting  well 
behind  the  growth  if  the  section  below  is  made  dangerously  near  it. 
(3)  When  the  tongue  is  removed  there  must  be  no  hurry  in  taking  the 
patient  back  to  bed  before  all  bleeding  is  thoroughly  arrested.  As  long 
as  any  blood  tends  to  trickle  out  of  one  corner  of  the  mouth  some  vessel, 
probably  one  of  the  Unguals  or  a  dorsalis  linguae,  requires  tying.  Yet 
another  condition  calling  for  patience  and  coolness  on  the  part  of  the 
surgeon  is  where  the  patient,  because  he  was  not  sufficiently  anaesthetised 
at   first,    or   from   some    delay   in    the    operation,    requires   additional 


REMOVAL  OF  THE  TONGUE  5;37 

aiiwsthosia.  No  crowding  on  the  operator,  no  obstruction  to  the  light  by 
bystanders,  should  be  permitted  for  a  nion\ent. 

The  anaesthetic  having  been  administered,  preferably  by  Crilc's  or 
by  the  intratracheal  method,  the  patient  is  brought  quite  to  that  side 
of  the  table  at  which  the  surgeon  stands.  A  gag  ^  is  placed  on  the  side 
of  the  mouth  opposite  to  the  growth,  and  the  mouth  widely  opened. 
The  tongue  is  then  transfixed  on  the  diseased  side,  well  back  in  its  anterior 
third,  with  a  needle  loaded  with  stout  silk  or  catgut ;  this  is  looped  and 
knotted,  and  the  tongue  thus  well  drawn  out  of  the  mouth.  The  surgeon 
then,  where  one  half  only  is  involved,  with  a  sharp  knife  splits  the  tongue 
longitudinally  along  the  median  raphe,  to  a  point  well  behind  the  growth. 
Where  the  whole  anterior  portion  of  the  tongue  is  diseased  this  step,  which 
would  mean  cutting  through  the  growth,  is  to  be  omitted. 

The  diseased  half  or  the  whole  tongue  being  drawn  well  out  of  the 
mouth  by  means  of  the  silk  loop  or  by  reliable  forceps,  the  surgeon  next 
divides  with  scissors  the  mucous  membrane  between  the  tongue  and  the 
alveolar  process,  keeping  close  to  the  bone  so  as  to  be  wide  of  the  disease. 
The  anterior  pillar  of  the  fauces  is  next  divided.  While  the  above  steps 
are  taken,  an  assistant  sponges  away  any  blood  into  the  hollow  of  the 
cheek  and  out  of  the  mouth.  Careful  sponging,  and  sponge-pressure  on 
bleeding-points,  are  most  essential  if  the  surgeon  is  to  see  his  way  and  cut 
wide  of  the  disease. 

If  the  disease  has  implicated  the  frsenum  and  its  vicinity,  two  or 
three  of  the  lower  incisors  should  have  been  previously  extracted  so  that 
the  scissors  may  be  introduced  below  the  level  of  the  disease.  If  this 
be  not  done  the  scissors  have  to  be  dipped  in  over  the  teeth  in  an  awkward 
way,  and  one  which,  as  soon  as  bleeding  occurs,  makes  it  impossible  to  be 
certain  of  getting  below  the  disease.  The  scissors  can  be  introduced 
with  much  greater  facility,  and  used  to  much  better  purpose,  if  a  gap  be 
made  by  extraction  of  these  teeth. 

When  half  of  the  tongue  has  been  freed  all  round  the  muscles  between 
it  and  the  floor  of  the  mouth  are  cut  through  with  a  series  of  short 
snips  until  the  diseased  portion  is  separated  on  the  level  of  the  lower 
part  of  the  jaw,  and  well  beneath  the  growth,  as  far  back  as  is  needful. 
Where  the  surgeon  feels  that  he  is  cutting  dangerously  near  the  base 
of  the  growth,  the  tongue  should  be  raised  by  a  vulsellum-forceps  grasping 
it  laterally.  During  this  stage  oozing  will  take  place,  and  one  or  two  small 
arteries  bleed  with  varying  freedom  in  different  cases,  but  these  will  yield 
to  pulling  steadily  on  the  tongue,  and  to  firmly  applied  sponge-pressure. 

The  tongue  having  been  freed  horizontally  up  to  a  point  well  behind 
the  growth,  the  transverse  section  is  now  made,  and  here  arises  the  question 
as  to  the  best  way  of  securing  the  lingual  artery.  The  most  accurate 
method  is  that  of  Mr.  Cathcart.  Many  surgeons  are  in  the  habit  of 
finding  the  lingual  artery  by  cutting  down  on  it  gradually  as  the  deeper 
parts  of  the  tongue  are  divided  :  Mr.  Cathcart  has  put  this  most  important 
step  on  a  definite  anatomical  basis. ^ 

His  method  is  founded  on  the  fact  that  the  hyoglossus  under  which 
the  lingual  artery  runs,  though  attached  to  the  posterior  third  of  the 
tongue,  can  be  reached  from  the  mouth  when  the  tongue  is  drawn  far  out, 
and  the  mucous  membrane  has  been  divided  between  it  and  the  jaw.     The 

^  Sir  F.  W.  Hewitt's  modification  of  Mason's  gag  is  the  readiest  and  most  efficient  in 
cases  where  sufficient  teeth  are  present. 
-  Ann.  of  Surg.,  July  1902,  p.  15. 


538  OPERATIONS  ON  THE  HEAD  AND  NECK 

mouth  being  opened  widely,  and  the  tongue  drawn  forwards  with  a  stout 
ligature  in  each  half,  the  mucous  membrane  is  divided  along  the  middle 
line  of  the  dorsum,  behind  the  growth  and  between  the  tongue  and  the 
jaw  ;  the  tongue  is  split  and  the  fibres  of  the  genio-hypoglossus  divided 
close  to  the  symphysis  with  scissors.  The  diseased  half  of  the  tongue  can 
now  be  drawn  well  out  of  the  mouth,  especially  if  the  anterior  pillars  of  the 
fauces  have  been  snipped  through  as  well.  With  a  few  vertical  strokes 
of  a  director  the  anterior  edge  of  the  hyoglossus  is  next  defined.  The 
director  is  then  insinuated  beneath  the  muscle,  the  tissues  being  separated 
with  the  point  before  the  instrument  is  pushed  on.  The  muscle  is  next 
carefully  cut  through  on  the  director  for  about  two-thirds  of  its  extent, 
and  the  fibres  retracting  leave  the  artery  at  the  bottom  of  the  wound 
covered  only  by  a  little  connective  tissue.  With  the  point  of  a  director 
the  vessel  can  then  be  easily  defined  as  a  bluish  cord,  and  traced  down- 
wards and  backwards.  An  aneurysm-needle  should  then  be  passed  under 
it,  and  the  vessel  tied  before  it  is  cut.  Some  may  prefer  to  seize  it  with 
forceps  and  cut  before  tying  it,  but  the  previous  ligature  is  easier.  After 
the  artery  has  been  ligatured  and  divided,  a  few  snips  should  be  made  with 
the  scissors  radiating  out  from  the  ligatured  artery  into  the  substance  of 
the  tongue  ;  this  lessens  the  chance  of  cutting  the  artery  again  in  the  later 
stages  of  the  operation.  All  that  now  remains  to  be  done  is  to  complete 
the  operation,  cutting  wide  of  the  disease.  The  advantages  claimed  by 
Mr.  Cathcart  for  his  method^ — and  anyone  making  use  of  it  will  confirm 
every  word  that  he  says — are  ease  and  certainty  in  securing  the  lingual  : 
diminished  bleeding  from  small  vessels  ;  greater  certainty  in  cutting  wide 
of  the  disease.  Mr.  Cathcart  finds  that,  by  his  method  the  same  part  of 
the  artery  is  reached  as  is  tied  in  the  usual  operation  for  a  preliminary 
ligature  in  the  submaxillary  triangle. 

Another  method  which  will  occasionally  be  found  most  serviceable 
for  the  temporary  control  of  bleeding  is  that  of  the  late  Mr.  Heath.  If  any 
difficulty  occur  in  dealing  with  a  divided  lingual  (Mr.  Cathcart 's  methodical 
plan  should  prevent  this),  especially  when  the  tongue  has  been  severed 
far  back,  or  a  ligature  has  slipped,  Mr.  Heath  advised  that  one  or  two 
fingers  should  be  slipped  into  the  pharynx  over  the  stump  of  the  tongue, 
so  as  to  draw  this  forwards.  This  step  immediately  arrests  the  haemor- 
rhage by  pressure,  and  usually  brings  into  view  the  bleeding-point,  which 
is  at  once  secured. 

If  it  be  needful,  the  surgeon  then  proceeds  to  deal  with  the  other  half 
of  the  tongue,  a  step  which  is  much  facilitated  by  the  room  given  for 
manipulation  by  the  removal  of  the  first  half. 

In  this  and  other  operations  for  removal  of  the  tongue,  when  sufficient 
absolutely  healthy  mucous  membrane  can  be  safely  left,  it  may  be  drawn 
together  and  sutured  over  the  cut  surface  with  sterilised  catgut.  This 
step  undoubtedly  saves  pain  and  promotes  rapid  healing,  and  should, 
wherever  feasible,  be  carried  out. 

Removal  of  Half  the  Tongue.  Removal  of  half  the  tongue  should  be 
reserved  for  early  cases,  where  the  growth  is  situated  on  the  free  border 
and  has  not  deeply  extended  into  the  muscular  substance.  (1)  The 
removal  of  half  the  tongue  is  suitable  and  strongly  called  for  in  certain 
cases.  (2)  That  such  an  operation,  performed  in  fitting  cases,  leaves  the 
patient  with  an  organ  which  is  (a.)  safe  from  recurrence,  (b)  a  most  helpful 
one  in  speaking,  swallowing,  &c.  (3)  Thatitisonly  by  operating  early  in 
these  cases,  and  by  thus  being  in  a  position  to  promise  the  patient  that  the 


REMOVAL  OF  THE  TONGUE  539 

less  severe  operation  will  be  sufficient,  and  will  give  him  immunity  from 
disease  and  leave  him  with  a  most  useful  organ,  that  we  shall  ever  attain 
to  better  success  in  our  operations  for  cancer  of  the  tongue,  removal  of 
the  tongue  being  a  nuitilation  especially  dreaded  and  deferred  by  the 
patient.^ 

When  half  the  tongue  is  removed  the  tip  is  likely  to  be  drawn  over 
and  bound  down  to  the  floor  of  the  mouth  on  the  opposite  side,  partly 
by  cicatrisation  and  partly  by  muscular  action.  A  more  mobile  and 
useful  though  shorter  stump  may  be  obtained  by  removing  the  anterior 
end  of  the  sound  half.     (Fig.  241 .) 

Removal  of  the  Lymphatic  Glands.  This  should  be  carried  out  in  every 
case  as  a  routine  measure,  whether  enlarged  glands  can  be  felt  or  not, 
for  the  following  reasons,  (a)  Infection  of  the  glands  begins  here  almost 
from  the  day  that  the  ulcer  assumes  suspicious  features,  (b)  That  this 
infection  may  be  started  by  ulcers  of  the  smallest  size  and  of  but  brief 
duration,  (c)  That  deposits  of  epithelioma  may  here  remain  latent  in  the 
lymphatic  glands  for  two  years  certainly,  and  then  commence  to  grow. 
{d)  That  gland  infection  here  is  not  only  certain  but  peculiarly  baneful 
(p.  530). 

For  the  above  reasons  exploration  of  the  anterior  triangle  and  removal 
of  glands  should  always  be  urged  as  a  matter  of  routine  on  patients  with 
cancer  of  the  tongue.  By  adopting  this  routine  practice,  no  doubt,  a  few 
needlessly  extensive  operations  will  be  performed,  but  with  cancer  of  the 
tongue  as  with  cancer  of  the  breast,  we  do  not  know,  and  have  no  means 
of  diagnosing,  the  few  cases  in  which  the  glands  are  not  involved.  If  not 
done,  reappearance  of  the  disease  in  glands,  which  could  not  be  felt  to  be 
enlarged  on  ordinary  palpation  at  the  time  of  the  operation  on  the  tongue, 
is  certain.  The  c[uestion  of  removing  the  glands  at  the  same  time  as  the 
tongue,  or  at  a  second  operation,  is  discussed  on  p.  534.  Even  greater 
thoroughness  is  required  here  than  in  the  case  of  removal  of  tuberculous 
glands  ;  the  full  details  given  at  p.  641  for  the  removal  of  these  should  be 
referred  to.  The  chief  guiding  principles  alone  will  be  given  here.  Each 
subdivision  of  the  anterior  triangle,  and  all  the  groups  of  glands  mentioned 
below,  must  be  exposed  in  the  fullest  way.  For  this  purpose  a  curved  in- 
cision is  made,  commencing  just  behind  and  above  the  angle,  extending 
forwards,  below  the  body  of  the  jaw,  nearly  to  the  symphysis.  A  second 
incision  commences  in  the  posterior  third  of  the  first,  and  is  carried  down- 
wards along  the  anterior  border  of  the  sterno-mastoid  (Fig.  242).  Flaps 
composed  of  skin,  fasciae,  and  platysma,  are  raised,  thus  allowing  of  a  free 
exposure  of  the  infected  structures.  The  mylo-hyoid  is  divided  to  allow  of 
the  removal  of  those  glands  between  it  and  the  hyoglossus  and  genio- 
hyoglossus  muscles  :  the  sterno-mastoid  is  also  divided,  if  necessary. 
Not  only  is  every  one  of  the  groups  of  glands  mentioned  below  to  be 
investigated,  and  every  gland  that  can  be  seen,  whether  enlarged  or  no, 
to  be  removed,  but,  in  order  to  extirpate  possibly  infected  lymphatics,  the 
subjacent  muscles  are  to  be  dissected  clean,  and  all  cellular  tissue  and 
fat  cleared  away.  The  internal  jugular  is  here  also  the  chief  landmark, 
but  in  this  case  there  may  be  less  hesitation  in  removing  it  between  two 
ligatures.  The  chief  groups  of  glands  are  to  be  taken  away  as  far  as 
possible  in  one  piece.  The  greatest  care  must  be  taken  not  to  rupture 
infected  glands  or  to  cut  into  them  when  the  overlying  soft  tissues  are 
very  thin.     The  chief  groups  affected  are  the  hngual,  the  submaxillary, 

1  See  Guy's  Hospital  Reports,  1889,  p.  252. 


540 


OPERATIONS  ON  THE  HEAD  AND  NECK 


the  submental,  and  the  deep  cervical.^  The  submental  is  often  over- 
looked. In  addition  to  the  lymphatic  glands,  the  submaxillary  sahvary 
gland  should  also  be  excised,  for  infected  lymphatics  soon  become 
adherent  to  and  grow  into  it.  Wharton's  duct  should  be  ligatured. 
The  condition  of  the  deep  cervical  group  should  be  explored  by  following 
downwards  the  whole  length  of  the  carotid  sheath  as  far  as  it  is  accessible. 
Attention  must  be  directed  to  avoid  injury  to  the  descendens  hypoglossi. 
Should  enlarged  glands  be  present  on  both  sides  of  the  neck  a  similar  opera- 
tion must  be  carried  out  on  the  opposite  side  also.  Infection  of  the  glands 
on  the  opposite  side  to  that  of  the  growth  of  the  tongue  may  be  present 
though  unfelt.  It  may  take  place  by  means  of  lymphatics  meeting  in 
the  tongue,  or  by  the  free  communication  which  exists  between  the 
deep  lymphatics  of  the  two  sides  of  the  neck.     When  all  bleeding  vessels 

have  been  secured  and  ligatured,  and  all 
oozing  stopped,  the  wound  is  sutured,  a 
drainage-tube  being  inserted  at  its  lower 
angle. 

Advisability  of  operating  on  enlarged 
glands  at  a  later  date,  i.e.  some  time  after 
the  operation  on  the  tongue.  While  this 
step  can  be  sometimes  successfully  under- 
taken, it  is  done  under  much  less  favourable 
conditions.  There  are  few  more  difficult 
questions  to  decide  than  those  which  arise 
in  these  cases.  The  patient,  maybe  in  the 
prime  of  life,  with  a  soundly  healed  scar 
in  his  mouth,  comes  again  to  the  surgeon, 
perhaps  after  a  long  disappearance,  with 
infected  cervical  glands,  and  urges  further 
operation. 

Each  case  must  be  decided  upon  its  own 
merits.  It  is  not  the  least  use  operating 
when  the  uppermost  deep  cervical  glands  are 
involved,  i.e.  those  under  the  upper  third  of  the  sterno-mastoid,  where 
the  muscle  is  firmly  tied  down  by  processes  of  deep  cervical  fascia,  and 
where  the  glands  extend  to  the  mastoid  process  behind,  and  the  angle 
of  the  jaw  in  front,  and  into  the  pterygoid  region.  Operation  will  also 
probably  be  futile  (a)  when  any  of  the  glands  are  soft  and  breaking 
down  ;  (6)  where  both  anterior  triangles  contain  enlarged  glands. 

(2)  Koeher's  Modification  of  Syme's  Operation.  (Figs.  244,  245.)  2 
This  consists  in  dividing  the  symphysis  menti  and  then  removing  the 
whole  tongue  and  floor  of  the  mouth  with  knife  or  scissors.  This  is 
especially  indicated  when  the  growth  has  extended  deeply  into  the  tongue 
and  has  involved  the  floor  of  the  mouth.  It  is  a  severer  operation  than  the 
one  already  given,  and  may  involve  prolonged  after-treatment,  owing 
to  the  tardy  union  of  the  jaw.  Where  this  operation  is  contemplated 
in  an  aged  or  broken  down  patient  every  attempt  should  be  made  to 
improve  the  general  health  previously.  Prof.  Kocher  ^  has  given  up  the 
operation  through  the  submaxillary  region,  and  adopted  what  is  known 

^  Sir  H.  Butlin  {Brit.  Med.  Journ.,  February  11,  1905)  adds  that  search  should   be 
made  between  the  genio-hyoids  in  case  a  gland  lies  here. 
^  Lancet,  1858,  vol.  i,  p.  46,  and  vol.  ii,  p.  168. 
*  Text  Book  of  0 per.  Surg.,  4th  ed..  Stiles  and  Paul,  1911. 


Fig.  244.  Incision  for  Syme's 
operation  for  removal  of  the 
tongue.  The  dotted  line  shows 
how  the  incision  may  be  ex- 
tended for  the  removal  of 
glands. 


REMOVAL  OF  THE  TONGUE 


541 


with  us  as  Syinc's  operation.  In  his  words  (p.  418)  :  "  Our  '  normal  pro- 
cedure '  now  consists  in  dividing  the  jaw  in  the  mi(Wlc  hue  in  all  cases 
where  the  cancer  extends  as  far  back  as  the  isthmus  of  the  fauces,  and 
where  it  has  involved  the  arch  of  the  palate."  Again  he  writes  :  "  It 
is  only  when  there  is  a  small  new  growth  at  the  tip  or  the  side  of  the  tongue 
that  we  do  not  split  the  jaw."  His  modifications  of  »Syme's  operation  are 
given  below.  The  following  are  the  advantages  claimed.  "  It  gives  the 
best  access  and  causes  the  minimum  of  injury.     The  haemorrhage  is  very 


\ 


X 


DICASTRJC   M. 


MYLOHYOIO  M. 


Fig.  245.     Kocher's  modification  of  Syme's  operation. 


slight,  as  it  is  more  effectively  controlled  ;  the  secretions  of  the  wound 
drain  away  more  satisfactorily,  and,  what  is  most  important  to  our 
mind,  by  preserving  the  muscles  of  deglutition  along  with  their  nerves  a 
better  functional  result  is  obtained  than  by  any  other  method.  This  non- 
interference with  deglutition  is  of  the  greatest  importance  in  preventing 
secondary  aspiration-pneumonia,  the  greatest  danger  which  threatens  the 
patient.  It  is  astonishing  to  see  how  patients  can  swallow  on  the  same 
day,  the  following,  or  at  most  the  third  day  after  this  operation,  and  hence 
they  are  able  to  get  rid  of  the  wound  secretions  and  prevent  their  getting 
into  the  larynx."  The  severity  of  the  operation  in  patients  usually  of 
poor  vitality  must  be  weighed.     How  in  the  advanced  cases,  for  which 


542  OPERATIONS  ON  THE  HEAD  AND  NECK 

this  method  is  recommended,  the  muscles  of  deglutition  and  their  nerves 
can  be  safely  spared  and  the  result  claimed  attained,  it  is  difficult  to 
understand.  An  anaesthetic  having  been  given  ^  the  patient's  head  and 
shoulders  are  raised,  and  the  surgeon  divides  the  soft  parts  of  the  chin,  as 
far  down  as  the  hyoid  bone,  if  the  soft  parts  of  the  floor  of  the  mouth 
are  much  implicated.  The  vessels  being  secured,  the  jaw  is  drilled, 
without  any  previous  separation  of  the  periosteum,  below  the  teeth  a 
quarter  of  an  inch  on  either  side  of  the  middle  line,  and  then  sawn 
through. 2  The  mouth  must  be  kept  carefully  sponged  out,  the  halves 
of  the  jaw  being  forcibly  retracted.  The  tongue  is  well  drawn  out  by 
a  loop  of  stout  silk,  the  mucous  membrane  snipped  through  between  the 
tongue  and  the  alveolar  process  and  the  anterior  pillars  next  divided. 
The  mylo-hyoids  and  the  anterior  bellies  of  the  digastrics  are  now  separated 
in  the  mid-line. 

The  genio-hypoglossi  ^  and  genio-hyoids  thus  exposed  are  cut  through, 
and  the  tissues  in  the  floor  of  the  mouth  separated  as  deeply  as  necessary 
with  the  scissors  or  blunt  dissector,  aided  by  the  finger,  partly  by  cutting 
and  partly  by  tearing,  any  vessels  that  require  it  being  tied.  The 
lingual  artery  comes  into  view  at  the  anterior  border  of  the  hyoglossus 
and  is  easily  secured  and  ligatured.  The  tongue  being  thus  freed  laterally 
and  below  as  far  back  as  is  needful,  the  transverse  section  is  made,  one 
half  at  a  time,  with  the  precautions  recommended  at  p.  537. 

The  floor  of  the  mouth  is  now  carefully  inspected,  and  any  suspicious 
patches  or  enlarged  glands  most  carefully  removed.  In  raising  the 
former,  before  using  the  scissors,  a  sharp  hook  is  often  very  useful.  The 
two  halves  of  the  jaw  can  then  be  wired,  but  to  promote  speedy  union  a 
cap  of  vulcanite  or  silver  should,  later,  be  fitted  on  to  prevent  displace- 
ment of  the  fragments.  A  drainage-tube  should  be  brought  through 
from  the  mouth  to  a  point  just  above  the  hyoid  bone,  before  the  soft 
parts  are  united  with  sutures. 

The  chief  modifications  used  by  Prof.  Kocher  in  his  recent  adoption 
of  this  method  are  as  follows  :  He  operates  with  the  patient  in  the 
Trendelenberg  position.  After  section  of  the  jaw  and  the  preliminary 
division  of  the  mucous  membrane  he  severs  the  muscles,  the  mucous 
membrane  far  back,  the  soft  palate  and  pharynx,  if  invaded,  with  the 
thermo-cautery.  The  final  division  of  the  tongue  itself,  after  previous 
ligature  of  the  vessels,  is  made  in  the  same  way,  the  use  of  this  instrument 
being  considered  to  aid  in  the  complete  removal  of  the  disease.  Xeroform 
is  rubbed  into  the  cut  surfaces,  but  only  in  a  thin  layer,  so  as  not  to  produce 
toxic  symptoms  if  swallowed.  Bismuth  paste  is  smeared  over  the  line  of 
suture. 

(3)  Kocher's  Former  Method  by  Lateral  Inframaxillary  Incision. 
As  stated  above,  Prof.  Kocher  has  now  replaced  this  method  by  his 
modification  of  Syme's  operation.  This  operation  may,  however,  be 
selected  for  cases  where  there  is  coexisting  disease  of  the  mandible. 
As  it  is  still  employed  by  many  surgeons,  it  will  be  briefly  described. 

^  Intratracheal  anresthesia  is  strongly  recommended  for  this  and  similar  operations. 
*  By  some  it  is  advised  to  saw  this  somewhat  angularly  instead  of  vertically,  to  pro- 
mote interlocking  and  union  of  the  fragments.     As,  liowever,  necrosis  may  follow  this  as 
well  as  the  other  form  of  bone  section,  the  longer  time  that  it  entails  is  scarcely  worth 
giving. 

^  If  only  half  of  the  tongue  needs  removal — a  rare  contingency  in  the  cases  which 
call  for  this  operation — the  complete  sei:iaration  of  these  muscles  and  the  consequent 
danger  of  the  falling  back  of  the  tongue  will  alike  be  avoided. 


REMOVAL  OF  THE  TONGUE  543 

Tin-  following  an-  the  advaiifagcs  :  (1)  It  gives  very  good  access.  By  slitting 
the  cheek,  when  needful,  the  access  given  by  the  intrahuccal  method  is  quite  as 
good.  (2)  It  permits  of  the  simultaneous  removal  of  the  glands  as  well  as  of  all 
the  tissues  which  infirvcne  betwien  them  and  the  primary  ^cat  of  tlic  disease.  As 
far  as  the  submaxillaiy  glands  are  concerned  tliis  is  true,  and  at  first  sight  it  is  a 
distinct  advantage  over  the  intrabuccal  method,  this  advantage  is  not  so  real  as  to 
give  a  great  advantage  over  Wliitehead's  method.  When  the  submaxillary  glands 
are  involved  by  cancer,  the  deep  carotid  group  are  al.so  usually  infected,  though, 
to  the  \inaided  eye,  they  may  a])pear  healthy.  The  comi)lete  removal  of  all 
glanils  that  nuiy  be  affected  involves  a  long  and  most  careful  dissection.  Mr. 
Jacobson  is  of  ojiinion  that  the  close  of  such  a  severe  operation  as  removal  of  the 
tongue  is  not  the  time  for  such  a  dissection.  The  majority  of  patients  are  not 
fit  to  bear  further  operative  steps,  necessarily  prolonged.  Few  surgeons  under- 
taking it  will  do  justice  to  themselves.  With  regard  to  the  second  claim,  that 
this  method  removes  all  the  tissues  which  intervene  between  the  glands  and  the 
primary  seat  of  the  disease,  it  is  impossible  that  any  operation,  whether  by 
the  submaxillary  or  the  intrabuccal  route,  can  make  certain  of  removing  the 
lymphatic  tract  which  runs  under  the  jaw  between  the  cancer  and  the  glands. 
Even  remo\'ing  a  portion  of  the  jaw  as  a  regular  step  would  not  make  certain  of 
this  tract ;  and  being  not  only  uncertain,  but  also  adding  enormously  to  the  patient's 
discomfort  immediately  after  the  operation  and  for  the  rest  of  his  life,  should  not 
be  attempted.  (3)  It  admits  of  preliminary  ligature  of  the  lingual  or  external 
carotid  artery.  This  claim  is  a  just  one,  but  any  surgeon  familiar  with  the  intra- 
buccal method  and  the  precautions  given  above  will  know  that  no  such  preliminary 
ligatm'c  is  really  needed. 

The  disadvantages  are  :  This  operation  is  a  severe  one  ;  it  also  opens  up  freely 
the  connective  tissue  of  the  neck.  The  statement  that  the  operation  can  be  per- 
formed aseptically  must  be  received  with  much  caution.  It  is  impossible  to  cleanse 
thoroughly  the  naso-pharynx  and  other  regions  which  lie  near. 

The  Operation.  The  mouth  having  been  prepared  as  directed  at  p.  5.32  and  the 
anesthetic  having  been  administered  by  one  of  the  methods  recommended  on  p.  534, 
where  the  disease  extends  far  back,  an  incision  is  made  from  just  below  the  symphysis 
down  to  the  hyoid  bone,  and  following  the  digastric  muscle  back  to  the  anterior 
edge  of  the  sterno-mastoid,  then  up  to  near  the  lobule  of  the  ear.  The  flap  thus 
marked  out  of  platysma  and  fasciae  is  turned  up,  and  the  facial  artery  tied.  The 
submaxillary  region  is  then  thoroughly  cleaned  out  and  the  lingual  artery  secured 
beneath  the  hyoglossus.  By  cutting  through  the  mylo-hyoid  muscle  and  dividing 
the  mucous  membrane,  the  cavity  of  the  mouth  is  now  freely  opened,  and  the 
tongue  brought  out  through  the  wound  and  divided  as  far  back  as  needful,  one  half 
being  removed  after  splitting  the  organ,  or  the  whole  tongue  removed,  the  opposite 
lingual  being  tied  if  needed. 

The  large  wound  is  then  carefully  packed  with  strips  of  sterile  gauze,  a  drainage- 
tube  being  first  inserted,  and  xeroform  or  Whitehead's  varnish  (p.  547)  applied. 
The  patient  continues  to  breathe  through  the  laryngotomy-tube  until  the  wound 
and  mouth  are  quite  sweet,  and  thus  there  is  less  danger  of  infective  broncho- 
pneumonia. 

(4)  Trans-hyoid  Pharyngotomy.  Mr.  Carless  advises  ^  this  method  in 
certain  cases  of  growth  involving  the  posterior  third  of  the  tongue.  The 
cases  he  refers  to  are  those  of  disease  far  back  on  the  dorsum  of  the  tongue, 
spreading  towards  the  epiglottis  but  not  involving  the  root  of  the  tongue. 
He  hopes  that  by  this  operation  it  may  be  possible  to  save  the  anterior 
portion  of  the  organ.  Such  cases  are  rare,  the  tongue  being  usually  fixed 
and  the  disease  generally  infiltrating  forwards  as  well  as  backwards. 
Where  the  severe  operation  of  Syme  or  that  of  Langenbeck  (p.  545)  has 
been  thought  unsuitable  on  local  or  general  grounds,  such  cases  are  usually 
best  left  alone.  It  \\\\\  be  seen  that  there  was  no  local  recurrence  after 
Mr.  Carless 's  operation. 

His  patient,  aged  60,  was  admitted  September  1900,  A  "lump"  had  been 
noticed  on  the  back  of  the  dorsum  of  the  tongue  in  January  1900.  The  organ 
could  be  protruded  fully,  and  there  was  but  little  discomfort  in  swallowing.     Nothing 

1  Practitioner,  May  1903,  p.  661. 


544    OPERATIONS  ON  THE  HEAD  AND  NECK 

was  to  be  seen  of  the  growth  from  the  front.  With  a  laryngoscope  a  large  in- 
durated nicer  invading  the  epiglottis,  reaching  forward  from  it  about  an  inch 
and  a  half,  and  more  marked  upon  the  left  side  than  the  right,  could  be  seen. 
There  was  an  enlarged  gland  beneath  the  angle  of  the  mandible. 

September  4,  the  patient  was  operated  upon  by  traas-hyoid  pharyngotomy. 
A  preliminary  high  tracheotomy  was  performed,  a  Hahn's  tube  inserted,  and 
chloroform  administered  by  this,  a  sponge  being  kept  over  the  entrance  of  the 
larynx.  The  oi^eration  was  performed  on  the  lines  given  at  p.  558.  After  separa- 
tion of  the  genio-hyoids  and  exposure  of  the  hyoid  bone  this  was  divided  in  the 
middle  line  with  bone-pliers.  "  The  two  segments  were  drawn  apart  by  the  re- 
tractors, and  with  a  little  undercutting  a  considerable  interval  was  obtained,  in 
which  was  exposed  the  middle  thyro-hyoid  ligament,  and  beneath  it  a  pad  of  fat. 
Through  these  structures  an  opening  was  made  with  the  knife  just  above  the 
thyroid  cartilage,  and  the  base  of  the  epiglottis  was  cut  through  a  little  above  the 
false  vocal  cords.  This  opening  was  enlarged  by  scissors  on  either  side  by  dividing 
the  ligament  and  portions  of  the  thyro-hyoid  muscles,  so  as  to  enable  the  finger  to 
be  inserted,  and  thus  the  exact  size  and  situation  of  the  growth  on  the  back  of  the 
tongue  were  readily  defined.  It  was  then  merely  a  question  of  snipping  with  the 
scissors  to  take  away  the  growth.  Incisions  were  made  in  either  side  of  the  epi- 
glottis, well  away  from  the  lateral  margins,  and  thereby  the  segments  of  the  hyoid 
bone  were  more  easily  separated,  giving  additional  space  to  work  in  ;  next  I  re- 
moved a  V-shaped  segment  from  the  back  of  the  tongue,  including  the  whole  of  the 
diseased  tissues,  and  this  without  encroaching  on  the  main  vessels  and  nerves, 
although  the  left  hypoglossal  was  seen.  The  bleeding  was  very  slight  and  easily 
controlled  by  ligatures.  I  di'ew  the  edges  of  the  V -wound  together  at  the  anterior 
extremity,  but  behind  it  was  too  extensive  for  this  to  be  undertaken.  Three  catgut 
sutures  were  emjjloyed  in  this  way.  The  two  halves  of  the  hyoid  bone  were  stitched 
together  by  a  catgut  suture  passed  thi'ough  the  periosteum.  The  central  part  of 
the  wound  was  left  open  and  a  gauze  plug  introduced,  the  rest  being  closed  with 
sutures."  Finally  a  smaller  Hahn's  cannula  was  introduced.  This  was  replaced 
by  a  tracheotomy-tube  after  forty-eight  hours,  the  latter  being  removed  on  the 
tenth  day.  Five  weeks  after  the  first  operation  the  glands  on  the  left  side  were 
removed.  Eighteen  months  after  the  first  operation  the  ])atient  appeared  free 
from  recurrence,  but  a  few  months  later  the  glands  on  the  right  side  of  the  neck 
became  enlarged. 

(5)  The  Ecraseur.  This  method,  which  has  many  disadvantages,  and 
no  advantages  over  those  described  above,  is  now  practically  obsolete.  It 
will  not  be  described  and  is  only  mentioned  here  to  warn  against  its 
employment. 

EPITHELIOMA  OF  THE  TONGUE  AND  OTHER  PARTS  AS  WELL 

Question  of  Operation.  These  cases,  in  which  it  is  most  difficult  to 
decide  aright,  fall  mainly  into  two  groups. 

A.  Where  the  epithelioma  is  situated  far  back,  affecting  the  tongue, 
tonsil,  palate,  and  perhaps  the  posterior  part  of  the  body  of  the  jaw. 

Here  the  cancer  affects  a  region  very  rich  in  lymphatics,  and  invasion 
of  the  glands  will  probably  take  place  early.  For  this  reason  permanent 
successes  are  practically  unknown  here,  though  operations  are,  from  time 
to  time,  published  as  successes,  often  within  a  few  weeks  or  months  of 
their  performance. 

In  deciding  upon  operation  the  surgeon  will  be  guided  first  by  the  age 
of  the  patient,  the  natural  expectation  of  life,  the  vitality  and  power  of 
recovery,  and  the  state  of  the  viscera,  especially  the  Imigs. 

Then  he  will  investigate  very  carefully  the  following  points  :  How 
far  any  fixity  of  the  growth  here  points  to  involvement  of  the  muscles  at 
the  root  of  the  tongue,  if  the  mandible  is  involved  near  its  angle  ;  how 
far  the  epiglottis  or  the  upper  aperture  of  the  larynx  is  involved  ; 
whether  the  secondary  growth  of  the  tonsil  and  its  pillars  is  hard  and 


EPITHELIOMA  OF  THE  TONGUE,  ETC.  545 

fix(><l.  or  movable  on  the  parts  boiioatli  ;  whether  the  pliarynx  itself  is 
involved.  Next,  if  there  is  eiilarjjjeiuent  of  the  lymphatic  <i!aiids,  their 
extent,  fixity,  and  how  far  any  softening  or  breaking  dcnvn  is  already 
present. 

Any  of  tile  above  should  usually  decide  against  operation  in  these 
cases  ;  and  as  to  the  glands  here  and  in  all  kindred  cases,  epitheliomatous 
enlargement  in  the  posterior  triangle,  and  especially  thosc^  unchn-  the  upper 
third  of  the  sterno-mastoid,  renders  operative  interference  hopeless  as  to 
permanent  success. 

In  deciding  upon  an  operation,  the  points  fully  dealt  with  on  p.  539 
will  be  found  helpful. 

Operation.  In  these  cases  where  the  growth  involves  the  tongue  far 
back,  and  other  parts  such  as  the  jaw,  tonsil,  palate,  &c.,  the  only  steps 
tliat  can  be  possibly  adequate  will  be  those  taken  on  the  lines  of  Langen- 
beck's  operation  or  one  of  the  methods  of  pharyngotomy  given  in  the  next 
chapter,  according  to  the  site  and  direction  of  extent  of  the  epithelioma. 
The  chief  steps  in  Langenbeck's  operation  are  the  slitting  of  the  cheek 
and  the  division  of  the  jaw,  steps  which,  while  they  provide  good  access 
to  a  growth  situated  far  back,  also  emphasise  the  severity  of  the  operation 
in  the  case  of  the  lowered  vitality  often  presented  by  these  patients. 

The  patient  is  first  brought  fully  under  the  anaesthetic,  which  is  after- 
wards continued  by  a  nasal  or  intratracheal  tube. 

The  cheek  is  slit,  the  facial  artery  secured,  and  the  incision  then  carried 
across  the  mandible  just  in  front  of  the  masseter  into  the  submaxillary 
region,  over  which  it  is  continued  to  meet  the  anterior  border  of  the  sterno- 
mastoid  about  the  level  of  the  hyoid  bone.  From  this  point  flaps  are 
raised  sufficiently  for  thorough  exposure  of  the  submaxillary  region. 
This  is  cleared  out,  the  facial  artery  tied  again  low  down,  together  with  the 
lingual.  The  jaw  is  now  sawn  with  a  Gigli's  saw  obliquely  downwards  and 
forwards.  As  the  section  passes  through  the  basilar  border  the  saw  should 
be  turned  still  more  forwards.  The  object  of  this  oblique  section  is  to 
lock  the  fragments  together,  there  being  a  marked  tendency  for  the 
anterior  one  to  drop  and  the  posterior  one  to  be  raised.  Before  the 
saw  is  applied  holes  are  drilled  without  disturbing  the  periosteum.  This 
is  next  carefully  divided.  The  section  through  the  mandible  should  pass 
behind  the  last  molar  tooth.  If  the  posterior  belly  of  the  digastric  and  the 
stylo-hyoid  are  now  divided,  the  two  halves  of  the  jaw  can  be  very  widely 
separated,  and  the  diseased  area  rendered  accessible.  The  diseased  parts 
are  then  removed  by  the  knife  or  the  cautery.  The  choice  between  them 
is  referred  to  at  p.  552 .  As  the  lingual  artery  will  have  been  tied  on  one  side 
the  haemorrhage  will  not  be  troublesome,  or  more  than  a  watchful  assistant 
can  sponge  away  through  the  divided  cheek.  In  this  operation,  as  in 
lateral  pharyngotomy,  if  the  surgeon  is  in  doubt  as  to  the  lower  limits  of 
the  disease,  by  carefully  fixing  a  hook  in  the  epiglottis  and  lifting  up 
the  larynx  he  will  be  able  to  clear  up  this  point.  The  jaw  is  wired  and 
the  wound  closed  in  the  usual  way.  If  the  patient's  condition  admits  of 
it,  the  condition  of  the  deep  cervical  glands  must  be  investigated,  other- 
wise this  step  is  deferred  for  a  fortnight.  Adequate  drainage  must  be 
provided.  This  and  the  treatment  of  the  wound  are  referred  to  at  p.  556. 
Where  the  mandible  or  the  muco-periosteum  over  it  is  infiltrated,  part  of 
the  bone  must  be  removed.  If  it  be  possible  a  strip  of  the  basilar  border 
must  be  retained,  otherwise  the  sufierings  of  the  patient  and  the  difficulties 
of  the  after-treatment  are  much  increased.     On  this  point,  where  the 

SURGERY  I  35 


546 


OPERATIONS  OX  THE  HEAD  AND  NECK 


vitality  of  the  patient  is  uiuisiially  good,  the  case  next  related  is  encour- 
aging. 

B.  In  this  group  the  epithelioma  has  attacked  the  chin  and  fore  part 
of  the  tongue  and  the  floor  of  the  mouth.  Here  the  outlook  is  better  as  to 
a  permanent  cure,  owing  to  this  part  being  farther  from  the  larynx  and  less 
richly  supplied  with  lymphatics.  All  the  affected  parts  must  be  removed 
unsparingly,  and  the  resulting  deformity  may  be  very  great. 

Fig.  24:6  shows  this  well,  and  is  also  a  good  instance  of  the  fact  that 
occasionally,  when  occurring  on  a  superficial  surface,  and  one  which  dries 
quickly,  epithelioma  ulcerates  slowly  for  a  time. 


Fig.  246. 


The  patient,  a  man  aged  33.  had  been  originally  operated  on  for  epithelioma 
of  the  lip  at  a  hospital  in  the  south  of  England.  Tlic  di.sea.se  recurred,  and  gradually 
invaded  the  chin  and  symphsis  menti.  the  front  of  the  tongue,  and  the  floor  of  the 
mouth.  The  case  was  a  distressing  one,  on  account  of  the  large  foul  sore  prominently 
in  \iew,  the  filthy  smell  of  the  discharge,  and  the  neuralgic  pain  constantly  present 
due  to  the  di.sease  having  involved  both  inferior  dental  nerves.  The  man  had  been 
seen  by  two  other  London  surgeons,  and  operation  had  been  advised  against  owing 
to  the  vei'v  small  chance  of  a  permanent  cm-e,  and  the  deformity  which  was  certain 
to  follow  on  the  ojierative  interference  necessary-.  As  no  enlarged  glands  could  be 
felt,  and  as  the  patient,  young  himself  and  healthy  oih^rwise.  hacl  a  young  wife 
and  child,  the  decision  was  left  to  him.  after  the  two  sides  of  the  question  had  been 
put  clearly  before  him.  he  decided  to  run  the  risks. 

At  the  operation,  performed  by  cui'ved  incisions  carried  out  from  the  angles  of 
the  mouth  on  to  the  cheeks,  then  across  the  submaxillary  regions  to  the  anterior 
border  of  the  sterno-mastoid,  and  thence  running  inwards  to  meet  at  the  hyoid 
bone,  healthy  tissues  were  cut  tlirough,  but  it  was  quite  impossible  to  provide 
adequate  flajis.  It  was  necessary  next  to  saw  the  jaw  through  just  in  front  of  the 
masseter  on  each  side,  as  section  in  front  of  this  i)oint  showed  that  the  inferior 


EPITHELIOMA  OF  THE  TONGUE,  ETC.  547 

(U'lilal  canals  were  invadod  by  tlu'  giowth.  While  a  fiiigor  in  tho  mouth  carefully 
defined  the  extent  to  which  the  floor  and  soft  ])ai'ts  wer(^  invaded,  as  sliown  by  the 
induration — no  ulceration,  lia])])ily,  having  taken  place  hen^ — the  diseased  structures, 
including  the  anteiior  half  of  the  tongue,  were  cut  away  with  a  wide  rnaigin  of  healthy 
tissue.  All  haMUorrhage  having  been  arrested  and  drainage  j)rovidetl,  tlie  skin  on 
either  sick^  was  brought  together  as  far  as  possible.  No  ej)ithelioniatous  glands 
were  found.  The  patient  inatUi  a  good  recovery,  his  chief  trouble;  at  first  being 
inability  to  take  any  food  at  all,  which  necessitated  feeding  him  with  a  tube,  and 
tlie  pain  caused  by  the  sawn  fragments  }noving  in  inflamed  soft  parts  with  any 
spasmodic  action  of  the  muscles.  Now,  June  liMKi,  eight  years  aftt'r  the  operation,  he 
is  free  from  recurrence.  The  chief  drawbacks  to  his  lot,  in  ackhtion  to  the  necessary 
deformity,  are  that  he  needs  a  tube  for  liquid  food,  that  his  power  of  speech  is 
limited  owing  to  the  loss  of  his  lower  lip  and  the  way  in  wliich  the  stump  of  the 
tongue  is  tied  down  in  the  scar,  and  the  constant  dryness  of  his  mouth.  He  is  able 
to  work  at  home,  making  hen-coops  and  the  like.  His  wife  has  borne  him  a  second 
child.  If  he  continues  to  have  no  recmTcnce  of  the  growth,  it  might  be  possible  to 
close  in  the  gap  by  means  of  a  flap  taken  from  the  arm. 

After-treatment  of  operations  on  the  tongue.  The  chief  objects  here 
are  :  (1)  to  keep  the  wound  as  sterile  as  possible  :  (2)  to  give  sufficient 
food. 

The  importance  of  previous  cleansing  of  the  mouth,  teaching  the 
patient  to  do  this,  and  to  feed  himself  has  already  been  spoken  of 
at  p. 532.    . 

After  the  operation  the  cut  surface  may  be  brushed  over  with  "  White- 
head's varnish."  This  is  a  modified  "  Friar's  Balsam,"  a  saturated 
solution  of  iodoform  in  ether  being  substituted  for  the  spirit,  and  one 
volume  in  ten  of  turpentine  being  added.  Ice  is  given  to  suck,  and  milk 
and  brandy  and  beef -tea  are  administered  either  by  a  soft  oesophageal 
tube  or  by  enemata,  or  both.  But  it  is  generally  found  that,  after  the 
first  six  hours,  a  patient  previously  practised  in  the  matter  will  give  him- 
self sufficient  food,  with  a  feeder  and  tube  attached.^  After  the  patient 
has  had  his  first  sleep  the  surface  is  brushed  over,  every  two  or  three 
hours  at  first,  with  some  dilute  antiseptic  lotion,  and  he  is  soon  encouraged 
to  sit  up  and  wash  out  his  mouth  constantly  with  carbolic  acid  (1  in  60  or 
80),  a  wash  of  a  tablespoonful  of  spirit  of  wine  in  a  tumbler  of  water 
(Hutchinson),  or  Condy's  fluid  or  chinosol  1  in  2000.  It  is  not  the  kind  of 
wash  that  is  of  so  much  importance  as  the  frequency  and  painstaking  with 
which  it  is  used.  From  time  to  time  the  stump  may  be  painted  over  with 
Whitehead's  solution.  The  patient  should  be  kept  warm  and  free 
from  draughts,  and  propped  up  or  turned  on  to  either  side  alternately. 
It  is  well  to  try  to  induce  patients  to  sit  up  a  little  on  the  second  day,  if 
possible,  and  get  them,  when  this  is  feasible,  into  an  armchair  a  day  or 
two  later.  Yolks  of  eggs,  arrowroot,  soups,  pulped  vegetables  in  broth, 
and  such  like  are,  as  soon  as  possible,  taken  in  addition  to  the  milk  and 
brandy  and  beef -tea. 

Causes  of  Failure.  In  considering  the  deaths  which  follow  soon  after 
the  operation,  the  effects  of  pre-existing  bronchitis  and  emphysema, 
interstitial  nephritis,  aortic  disease,  and,  sometimes,  previous  haemorrhage 
from  the  growth  may  have  to  be  remembered. 

(1)  BroncJio-pneumonia,  Abscess  and  Ga^igrene  of  the  Lungs,  Empyema. 
As  these  are  infective  in  their  nature,  and  due  to  the  patient  breathing 
foul  gases  and  drawing  down  putrid  fluids  into  his  lungs,  the  treatment 
must  be  preventive,  every  endeavour  being  made  to  keep  the  mouth  sweet 

1  Tf  this  is  not  the  case,  a  soft  tube  must  be  passed.     Nutrient  enemata  are   not 
sufficient. 


548  OPERATIONS  ON  THE  HEAD  AND  NECK 

and  to  relieve  the  patient's  breathing  by  attention  to  the  details  alread}^ 
given. 

(2)  Hcemorrhage.  This  is  rarely  met  with  at  the  time  of  the  operation 
or  soon  after,  if  every  spirting  artery  has  been  properly  secured. 

Haemorrhage  also  will  be  rarely  met  with  as  a  secondary  complication 
if  the  womid  has  been  kept  sweet.  In  cases  of  bleeding,  if  the  application 
of  a  ligature  to  the  bleeding-point  taken  up  by  a  Spencer- Wells  forceps  or 
a  tenaculum  is  impossible,  firm  pressure  with  a  sponge  and  adrenahn 
chloride  should  be  made  use  of  after  all  clots  have  been  removed.  If 
the  wound  has  been  allowed  to  become  foul,  it  must  be  cleansed  by 
brushing  it  over  with  formahn  (1  in  250),  Whitehead's  varnish,  or,  in  the 
absence  of  these,  with  turpentine — a  most  powerful  cleansing  styptic.^ 
If  all  the  above  fail,  either  applying  and  leaving  in  situ  a  pair  of  Spencer- 
Wells  forceps,  packed  around  with  soft  gauze,  or  ligature  of  the  lingual, 
must  be  resorted  to  {q.v.). 

(3)  Cellulitis.  Erysi/pelas.  (4)  Pycemia.  (5)  Exhaustion — more  rarely, 
shock.  (6)  (Edema  of  the  glottis.  (7)  Suffocation  from  falling  back  of 
the  tongue.  (8)  Reappearance.  The  gravity  of  this  has  been  already 
mentioned  at  pp.  530  and  540.  For  the  first  year  after  the  operation 
every  patient  should  come  under  skilful  supervision  at  intervals  of  a 
month  and  no  longer. 

The  steps  already  detailed  of  the  different  operations  on  the  tongue 
will  suffice  for  the  rare  cases  of  sarcoma.  For  fuller  information 
reference  may  be  made  to  an  article  by  Sir  A.  D.  Fripp  and  Mr.  Swan.^ 
The  following  are  the  directions  for  treatment :  "  One  point  which  appears 
to  be  very  emphatically  demonstrated  by  the  cases  which  we  have 
collected  is  that  these  tumours  should  be  widely  removed  by  an  incision 
into  the  healthy  lingual  tissue  well  clear  of  the  growth  ;  for  although  the 
case  with  which  the  obvious  new  growth  can  sometimes  be  enucleated  is 
very  tempting,  yet  such  a  method  of  separation  from  the  surrounding 
compressed  tissues  is  extremely  liable  to  be  ineffectual  in  removing  all 
traces  of  the  growth,  the  pseudo-capsule  remaining  will  contain  the  nucleus 
for  a  recurrence  at  a  later  date.  The  question  which  method  of  operation 
is  most  applicable  depends  on  the  nature  of  each  individual  case,  and 
among  other  things  on  the  situation  and  volume  of  the  tumour.  Small 
tumours  of  the  anterior  part  can  be  attacked  from  the  mouth  ;  those 
placed  in  the  middle  third  of  the  tongue  can  be  more  easily  reached  by 
dividing  the  cheek  ;  but  those  cases  in  which  the  growth  has  extended 
downwards  in  the  muscular  attachment  of  the  tongue,  whether  projecting 
in  front  of  or  behind  the  circumvallate  papillae,  demand  a  supra-hyoid 
incision,  opening  up  the  floor  of  the  mouth  or  the  pharynx  as  the  case 
demands.  If  recurrence  should  ensue  the  secondary  tumour  must  again 
be  removed  and  widely." 

Ranula.  Dermoid  Cyst.  Mention  may  be  made  here  of  these  cysts,  the 
former  of  which  project  into  the  floor  of  the  mouth,  wliile  the  latter  are  surrounded 
by  the  muscle  of  the  base  of  the  tongue  and  can  be  felt  more  or  less  distinctly  on 
palpation  between  the  chin  and  the  hyoid  bone. 

A  ranula  is  a  term  somewhat  vaguely  used  for  cysts  in  the  floor  of  the  mouth. 

^  See  the  remarks  on  a  case  of  ligature  of  the  occipital  artery.  If  the  bleeding  is  of  the 
nature  of  oozing,  solution  of  adrenalin  and  one  or  two  injections  of  ergotin  should  certainly 
be  tried. 

2  Practitioner,  May  1903,  p.  67,3.  Endothelioma  is  another  rare  form  of  tumour 
occasionally  met  with  here.  Sir  F.  Eve  has  recorded  two  such  cases  ( Proc.  Roy.  Soc.  Med., 
Clin.  Sec,  May  1910,  p.  173). 


EPITHELIOMA  OF  THE  TONGUE,  ETC.  549 

These  c-y.st.s,  which  have  a  thin  wall  ami  a  bluish  colour,  are  generally  derived  from 
the  mucous  glands  in  the  lloor  of  the  mouth  or  from  the  incisive  glands:  rarely 
they  are  derived  from  Wharton's  duct  or  from  one  of  the  ducts  of  Kivini.  An 
attempt  should  be  made  to  dissect  the  cyst  out  after  incising  the  mucous  membrane 
of  the  lloor  of  tlie  mouth.  They  can  only  rarely  be  removed  entire,  though  the 
attempt  should  be  made.  When  the  cyst  is  opened  or  torn  a  thick  glairy  fluid 
escaj)es  ;  tiie  wall  of  the  cyst  should  then  be  cut  away  as  far  as  possible,  any 
portion  which  cannot  be  got  away  being  treated  with  a  strong  soluton  of  silver 
nitrate.  In  cases  where  the  cyst  does  not  come  away  entire  no  sutures  should  be 
employed. 

Dermoid  cysts  in  this  region  are  not  unconnnon.  They  are  generally  derived 
from  the  upi)er  })ortion  of  the  thyro-glossal  duct.  They  are  best  removed  by  making 
an  incision  in  the  middle  line  extending  from  the  chin  to  the  hyoid  bone.  The 
mylo-hyoid  nuiscles  are  then  se])aratcd  and  the  deeper  nuiscles  divided  in  the  line 
of  the  original  incision  until  the  capsule  of  the  cyst  is  reached.  It  is  then  enucleated 
with  the  help  of  a  blunt  dissector.  The  wound  is  then  clo,.ed,  drainage  not  being 
as  a  rule  required. 


CHAPTER  XXVI 

OPERATIONS  FOR  GROWTHS  OF  THE  TONSIL,  FAUCES, 
BASE  OF  THE  TONGUE  AND  PHARYNX 

The  new  growths  here  are  most  commonly  round-celled  sarcomata  and 
epitheliomata. 

In  sarcoma  of  the  tonsil,  in  adults,  there  is  a  steady  enlargement  of 
one  tonsil,  without,  at  first,  pain  or  inflammation  ;  a  globular  swelling, 
the  size  of  a  walnut,  appearing  firmly  elastic,  tending  to  infiltrate  adjacent 
structures,  and  fmigate  as  a  sloughing  mass  into  the  mouth. 

In  the  epitheliomata  the  patients  are  older  ;  the  mischief  often  begins 
as  "  a  sore  throat."  The  mass  occupying  the  site  of  the  tonsil  is  now 
much  harder,  and  soon  ulcerates,  forming  an  excavated  ulcer  with  the 
characters  of  epithelioma,  and  soon  implicating  adjacent  parts.  The  base 
of  the  tongue  may  be  involved  secondarily.  Dysphagia,  emaciation,  &c., 
are  more  rapid  here. 

Before  describing  any  operations  for  removal  of  tonsillar  growths  it 
is  right  to  allude  to  their  great  malignancy,  owing  to  the  rapidity  with 
which  the  glands  are  affected  both  in  epithelioma  and  most  of  the  sarco- 
mata. In  this,  rather  than  in  the  importance  of  its  relations,  lies  the 
failure  of  operations  on  the  tonsil,  and  no  one  who  has  watched  the  rapidity 
with  wliich  (owing  to  the  intimate  connection  between  the  tonsil  and  the 
lymphatic  glands)  enlargement  of  the  glands  at  the  angle  of  the  jaw 
takes  place  in  subacute  tonsillitis  vnW  wonder  at  this.  Diagnosis  at  the 
earliest  possible  moment  is  of  greatest  importance  here. 

Sir  H.  Butlin  ^  writes  on  this  malignancy  :  Sarcoma  of  the  tonsil 
'■  proves  fatal,  in  very  many  instances,  within  a  year  or  even  six  months 
of  its  first  appearance  ;  indeed,  few  persons  survive  for  more  than  three 
quarters  of  a  year." 

Dr.  Newman,^  writing  of  sarcomata  of  the  tonsil,  draws  a  distinction 
here  which  may  have  some  practical  importance.  While  admitting  that 
round-celled  sarcomata,  by  far  the  most  common  variety,  quickly  invade 
the  glands,  he  points  out  that  the  spindle-celled  sarcomata  may  remain 
limited  within  a  capsule,  and  so  be  capable  of  complete  removal.  Thus 
in  one  case  of  Dr.  Newman's  the  patient  lived  five  years  after  removal  of 
a  spindle-celled  sarcoma  through  the  mouth,  and  then  died  rapidly  owing 
to  disease  appearing  in  the  opposite  tonsil. 

OPERATIONS 

A.  Through  the  Mouth. 

B.  By  Incision  in  the  Neck.     Lateral  Pharyngotomy. 

C.  Combined  Operations.  Through  the  Mouth  by  shtting  the  Cheek 
and  Lateral  Pharyngotomy. 

1  Oper.  Surg,  of  Maliij.  DIs.,  p.  176. 

2  Malifj.  Dis.  of  Throat  and  Nose,  p.  17G. 

550 


Ol'KHATIOXS  TIlHOrCill  THE  MOUTH  551 

1).  Median,  or  Trans-Hyoid  Pharyngotomy. 

Whichever  method  is  chosen,  the  selection  of  cases  here  for  operation 
must  be  a  very  careful  one,  owing  to  the  great  malignancy  of  these 
growths,  and  tlie  advanced  stage  which  the  disease  has  often  reached  ; 
even  in  these  regions,  we  often  hear  the  statement  that  the  patient 
suffered  very  little  inconvenience  in  the  earlier  stages. 

Cases  Favourable  for  Operation.  Where  the  growth  is  still  small, 
localised  to  the  touch;  well  delined,  still  movable,  free  from  ulceration, 
and  where  no  enlarged  glands  can  be  made  out.  On  the  other  hand, 
where  the  swelling  in  the  mouth  is  continuous  with  one  in  the  neck, 
each  diffuse  and  ill-localised,  and  the  primary  growth  showing  a  friable, 
ulcerated  surface,  operation  will  be  contra-indicated.  Gastrostomy  may 
even  be  called  for  as  a  palliative  operation.  In  intermediate  and  doubtful 
cases,  as  where  one  or  more  enlarged  glands  exist,  but  still  separate  and 
mobile,  the  surgeon  will  be  justified  in  giving  his  patient  a  chance,  knowing 
the  distressing  future  if  the  growth  ibe  left — the  agonising  earache,  the 
dribbling  of  fwtid  saliva,  the  dysphagia,  &c.  The  following  points 
require  particular  attention.  Here,  especially,  is  it  true  of  malignant 
disease,  that  the  mischief  is  liable  to  be  found  more  extensive  than  was 
thought  to  be  the  case  before  the  operation.  Owing  to  the  danger  of 
infective  pneumonia  the  presence  of  any  bronchitis  is  against  operation. 
And  the  same  may  be  said  of  cases  w^here  there  is  any  fixity  of  the  jaw% 
as  this  suggests  extension  along  the  connective  tissue  between  the 
pterygoid  muscles.  Owing  to  the  difficulty  in  feeding  the  patient— and 
rectal  feeding  alone  will  be  quite  insufficient — the  vitality  of  the  patient, 
and  his  amenability  to  directions,  must  be  estimated  beforehand.  The 
more  the  growth  encroaches  on  the  orifice  of  the  larynx  the  greater  the 
risk  of  broncho-pneumonia  and  oedema  glottidis.  The  frequency  with 
which  the  glands  are  early  implicated  has  already  been  referred  to. 

A.  Through  the  Mouth  alone.  This  method  can  only  rarely  be  made 
use  of,  e.g.  in  a  very  early  stage  of  tonsillar  new  growths,  when  the  disease 
is  limited  to  the  tonsil  itself,  not  implicating  the  adjacent  pillars,  and 
when  there  is  not  the  least  evidence  of  glandular  enlargement. 

If  the  following  operation  seems  somewhat  severe,  the  infiltrating 
tendency  of  growths  here  must  be  remembered. 

With  regard  to  the  anaesthetic  and  other  general  considerations 
reference  may  be  made  to  the  remarks  on  p.  533. 

The  patient's  head  is  suitably  raised  and  supported,  in  a  good  light, 
and  the  cheek  on  the  affected  side  divided  from  the  angle  of  the  mouth 
to  the  masseter,  the  two  ends  of  the  facial  artery  being  secured.  The 
mouth  is  now^  kept  widely  open  by  a  gag  insertect  on  the  opposite  side, 
the  tongue  draw^l  out  of  the  mouth,  and  the  masseter  pulled  backw^ards 
by  a  retractor.  As  much  room  and  light  as  possible  being  thus  obtained 
the  surgeon  di\ddes  the  soft  palate  first  in  the  middle  line,  and  then  from 
within  outwards  with  scissors  ;  he  next,  either  w^ith  the  same  instrument 
or  with  a  blunt  dissector,  dissects  around  and  carefully  extirpates  the 
tonsil  wdth  the  pillars  of  the  fauces.  The  whole  operation  should  be  slowly 
and  deliberately  carried  out,  the  surgeon  cutting  wide  of  the  grow  th  and 
encroaching  on  the  tongue,  &c.,  if  needful.  He  thus  removes  the 
growth  together  with  a  margin  of  healthy  tissue,  and  gives  his  patient  the 
best  chance.  Though  some  sarcomata  here  are  encapsuled,  and  can  be 
shelled  out,  recurrence  is,  unfortunately,  probable  after  this  step.^  The 
^  Butlin,  loc.  supra,  cif,  p.  175. 


OPERATIONS  ON  THE  HEAD  AND  NECK 


method  of  removing  widely  is  far  preferable.     Bleeding  will  be  best  ar- 
rested by  temporary  forci-pressure  and  firm  sponge-pressure. 

Some  surgeons  do  the  whole  operation  with  the  cautery  instead  of  the 
scissors.  1  The  objections  to  the  cautery  are  :  (1)  that  it  requires  a 
special  instrument,  which  may  not  be  at  hand  ;  (2)  if  it  destroys  an 
infected  surface,  it  also  introduces  infection  and  risk  of  secondary  hsemor- 
rhage  ;  (3)  with  it,  it  is  very  difficult  to  judge  aright  of  the  nature  of  the 
surfaces  di\dded,  whether  sound  or  infiltrated  ;  (4)  it  necessitates  the 
use  of  chloroform,  which  may  be  inconvenient.  For  these  reasons  the 
use  of  the  cautery,  if  it  be  employed  at  all,  should  be  limited  to  searing 
thoroughly  the  surface  of  the  wo  mid. 

The  case  of  small  growths  of  the  tonsil  accessible  from  the  mouth 
having  been  considered,  that  of  malignant  disease  situated  or  extending 
lower  do^vm  will  be  next  referred  to.  We  ^^^ll  suppose  that  the  glands 
require  investigation,  but  that  there  is  no 
softening  or  adhesion  of  these  to  the  soft  parts 
overlying  them  or  to  the  pharynx. 

The  following  courses  are  open  to  the  sur- 
geon : 

B.  Lateral  Pharyngotomy.  C.  Lateral  Pharyn- 
gotomy  combined  with  division  or  partial  resec- 
tion of  the  mandible,  with  one  through  the  mouth, 
by  slitting  the  cheek,  or  with  Langenbeck's  opera- 
tion (p.  545).  D.  Median,  Sub-  or  Trans-hyoid 
Pharyngotomy. 

B.  Lateral  Pharyngotomy  ^  (Fig.  247).  The 
glands  having  to  be  dealt  with  an  incision  is 
made  along  the  upper  half  of  the  anterior  border 
of  the  sterno-mastoid — it  may  have  to  be  ex- 
tended to  the  sternum — and  a  second  carried 
forwards  from  this  at  the  level  of  the  hyoid  bone 
curving  upwards  to  the  mandible  to  one  side 
of  the  chin.  The  submental  group  of  glands  is  rarely  involved  in  these 
cases.  The  skin,  platysma  and  fascia  having  been  divided  and  the 
external  jugular,  occasionally,  secured,  the  flaps  are  dissected  up  and 
down  and  wrapped  in  sterile  gauze.  The  facial  vessels  are  next  divided 
between  ligatures  and  the  submaxillary  salivary  and  lymphatic  glands 
cleared  out.  If  the  glands  are  extensively  involved  the  incision  along  the 
sterno-mastoid  must  be  extended  to  the  sternum  and  the  deep  cervical 
group  extirpated  with  the  precautions  given  at  p.  539. 

The  operator  now  decides  according  to  the  vascularity  and  extent  of 
the  primary  growth  whether  he  will  deal  with  the  external  carotid  by  liga- 
ture and  extirpation  of  its  branches  {see  ligature  of  external  carotid), 
or  whether  he  will  be  satisfied  by  tying,  close  to  their  origin,  such  branches 
as  the  hngual,  the  ascending  palatine  (if  not  already  secm-ed  by  the 
ligature  of  the  facial)  and  the  ascending  pharyngeal.  This  question  is 
considered  a  httle  later  (p.  554).  The  further  steps  in  the  exposure  of 
the  pharynx  are  division  of  the  muscles  which  overlie  it,  the  digastric  and 

1  Treatment  of  the  raw  surface,  or  of  any  doubtful  area  where  it  has  been  impossible 
to  cut  sufficiently  widely  of  the  growth  by  dia-thermy  (see  p.  396),  may  also  be  tried. 

Mr.  F.  J.  Steward  has  recorded  a  case  in  which  he  removed  a  growth  from  the 
anterior  and  left  lateral  aspects  of  the  pharynx  by  this  method.  The  pharynx  was 
exposed  by  division  of  the  depressor  muscles,"^  thvrohvoid  membrane,  superior  cornu  of 
thyroid  cartilage,  and  left  lateral  wall  of  the  pharvnx  ( Proc.  Boi/.  Soc.  Med.,  Clin.  Sec, 
March  1912,  p.  137).  i       .        \  J 


Fig.  247.      Incision  for 
lateral  pharyngotomy. 


LATERAL  PHARYNGOTOMY  553 

styl()-li\()i(l  lirst,  tlien  tlu>  stylo-glossiis  and  stylo-pliaryn<i!;eiis,  and  the 
niylo-hyoid  and  the  hyoglossus  as  far  as  may  be  necessary.  The  hypo- 
glossal," gustatory  and  glossopharyngeal  will  be  in  the  upper  part  of  the 
wound  and  the  superior  laryngeal  nerve  in  the  lower.  All,  especially 
the  last,  are  to  be  spared  when  possible.  The  pharyngeal  wall  is  now 
exposed.  With  the  aid  of  a  finger  in  the  mouth,  or  slitting  the  cheek, 
tiu>  growth  is  now  removed  with  as  free  a  margin  as  possible  with  scissors. 
If  tile  vascularity  of  the  growth  or  other  conditions  seem  to  require  the 
use  of  the  cautery,  the  surgeon  must  remember  the  difficulty  which  this 
method  entails  in  estimating  the  condition  of  the  tissues  left  after  its  use.' 

Question  of  Closure  o£  the  Pharynx.  This  very  important  matter  must 
now  be  referred  to.  Innnediate  closure  with  sterilised  catgut  in  one  or 
two  layers,  care  being  taken  not  to  allow  any  inversion  of  the  mucous 
membrane,  has  the  advantage,  if  the  sutures  are  sufficiently  close  and  if 
they  hold,  of  diminishing  very  largely  the  escape  of  infected  discharges 
from  the  pharynx-,  and  of  facilitating  the  swallowing  and  feeding  of  the 
patient.  On  the  other  hand,  owing  to  the  stitches  very  rarely  holding 
here  as  in  the  case  of  the  oesophagus  {q.v.),  escape  of  the  above  discharges 
into  the  deepest  part  of  the  wound  and  a  most  dangerous  cellulitis  has  not 
infrequently  followed  suture  of  the  pharynx,  especially  when  this  has  been 
followed  by  suture  of  the  superficial  incisions.  For  this  reason  the  upper 
part  only  of  the  opening  in  the  pharynx  should  be  sutured,  a  drainage-tube 
inserted  here,  the  wound  lightly  plugged  with  a  strip  of  sterile  gauze,  and 
a  few  sutures  of  stout  salmon-gut  inserted  in  the  flaps  so  that  these  can 
be  partly  drawn  together  when  the  deeper  part  of  the  wound  is  safely 
closed.  As  feeding  of  these  patients  by  the  mouth  is  imperatively  needful, 
an  additional  precaution  taken  by  some  is  to  pass  a  soft  tube  by  the  nose 
below  the  wound  in  the  pharynx.  To  prevent  this  being  vomited  when 
the  patient  is  recovering  from  the  anaesthesia,  or  when  he  is  restless  and 
unamenable,  the  tube  may  be  sutured  to  the  mucous  membrane  of  the 
pharynx  with  catgut.^  Where  the  opening  in  the  pharynx  is  too  large 
for  suturing,  or  where  the  cautery  has  been  employed,  plugging  with  gauze 
both  of  the  deep  and  superficial  wounds  must  be  resorted  to. 

C.  We  will  now  consider  cases  where  the  growth  is  situated  higher 
up  and  farther  back,  and  an  ordinary  lateral  pharyngotomy  is  not  sufficient 
for  its  exposure.  This  is  afforded  by  division  or  resection  of  part  of  the 
mandible.  The  preHminary  steps  are  the  same  as  those  already  given, 
the  upper  end  of  the  first  incision  (p.  552)  being  carried  farther  back,  and 
the  upper  flap  dissected  higher  up.  When  the  mandible  is  exposed  and 
the  submaxillary  region  cleared  out  the  bone  is  divided  in  front  of 
the  masseter  with  a  Gigli's  saw,  the  section  being  made  obliquely  so 
that  its  line  encroaches  more  upon  the  outer  and  lower  aspect  of  the 
bone  than  upon  its  inner  and  upper,  because  the  sawn  extremity  of  the 
posterior  fragment  has  a  tendency  to  pass  inwards  and  upwards  (Kocher). 
Before  the  saw  is  used,  holes  should  be  drilled  for  the  passage  of  the  uniting 
wire.  The  two  halves  of  the  mandible  are  now  drawn  forcibly  apart,  the 
displacement  of  the  anterior  fragment  being  aided  by  free  division  of  the 
posterior  belly  of  the  digastric  and  the  stylo-hyoid.  Where,  owing  to 
the  extent  of  the  growth,  mere  division  of  the  bone  and  separation  of  the 
fragments  will  not  give  sufficient  room,  the  mandible  should  be  divided 
obliquely  just  behind  the  angle  and  the  ascending  ramus  removed  by 
disarticulating  the  condyle.  The  muscles  must  be  detached,  including  the 
posterior  part  of  the  masseter,  and  the  inferior  dental  artery  ligatured. 

^  The  passage  of  a  soft  nasal  tube  at  intervals  for  the  purpose  of  feeding  is  preferable. 


554 


OPERATIONS  ON  THE  HEAD  AND  NECK 


If  the  angle  is  left,  a  precaution  always  to  be  taken,  the  above  resection, 
while  giving  good  access  to  the  disease,  will  be  found  to  give  satisfactory 
results  as  to  subsequent  mobihty  of  the  jaw  and  disfigurement. 

The  above  methods  apply  chiefly  to  growths  involving  the  parts  about 
the  fauces  ;  where  it  is  chiefly  the  region  of  the  orifice  of  the  larynx  that 
is  encroached  upon,  viz.  base  of  tongue  and  epiglottis,  these  parts  can  be 
exposed  by  a  lateral  pharyngotomy  which  opens  the  pharynx  farther 
forwards,  and  by  removing  the  great  cornu  of  the  hyoicl  bone.  As  this 
course  runs  additional  risk  of  causing  injury  to  the  superior  laryngeal 
nerve,  and  thus  an  insensitive  condition  of  the  larynx,  and  as  cases 
involving  the  epiglottis  are  the  most  unfavourable  of  all  owing  to  the 
especial  risk  of  aspiration-pneumonia,  if  any  operation  is  performed,  it 
should  be  a  median  or  trans-hyoid  pharyngotomy  (p.  557). 

The  after-treatment  will  be  the  same  as  that  given  at  pp.  547  and  556. 
Choice  oS  Operation.  Where  the  growth  is 
no  longer  quite  small,  where  it  is  not  hmited 
to  the  tonsil  itself,  where  there  is  any  enlarge- 
ment of  glands,  or  where  the  existence  of  this, 
though  not  certain,  is.  from  the  duration  of  the 
case  or  the  presence  of  ulceration,  very  probable, 
lateral  pharyngotomy,  with  or  without  incision 
of  the  cheek,  should  be  performed.  It  gives  free 
access  to  the  tonsil  and  adjacent  parts,  it  enables 
the  surgeon  to  have  the  important  vessels  of  the 
neck  retracted,  it  admits  of  a  simultaneous  re- 
moval of  enlarged  glands,  and  putting  a  tem- 
porary loop  upon  the  common  carotid  {q.v.),  or 
ligature  of  the  external  carotid,  or  trusting  to 
securing  the  facial  and  lingual  close  to  their 
origin,  whichever  course  be  preferred.  On  the 
other  hand,  this  operation  is  a  severe  one.  The 
jaw,  if  divided,  must  be  wired,  and  necrosis  of 
the  bone  or  non-union  may  follow.  For  it 
must  be  remembered  that  this  wound  cannot  be  an  aseptic  one, 
and  the  opening  in  the  pharynx,  especially  if  this  has  been  made  by 
the  cautery,  may  set  up  septic  infection  in  spite  of  drainage.  The 
following  words  of  Prof.  Kocher  on  the  extent  of  operation  probably  re- 
quired are  weighty  ones  :  "  We  would  warn  our  readers  especially  against 
attempting  to  operate  from  the  mouth  in  those  common  cases  of  carcinoma 
situated  at  and  behind  the  isthmus  of  the  fauces,  and  spreading  on  to 
the  epiglottis,  and  involving  the  soft  palate  and  lateral  wall  of  the  pharynx, 
because,  in  cutting  wide  of  the  diseased  tissues,  one  cannot  avoid  doing 
a  serious  injury  to  adjacent  parts  and  di\ading  large  arteries.  If  the 
carotid  is  wounded  in  adherent  indurated  tissues,  there  is  a  great  risk 
of  not  being  able  to  arrest  the  haemorrhage  quickly  enough,  whereas  from 
outside  one  can  control  the  large  vessels  with  much  greater  certainty.  If 
the  new  growth  involving  the  tongue  and  pharynx  has  extended  to  the 
fold  between  the  jaws  and  the  bone  itself,  it  is  best,  after  dividing  the 
lower  jaw  as  above  described,  and  separating  the  capsule  of  the  joint  and 
the  external  pterygoid,  to  disarticulate  and  remove  the  ascending  ramus, 
after  detaching  the  healthy  muscles,  including  the  masseter.  In  this  way, 
subsequent  closure  of  the  jaw  is  most  certainly  avoided."  Cases  involving 
the  epiglottidean  folds  or  their  neighbourhood  are  the  most  unfavourable 
of  all  owing  to  especial  risk  of  aspiration-pneumonia. 


Fig.     248.        Incision    for 

lateral  pharj-ngotomy  with 

division  of  the  lower  jaw. 


COMBINED  OPKHATIONS  555 

Possible  Aids  in  the  above  Operations.  (1)  Ligature  of  External 
Carotid.  At  first  sight  this  step,  which  ensures  very  Uttle  bleeding, 
a  clear  field  of  operation,  and  absence  of  anxiety  as  to  blood  entering 
the  larynx,  seems  one  of  universal  application.  But  again,  the  fact 
that  the  wound  may  become  infected  renders  mere  ligature  one  of  risk. 
With  the  pliaiynx  opened  in  the  neck,  or  a  laryngotomy  or  tracheotomy 
performed,  and  the  tube,  if  necessary,  retained,  infective  softening 
and  ulceration  about  the  ligature  may  occur  with  fatal  secondary 
haemorj'hage.  Thus  Sir  Watson  Cheyne  lost  a  patient  twenty-five 
days  after  an  extensive  operation  for  epithelioma  of  one  tonsil.^  He 
states  that  Polaillon,  who  has  tied  the  external  carotid  in  most  of  his 
cases,  has  lost  several  from  this  cause.  Sir  Watson  Cheyne  is  inclined, 
therefore,  only  to  make  use  of  ligature  of  the  external  carotid  when  the 
operation  is  performed  in  two  stages,^  viz.  removal  of  the  enlarged 
glands  and  ligature  of  the  external  carotid  first,  and,  about  a  week 
later,  the  removal  of  the  growth  in  the  throat. 

Primary  and  secondary  htemorrhage  alike  will  best  be  met  by  adopting 
Dawbarn's  method  of  excising  the  external  carotid  and  its  branches 
{see  ligature  of  this  vessel). 

(2)  Question  of  a  Preliminary  Laryngotomy  or  Tracheotomy  The 
question  of  a  preliminary  laryngotomy  for  the  administration  of  the 
anaesthetic  in  these  cases  has  already  been  considered.  In  these  cases  it 
may  also  be  called  for  on  the  following  grounds  :  (a)  the  growth  is 
likely  to  extend  to  the  base  of  the  tongue,  the  epiglottis,  or  the  upper 
opening  of  the  larynx ;  (6)  there  will  be  increased  difficulty  in  swallowing 
and  increased  difficulty  in  keeping  the  wound  clean. 

The  objections  to  this  step  are  obvious.  It  introduces  ariother  and 
necessarily  infected  wound  ;  it  is  the  means  of  colder  air  being  introduced  ; 
it  interferes  with  coughing  and  emptying  the  upper  air-passages,  an  inter- 
ference already  brought  about  by  the  wound  in  the  pharynx.  The  nearer 
to  the  larynx  that  the  growth  extends,  the  more  emphatically  is  a  laryn- 
gotomy or  a  tracheotomy  with  its  additional  risks  required.  And  more 
than  this,  the  longer  will  the  tube  need  to  be  retained,  owing  to  the  risk 
of  oedema  of  the  glottis.  This  risk  is  present  during  the  first  fortnight, 
and  if  the  tube  has  been  removed  early,  it  must  always  be  kept  at  hand. 

(3)  The  Trendelenherg  position.  Where  a  prehminary  laryngotomy 
or  tracheotomy  has  not  been  performed,  this  may  be  tried  after  the  first 
part  of  the  operation  when  the  glands  have  been  removed.  It  has  been 
strongly  advocated  by  Prof.  Keen,  of  Philadelphia,  in  all  severe  operations 
affecting  the  larynx.  At  the  time  of  the  operation  its  liability  to  cause 
venous  congestion  must  be  remembered,  and  its  maintenance  afterwards, 
on  which  Prof.  Keen  lays  stress,  is  difficult  omng  to  the  tendency  of  the 
patient  to  slip  down  against  the  head  of  the  bed.  This  may  be  obviated, 
in  part,  by  flexing  the  knees  over  an  inclined  plane.  Like  a  laryngotomy 
or  tracheotomy,  it,  of  course,  cannot  be  relied  upon  entirely  to  prevent  the 
occurrence  of  aspiration-pneumonia. 

1  Objects  and  Limits  of  Operations  for  Cancer,  p.  59. 

-  In  a  case  in  which  Sir  W.  Cheyne  adopted  this  ])lan,  a  week  intervening  between 
the  two  operations,  "  there  was  no  more  bleeding  from  the  deeper  parts  than  if  the 
external  carotid  had  just  been  tied  "  (ibid.,  p.  67).  Sir  W.  Cheyne  only  advises  that ' 
the  operation  be  performed  in  two  stages  in  cases  where  the  patients  are  weakly,  and 
the  primary  and  glandular  disease  both  extensive,  and  perhaps,  also,  where  ligature  of 
the  external  carotid  appears  to  be  desirable.  He  points  out  a  serious  objection  to 
this  method  of  operating,  viz.  that  after  removing  the  glands,  open  lymphatic  vessels 
are  left  which  may  contain  or  convoy  cancerous  material  to  the  newly  made  wound,  and 
thus  infect  it  before  the  second  oiieration. 


556 


OPERATIONS  ON  THE  HEAD  AND  NECK 


(4)  Tlie  use  of  Eucaine.  This  is  worth  remembering  in  the  deeper 
stages  of  these  operations,  especially  those  carried  on  near  the  orifice  of 
the  larynx.  By  the  smaller  quantity  of  general  anaesthetic  thus  required 
the  amount  of  bleeding  at  a  trying  time  may  be  lessened. 

After-treatment.  The  same  precautions  as  after  removal  of  the 
tongue  must  be  taken  for  keeping  clean  the  wound  in  the  mouth  and 
neck.  At  the  close  of  the  operation  Whitehead's  varnish  may  be  applied. 
The  treatment  of  the  wound  in  the  pharynx  has  been  referred  to  above, 
the  patient  very  frequently  washing  it  out  by  one  of  the  fluids  given  at 
p.  547.  The  patient  should  have  practised  gargling  out  his  mouth  and 
fauces  beforehand  (p.  532).  In  order  to  prevent  the  frequent  soaking 
and  changing  of  the  dressings  as  much  as  possible,  he  should  use  small 

quantities,  and  hold  his  head  to  the  oppo- 
site side.  It  will  probably  be  well  to  retain 
one  drainage-tube  in  situ  for  a  week  or 
ten  days.  This  has  been  objected  to  on 
account  of  the  danger  of  erosion  of  the 
external  carotid.  This  may  be  prevented 
by  dealiiig  with  the  vessel  as  advised  at 
p.  555.  In  any  case  the  risk  of  insufficient 
drainage  is  far  greater.  It  should  be 
taken  out  and  boiled  before  re-insertion 
daily.  Feeding  by  aid  of  a  soft  tube  passed 
along  the  sound  side  will  be  needful  for 
some  time,  perhaps  as  long  as  two  or  three 
weeks,  where  removal  of  parts  around  the 
tonsil,  the  wall  of  the  pharynx,  or  the  base 
of  the  tongue  has  been  extensive.  The 
patient's  feeding  himself  should  be  for- 
bidden as  long  as  any  attempt  at  this 
causes  choking  or  coughing,  owing  to  the 
danger  of  fluids  entering  the  air-passages. 
During  feeding  a  pad  of  gauze  should  be 
placed  over  any  opening  in  the  neck.  Sir  Watson  Cheyne  has  found  it 
useful  to  keep  the  patient's  head  hanging  over  the  side  of  the  bed  and 
turned  towards  the  sound  side,  the  liquid  being  taken  in  small  amounts 
and  very  slowly.  As  after  removal  of  the  tongue,  the  patient  should  sit 
up  and  be  got  out  of  bed  as  soon  as  possible. 

Median  Pharyngotomy.  As  this  form  of  pharyngotomy  has  been  but 
little  performed  in  England,  and  as  it  is  highly  spoken  of  by  Prof.  Kocher, 
the  different  methods  which  he  recommends,  ^dz.  sub-hyoid  pharyngo- 
tomy by  a  free  transverse  incision,  and  median  pharyngotomy  by  a 
T-shaped  incision,  by  which  not  only  is  a  growth  of  the  pharynx  but 
part  of  the  larynx  as  well  removed,  are  described  fully  below.^  Mention 
may  also  be  made  of  the  French  method  of  trans-hyoid  pharyn- 
gotomy, in  which  a  vertical  incision  is  made  and  the  hyoid  bone  divided. 
In  Mr.  Jacobson's  experience,  the  last,  aided,  if  needful,  by  division 
of  the  thyroid  cartilage,  gives  sufficient  room  for  dealing  with  growths 
of  any  extent  which  it  is  advisable  to  attack.  The  first  two  will  enable 
the  surgeon  to  deal  with  growths  of  more  limited  size. 

"  Sub-hyoid  pharyngotomy,  introduced  by  Malgaigne  and  Langenbeck,  deserves 
special  attention.  By  utilising  all  the  advantages  of  this  procedure,  the  operation 
becomes  much  more  frequently  indicated  than  former  authors  supposed.     It  has 

1  Third  Eng.  Ed.  Trans.,  Stiles  and  Paul,  p.  434. 


Fig.  249.  A,  Incision  for  sub- 
hyoid i^haryngotomy.  B,  Ver- 
tical incision  in  addition  to  the 
above  recommended  by  Kocher 
for  tumours  of  the  sinus  pyrifor- 
mis  and  the  region  of  the  ary- 
teno-epiglottidcan  folds. 


MEDIAN  PHARYXGOTOMY  557 

the  adviuitago  of  giving  excdU'iit  acooss  with  little  injury  to  the  surrounding  struc- 
tures. Not  only  is  the  ojKTation  indicated  for  the  removal  of  all  growths  situated 
at  the  entrance  of  the  larynx,  e.g.  growths  involving  the  epiglottis,  aryteno- 
epiglottidean  folds,  arytenoid  cartilage,  mucous  membrane  at  the  level  of  the 
hyoid  hone,  and  of  the  sinus  pyriformis,  but  equally  for  growths  situated  at  the 
root  of  the  tongue,  and  on  the  lateral  and  jmsterior  walls  of  the  pharynx  as  far 
down  as  the  a\sophagus. 

"  We  have  found  ])reliminary  tracheotomy  and  jjacking  unnecessary  ;  blood 
can  be  prevented  entering  the  larynx  by  having  the  jjaticnt  in  the  correct  oblique 
position.  A  general  an;esthetic  can  be  dispensed  with,  and  instead,  a  1  jxjr  cent, 
solution  of  cocaine  can  be  injected  for  the  skin  incision,  and  5  to  10  per  cent,  .solution 
can  be  re}ieatedly  ])ainted  on  the  mucous  membrane. 

"  The  incision,  four  inches  long,  is  made  along  the  hyoid  bone  from  the  greater 
horn  on  one  side  to  that  on  the  other,  dividing  the  skin  and  muscular  fibres  of  the 
platysma.  The  hyoid  bone  is  then  exposed  and  the  anastomosis  of  veins  crossing 
it  are  ligatured.  The  hyoid  artery  and  vein  lie  on  the  bone,  and  are  retracted  to 
the  upi)cr  side  of  the  wound.  The  muscles  inserted  into  the  lower  border  of  the 
hyoid  bone  are  divided  at  their  insertions. 

"  The  thyro-h^'oid  membrane  is  now  exposed.  The  central  part  appears  as  a 
broad  tense  ligament,  but  the  lateral  parts  are  thinner.  The  central  portion,  which 
encloses  fat  and  often  a  bursa,  is  transversely  di%ided  along  the  bone.  The  mucous 
membrane  is  similarly  divided,  giving  rise  to  some  spirting  from  small  vessels. 
We  do  not  consider  it  advisable  to  divide  it  at  a  distance  trom  the  hyoid,  on  account 
of  the  superior  laryngeal  nerve,  which  enters  the  larynx  by  piercing  the  lateral  part 
of  the  thjTO-hj-oid  membrane.  If  the  twigs  of  the  nerve  are  cut,  the  larynx  becomes 
insensitive,  and  allows  of  the  entrance  of  food,  mucus,  and  wound  secretions  into  the 
lar_%Tix.  As  these  foreign  bodies  cannot  be  reflexly  coughed  up  aspiration-pneumonia 
is  developed. 

"  The  epiglottis  can  now  be  seized  with  a  hook  at  its  upper  border  and  drawn 
forwards.  This  gives  an  excellent  \new  of  the  entrance  of  the  larynx,  especially 
the  neighbourhood  of  the  arytenoid  cartilages,  which  is  so  often  the  seat  of  disease 
(tuberculosis  and  cancer),  and  also  of  the  lowest  part  of  the  pharynx  and  the  root  of 
the  tongue.  If  the  epiglottis  must  be  removed,  it  is  seized  with  a  hook  at  its  lowest 
point  (which  can  be  easilj'  felt  above  the  dip  in  the  th\Toid  cartilage)  and  dragged 
outwards.  After  the  mucous  membrane  has  been  divided  it  can  be  easily  pulled 
out  and  cut  awaj".  As  in  laryngotomy,  the  reflex  irritation  of  the  mucous  membrane 
must  be  quieted  bj-  frequent  applications  of  a  5  jier  cent,  cocaine  solution,  so  as  to 
enable  the  operation  to  be  continued  in  comfort. 

"  The  new  growth  should  be  thoroughly  removed  with  the  thermo-cautery,  the 
parts  being  clearly  exposed  to  view.  The  cautery  arrests  all  oozing,  and  gives  a 
better  chance  of  a  radical  cure.  As  regards  after-treatment,  it  is  well  under  certain 
circxnnstances  to  perform  tracheotomy  to  avoid  the  danger  from  oedema  glottidis, 
which  often  develops  in  an  extremely  insidious  way,  and  may  cause  danger  from 
asphyxia.  The  main  wound  is  dressed  with  iodoform  gauze  and  collodion.  We 
used  formerly  to  stuff  the  wound,  but  we  have  now  abandoned  the  practice.  As  we 
always  cut  round  new  growths  -«-ith  the  fine  blade  of  a  thermo-cautery  and  carefully 
stop  all  bleeding,  we  have  found  it  sufficient  to  insist  that  the  patient  must  lie  with 
the  head  low  whenever  he  is  recumbent  ;  but  he  should  be  allowed  to  sit  up  very  early, 
to  allow  of  easy  expectoration  of  the  secretions  of  the  wound. 

"  We  avoid,  wherever  it  is  possible,  performing  secondary  tracheotomy.  It 
is  only  when  the  sensitiveness  of  the  larynx  has  been  destroyed  by  injury  to  the 
superior  laryngeal  nerve  that  one  cannot  trust  to  the  cough-reflex  to  prevent  secre- 
tions from  floAving  do\\ii. 

"  Median  Pharyngotomi/.  Owing  to  the  extreme  frequency  of  tumours,  especially 
carcinoma,  in  the  region  of  the  entrance  of  the  larynx,  i.e.  affecting  one  of  the 
arytenoid  cartilages  and  the  aryteno-epiglottidean  folds,  and  infiltrating  the  wall  of 
the  pharpix  and  the  sinus  j^jTiformis,  it  is  ad\'isable  to  give  a  definite  description  of 
the  method  of  exposing  the  lowest  part  of  the  pharj-nx  with  the  least  destruction  of 
the  parts. 

"  Just  as  we  have  lately,  on  principle,  employed  a  median  incision  for  the  tongue 
and  upper  part  of  the  larj^nx,  we  have  similarly  restricted  the  use  of  lateral  pharyn- 
gotomy  in  favour  of  median  pharjnigotonn-,  for  cases  of  carcinoma  such  as  those  for 
which  we  have  frequently  been  called  upon  to  operate,  and  the  results  have  been 
thoroughly  gratifying  as  regards  its  precision  and  the  minimum  damage  done  to  the 
surrounding  structures. 


558    OPERATIONS  ON  THE  HEAD  AND  NECK 

"  The  incision  is  made,  as  in  sub-hyoid  pharyngotomy,  along  the  lower  border 
of  the  hyoid,  but  extending  farther  outwards  on  the  diseased  side,  and  only  about  an 
inch  and  a  half  across  tlie  middle  line  on  the  healthy  side.  From  this  another 
incision  is  carried  down  to  the  thyroid  and  cricoid  cartilages  in  the  middle  line  as 
far  as  the  isthmus  of  the  thp-oid,  care  being  taken  to  avoid  the  vertical  veins  ; 
the  transverse  veins  are  ligatured  as  in  median  laryngotomy. 

"  On  the  diseased  side  the  sterno-hyoid,  thyi'o- hyoid,  and  omo-hyoid  are  divided 
parallel  to  the  hyoid,  and  the  subjacent  thyro-hyoid  membrane  is  cut  across  as 
described  in  sub-hyoid  pharyngotomy  :  the  tiji  of  the  epiglottis  is  then  seized  with 
a  small  sharp  hook  and  dragged  forwards  and  towards  the  healthy  side. 

"  The  extent  of  the  new  growth  anteriorly  is  now  defined,  and  the  epiglottis  is 
divided  J  cm.  in  front  of  the  disease  along  its  lateral  border  down  to  its  base.  By 
this  means  a  better  view  is  obtained,  and  one  is  able  to  decide  how  much  of  the 
cartilaginous  plate  of  the  thyroid  will  have  to  be  excised.  The  thyroid  cartilage  is 
then  split  in  the  middle  line,  and  the  muscles  attached  to  the  wing  of  the  thyroid 
cartilage  are  separated,  along  with  the  perichondrium,  from  the  diseased  side.  With 
a  sharp  hook  the  wing  of  the  thyroid  on  the  diseased  side  can  be  sufficiently  drawn 
outwards  and  downwards  to  enable  the  tumour  to  be  detached  from  below  and  then 
from  behind,  and  the  mucous  membrane  to  be  divided  in  healthy  tissue  in  the  region 
of  the  arytenoid  cartilage  (it  is  often  necessary  to  divide  it  between  the  arytenoids). 
The  new  growth  is  now  grasped  by  the  fingers,  and  the  limits  of  the  hardness  examined 
with  sufficient  exactness  to  decide  where  the  soft  parts  (the  muscular  attachments  of 
the  pharynx)  are  to  be  chvided  from  the  outside.  The  limits  of  the  mucous  membrane 
towards  the  pharynx  along  with  part  of  the  pharynx  can  be  carried  out,  the  bleeding 
being  easily  controlled  and  the  diseased  tissues  completely  removed. 

"  As  will  be  gathered  from  the  description,  we  get  at  the  lateral  and  posterior 
walls  of  the  pharynx  by  adding  to  the  incision  parallel  to  the  hyoid  the  median 
incision  with  splitting  of  the  thyroid  cartilage.  This  allows  one  half  of  the  larynx 
to  be  powerfTilly  ])ul]ed  downwards  and  forwards." 

Trans-hyoid  Pharyngotomy  by  a  Vertical  Incision.  This  method  has 
considerable  advantages  for  the  removal  of  growths  at  the  base  of  the 
tongue,  the  epiglottis  and  the  opening  of  the  larynx.  A  case  in  which  it 
enabled  the  operator,  Mr.  Carless,  to  deal  with  a  growth  situated  far  back 
in  the  tongue,  has  been  referred  to  at  p.  543,  where  details  of  the  operation 
will  also  be  found. 

Operation.  An  incision  is  made  through  the  skin  and  subcutaneous  tissue, 
in  the  middle  line  from  the  symphysis  to  the  top  of  the  thyroid  cartilage.  The 
raphe  of  the  mylo-hyoid  is  divided,  the  hyoid  bone  exposed  exactly  in  the  mid 
line,  and  divided  with  bone-forceps.  The  two  halves  of  the  bone,  together  with 
those  of  the  mylo-hyoid  and  the  genio-hyoids  are  well  retracted.  This  affords  a 
space  of  about  one  and  a  half  inches  in  width.  According  to  the  site  and  size  of 
the  growth  further  access  must  be  obtained  by  dividing  the  mucous  membrane 
above  and  the  thyro-hyoid  ligament  below.  The  operator  now  inserts  a  finger 
to  ascertain  the  position  and  size  of  the  growth  ;  another  introduced  through  the 
mouth  will  aid  this.  The  epiglottis  is  now  drawn  forwards  as  advised  (p.  557)  and 
excised  with  the  growth  by  a  V-shaped  incision  if  possible,  as  this  can  be  partly 
sutured  with  catgut  at  the  upper  part.  If  the  epiglottis  is  clearly  not  involved, 
it  may  be  dissected  free  and  left.  The  wound  is  packed  with  gauze,  which  is  brought 
out  at  the  lower  angle,  sutures  being  only  employed  above. 

Numerous  details,  already  given,  have  been  omitted  here.  A  preliminary 
tracheotomy  will  be  required  owing  to  the  manipulations  about  the  upper  aperture 
of  the  larynx.  The  risk  of  subsequent  oedema  glottidis  (p.  555)  must  not  be 
forgotten.  It  would  probably  add  to  the  after  safety  of  the  patient,  if  before  the 
pharynx  is  opened,  the  Trendelenberg  position  were  adopted.  The  patient  must  be 
fed  at  first  with  a  soft  tube. 

Lateral  pharyngotomv  has  an  apparent  advantage  over  the  median  method 
in  that  the  incis^ion  for  the  former  operation,  if  added  to,  admits  of  removal  of 
infiltrated  glands  at  the  same  time.  Mr.  Jacobson  says,  "  For  my  own  part,  I  am 
strongly  of  opinion,  with  all  deference  to  that  of  Sir  W.  Cheyne  (p.  555),  that  it 
will  be  much  wiser  to  remove  the  glands  by  A  second  operation,  as  has  been  advised 
in  the  case  of  epithelioma  of  the  tongue  (q.v.).  An  operation  with  the  object  of 
extirpating  all  the  glands  which  may  be  affected  (not  only  the  group  which  can  be 
felt),  is  sufficiently  trying  both  to  patient  and  surgeon  to  require  a  time  for  itself." 


CHAPTER  XXVTT 

OPERATIONS  ON  THE  AIR  -  PASSAGES  IN  THE  NECK. 
TRACHEOTOMY.  INTUBATION.  LARYNGOTOMY.  THY- 
ROTOMY.     EXCISION  OF  THE  LARYNX 

THYROTOMY 

Indications.  Owing  to  the  improvement  of  the  endo-laryngea]  methods 
of  operating  thyrotomy  is  now  less  frequently  called  for.  Tt  may, 
however,  be  required  under  the  following  circumstances. 

(1)  Growths  which  cannot  be  removed  through  the  mouth,  but  which 
do  not  require  severer  operations  on  the  larynx  itself.  The  following 
are  the  chief  conditions  which  must  decide  the  removal  of  laryngeal 
growths  by  an  operation  from  the  mouth  or  by  thyrotomy  : 

(a)  The  amount  of  special  laryngeal  skill  possessed  by  the  operator. 

(b)  The  nature  of  the  growth,  whether  multiple  or  no,  if  pedmiculated, 
if  recurrent  after  attempts  at  removal  from  the  mouth, 

(c)  The  extent  of  the  growth. 

(d)  The  irritability  of  the  larynx.  The  amount  of  self-control  of  the 
patient.  Any  tendency  to  asphyxia.  While  the  much  rarer  fibromata 
are  to  be  remembered,  it  is  to  papillomata  in  children  that  the  following 
remarks  apply. 

It  will  be  assumed  that  endo -laryngeal  interference  is  not  available, 
or  that  it  is  not  to  be  entertained  from  the  age  of  the  patient,  the  history 
of  dyspnoea,  or  the  marked  degree  of  aphonia  which  points  to  the  growths 
having  reached  an  extent  which  may  at  any  time  bring  on  sudden  and 
rapidly  fatal  dyspnoea.  The  question  now  lies  between  thyrotomy  and 
tracheotomy,  both  of  which  operations  have  serious  disadvantages. 

The  disadvantages  of  thyrotomy  are  undoubted.  It  is  frequently 
insufficient,  the  growths  quickly  reappearing.  It  is  liable,  when  repeated, 
to  be  followed  by  stenosis,  this,  perhaps,  occurring  in  proportion  to  the 
vigour  of  the  treatment.  It  is  obvious  that  in  little  children — and  these 
growths  may  occur  in  the  first  years  of  life — owing  to  the  anaesthetic  and 
the  nature  of  the  part  which  is  operated  on,  there  must  be  some  risks  at 
the  time,  and  a  little  later.  The  possibility  of  aphonia  is  another  serious 
disadvantage.  This  will,  however,  probably  be  already  present,  and,  in 
many  cases,  after  the  operation  the  voice  steadily  improves  with  the 
growth  of  the  child. 

The  full  description  given  at  p.  588  of  the  technique  of  thyrotomy  for 
maHgnant  disease  will  suffice  for  those  cases  of  papillomata  or  fibromata 
which  occasionally  occur  in  adults. 

(2)  Large  rough  foreign  bodies,^  e.g.  bits  of  bone,  &c. 

^  At  the  present  day,  such  foreign  bodies  would  ahuost  always  be  extracted  by 
Briining's  direct-vision  tubes.  As  this  accident  might  occur  when  these  very  special  instru- 
ments were  not  available,  this  indication  is  still  included. 

559 


560  OPERATIONS  ON  THE  HEAD  AND  NECK 

In  a  case  brought  before  the  Clinical  Society  ^  by  Dr.  Taylor  and  I\Ii-.  Golding  Bird 
a  bit  of  mutton  bone  was  impacted  between  the  vocal  cords,  where  it  could  be  seen 
with  the  laryngoscope.  It  was  removed  by  Mr.  Golding  Bird  by  a  vertical  incision 
with  its  centre  over  the  cricoid  cartilage,  the  cricothjToid  membrane  being  incised 
horizontally.  A  tracheal  cUlator  being  introduced,  the  bone  was  seen  at  once,  and 
extracted  with  Toynbee's  ear-forceps.  The  large  size  of  the  fragment,  its  apparentlj'^ 
firm  position,  the  fact  that  the  broad  surface,  and  not  the  edge,  presented,  together 
Avith  its  position  just  at  the  cricothyi-oid  membrane,  led  to  the  external  operation 
being  made  use  of. 

Mr.  M.  Shield  ^  related  a  similar  case  successfully  dealt  with  by  thjTotomy.  The 
bone  had  been  impacted  four  days.  Pus  escaped  when  the  preliminary  tracheotomy 
was  performed.  The  bone  could  not  be  seen  when  the  thjToid  cartilage  was  divided, 
but  was  detected,  very  firmly  impacted  below  the  cords,  with  the  finger.  The 
tracheotomy-tube  was  removed  in  twelve  hours,  and  the  wound  then  drawn  together 
by  sutures  previously  passed.     The  voice  was,  ultimately,  completely  recovered. 

(3)  Much  rarer  indications  for  thyrotomy  are  :  CaSes  of  stenosis  of 
the  larynx  as  a  result  of  injury  or  syphihs.  The  late  Mr.  M.  Shield  has 
described  two  such  cases.  In  that  due  to  fracture  of  the  larynx,  thyro- 
tomy a  few  months  later  with  removal  of  the  cicatricial  tissue  and 
dilatation  of  the  larynx  with  the  finger  enabled  the  patient  to  dispense 
with  her  tracheotomy-tube,  and  to  speak  with  a  good  voice  at  the  time 
when  she  was  last  seen,  two  months  after  the  thyrotomy.  The  s}'^hilitic 
case  admitted  of  less  benefit,  and  retentiou  of  the  tracheotomy-tube  was 
needful. 

Operation.  As  a  high  tracheotomy  will  usually  be  reCj[uired,  it  will 
facilitate  matters,  especially  in  little  children,  where  the  field  is  small, 
if  the  first  incision  is  made  from  the  top  of  the  thyroid  cartilage  to  a  point 
about  an  inch  and  a  half  below  the  cricoid.  An  ordinary  tracheotomy- 
tube  will  suffice  here  if  a  small  tampon  of  gauze  secured  A\dth  silk  is 
placed  above  it.  It  affords  an  additional  element  of  safety  to  open  the 
trachea  as  a  preliminary  step,  owing  to  causes  of  interference  with  respiia- 
tion  even  in  the  case  of  a  foreign  body,  as  this  may  prove  to  be  fixed  ;  as 
the  upper  part  of  the  wound  may  usually  be  closed  in  these  cases  there 
is  less  need  to  make  two  distinct  incisions,  a  step  which  may  cramp  the 
operator  considerably. 

After  the  performance  of  the  tracheotomy  the  next  steps  vary  some- 
what according  to  the  condition  which  calls  for  the  operation.  If  it 
be  a  foreign  body,  the  upper  part  of  the  incision  should  be  deepened 
over  the  cricothyroid  space,  the  membrane  opened,  and  a  tracheal  dilator 
inserted.  If  the  body  be  not  seen,  a  probe  will  probably  find  it  and  suit- 
able forceps  extract  it.  This  will  prevent  any  of  the  interference  with  the 
vocal  corcls  inflicted  by  thyrotomy.  If  the  latter  step  be  required,  as  in 
the  case  of  papillomata,  after  all  haemorrhage  is  arrested,  the  thyroid 
cartilage  is  divided  along  its  centre  with  scrupulous  exactness.  This 
is  easily  affected  in  children  with  scissors  introduced  through  an  opening 
in  the  cricothyroid  membrane.  In  adults  a  fine  pair  of  bone-shears  or  a 
very  fine  saw  will  be  needed.  The  two  halves,  treated  with  the  utmost 
delicacy,  are  now  opened  out  with  sharp  hooks.  A  solution  of  eucaine  and 
adrenalin  is  next  applied  ;  and  at  this  stage  a  trial  of  the  Trendelen- 
berg  position  may  be  made. 

The  removal  of  papillomata  is  often  attended  with  much  difficulty 
owing  to  their  friability.  They  are  best  snipped  away  with,  small  scissors 
curved  on  the  fiat  ;   the  apphcation  of  fused  chromic  acid,  silver  nitrate, 

1  Trans.,  vol.  xvii,  p.  214. 

2  Brit.  Med.  Journ.  1902,  vol.  ii,  p.  941. 


TIIVHOTOMV  561 

sulphuric  acid,  or  tlie  cautery  may  be  tried,  though  often  without  success, 
to  prevent  the  inveterate  tendency  to  reappearance. 

The  object  of  the  operation  being  accomplished,  and  all  haemorrhage 
arrested,  the  al»  of  the  thyroid  are  united  by  one  or  two  points  of  silver 
suture  not  passed  through  the  entire  thickness  of  the  cartilage.  A  steril- 
ised dressing  is  then  applied. 

The  tracheotomy-tube  must  not  be  removed  till  all  risk  of  intra- 
laryngeal  oedema,  &c.,  has  passed  by,  though  it  may  be  early  replaced 
by  one  of  india-rubber.  The  after-treatment  and  complications  are  much 
as  after  tracheotomy  (pp.  570,  572). 

(*oughing  will  be  especially  harmful  now. 

Impairment  of  the  voice  occurring  after  thyrotomy  has  been  alluded 
to  above.  It  may  arise  quite  apart  from  any  injury  inflicted  on  the  cords 
during  the  operation,  owing  to  the  cicatrix  subsequently  involving  the 
anterior  commissure  of  the  cords.  Where  the  masses  of  papillomata 
are  large,  though  the  removal  has  been  complete,  the  patient  has  in  a 
few  cases  never  been  able  to  dispense  \\4th  the  tube.  In  this  event,  the 
presence  of  papillomata  above  the  opening  in  the  trachea  must  be 
thought  of.  In  order  to  deal  with  them,  the  trachea  must  be  opened 
again  a  lirtle  lower  down. 

1'he  treatment  of  laryngeal  papillomata  by  the  endo-laryngeal 
method  (bv  Kilian's  or  Briining's  direct -vision  tubes)  described  on  p.  608 
is  probablv  the  most  satisfactory  method  of  treatment. 

Treatment  of  Laryngeal  Papillomata  by  Tracheotomy  alone.  The 
results  (jf  thyrotomy  for  papillomata  are  so  unfavouraljle  both,  as  regards 
reappearance,^  much  impairment  of  voice,  and  stenosis  that  it  has  been 
proposed  to  resort  to  tracheotomy  alone  with  the  object  of  giving  entire 
rest  to  the  parts  :  further,  there  is  some  reason  to  believe  that,  if  un- 
irritated,  these  gi'owths  have  a  tendency  in  early  life  to  disappear.  The 
disadvantages  of  this  method  are pb\4ous,  viz.  the  length  of  time  the  tube 
will  have  to  be  worn  and  the  difiicidties  which  will  arise  when  the  tube  is 
ultimately  dispensed  with  (p.  572).  Dr.  G.  Hunter  Mackenzie  was  the 
first  to  bring  this  step  forward,-  showing  that  the  papillomata  tended 
slowly  to  atrophv  when  the  larynx  was  put  at  rest  and  freed  from  the 
irritation  incidental  to  coughing,   &:c. 

The  length  of  time  during  which  the  cannula  ^  requires  to  be  worn 
varies  much.  In  Dr.  G.  H.  Mackenzie's  three  cases  it  remained  in  the 
trachea  twelve,  six  and  seven  months  respectively.  Numerous  conj&rma- 
tory  cases  are  given  by  this  authority.*  He  agrees  with  the  statement 
already  made  that  the  trachea  should  be  opened  as  soon  as  the  aphonia 
is  complete  and  permanent,  without  any  waiting  for  the  onset  of  dyspncea. 
To  this  Dr.  Mackenzie  adds  the  warning  "  that  infraglottic  papillomata 
may  be  present  without  much  vocal  alteration,  but  with  considerable 
respiratory  disturbance." 

Dr.  Railton,  of  Manchester,  published ^  two  cases  illustrating  the  value 
of  this  treatment.     In  one  child  the  cannula  was  worn  for  three  years  and 

1  In  addition  to  this  very  marked  tendency  to  reappearance,  there  is  the  risk  that 
the  trachea  may  have  to  be  opened  to  prevent  suffocation  after  the  child  has  appeared 
to  be  convalescent. 

2  Edin.  Jled.  Journ..  November  1884  ;  Lancet,  April  6,  1889  ;  and  Brit.  Med  Journ., 
September  12.  1896.  p.  609. 

'  An  india-mbber  tube  is  to  be  used  whenever  possible,  and  granulations  springing 
up  at  the  wound  are  to  be  destroved  at  regular  intervals. 
^  Brit.  Med.  Journ..  1901.  vol.  ii,  p.  884. 
5  Ibid.,  February  19.  1898,  p.  489. 
SURGERY  I  .  36 


562  OPERATIONS  ON  THE  HEAD  AND  NECK 

nine  months,  and  in  the  other  for  twenty-five  months  before  it  was  finally 
removed.^ 

In  these  cases  the  condition  of  the  voice  and  the  breathing  is  examined 
from  time  to  time  by  taking  ont  the  cannula  and  closing  the  opening, 
but  the  instrument  is  not  finally  withdrawal  until  every  trace  of  stridor 
and  hoarseness  has  disappeared. 

George  A.  Wright,  of  Manchester,  whose  experience  at  the  Pendlebury 
Children's  Hospital  has  been  very  large,  gives  ^  an  interesting  case  in 
proof  of  this  warning. 

In  a  child  of  five,  tracheotomy  had  been  performed  for  Lxryngeal  jiapillomata. 
The  tube  had  been  removed,  at  first  for  short  intervals,  and  later  altogether.  The  child 
died  suddenly  in  an  urgent  attack  of  dyspnoea.  The  fact  that,  in  addition  to  a  mass 
of  papillomata  on  the  vocal  cords  and  at  the  site  of  the  tracheotomy  wound,  there 
was  an  early  stage  of  tuberculosis  of  the  bronchial  glands  and  lungs,  suggests,  as 
is  pointed  out,  the  possibility  of  a  hospital  infection  with  tuberculosis  through  the 
tube. 

LARYNGOTOMY  OR  INTER-CRICO-THYROTOMY 

In  this  operation  the  tube  is  inserted  through  an  opening  in  the 
cricothyroid  membrane.  It  is  called  for,  in  preference  to  tracheotomy, 
on  account  of  the  greater  facility  with  which  it  is  performed,  in  cases  of 
emergency,  and  in  those  where  a  tube  can  quickly  be  dispensed  with.^ 
Finally,  it  is  inapplicable  before  adolescence. 

Indications,  (i)  Sudden  impact  of  large  foreign  bodies  threatening 
suffocation,  as  when  a  bolus  of  food  carelessly  swallowed  lodges  in  the 
upper  aperture  of  the  larynx.^ 

(2)  Before  operations  likely  to  be  attended  with  much  bleeding, 
e.g.  those  on  the  tongue,  jaw,  tonsils,  &c.,in  order  that  the  fauces  may  be 
plugged  with  a  sponge.  Wherever  the  tube  can  be  soon  dispensed  with, 
this  operation  is  very  superior  to  a  high  tracheotomy,  often  reconnnended. 

(3)  When  spasm  of  the  larynx  is  .threatening  very  suddenl}^  as  in 
tetanus  or  aortic  aneurysm.  As  a  rule,  tracheotomy,  when  there  is  time 
to  perform  it,  is  preferred  in  these  spasmodic  affections,  and  it  will  be 
considered  later  (p.  563  et  seq.). 

Operation.  An  anaesthetic  will  be  given  in  those  cases  in  which 
laryngotomy  precedes  another  operation  ;  in  other  cases  the  patient's 
head  must  be  kept  steady.  In  either  instance  the  head  will  be  thrown 
back  as  far  as  possible,  while  the  neck  rests  on  a  firm  support.  The 
precise  position  of  the  thyroid  and  cricoid  cartilages  is  then  distinctly 
made  out,  the  notch  in  the  upper  part  of  the  former  and  the  ring  of  the 
latter  being  almost  always  recognisable.  The  larynx  being  then  steadied 
(not  squeezed)  with  the  left  fingers  and  thumb,  and  the  skin  at  the  same 
time  drawn  moderately  tense,  an  incision  about  an  inch  and  a  half  long 
is  made,  exactly  in  the  middle  line,  over  the  lower  part  of  the  thyroid,  the 
cricothyroid  interval,  and  the  cricoid. 

^  Possibly  a  cure  may  be  secured  in  a  shorter  time  by  a  combination  of  the  methods  ; 
removing  the  papillomata  carefully  at  once  by  a  thyrotomy,  and  at  the  same  time  giving 
rest  to  the  larynx  by  keeping  a  tube  in  the  trachea.  As  these  papillomata  are  sometimes 
associated  with  congenital  syphilis,  it  is  always  worth  while  to  make  a  judicious  trial  of 
hyd.  e.  cret. 

2  Ashby  and  Wright's  Diseases  of  Children,  4th  ed.,  p.  350. 

^  Owing  to  the  proximity  of  the  tube  to  the  cords,  this  operation  is  not  suited  to  cases 
in  which  an  instrament  has  to  be  worn  for  any  time. 

*  In  these  very  urgent  cases  the  operation  may  be  performed  with,  pmte  de  mieux,  a 
sharp  penknife  and  toothpick  quill,  or  the  opening  may  be  kept  patent  for  a  time  by 
retractors  inprovised  out  of  bottle  wire. 


TKACIIKOTOMY 


503 


If  relief  be  urjiently  called  for,  the  knife  should  pasa  down  to  the 
cricothyroid  membrane  at  once,  and  the  left  index  having  identified  this, 
the  membrane  is  opened  by  cutting  horizontally  just  above  the  cricoid 
cartilage,  'llie  object  of  this  is  to  keep  away  from  the  neighbourhood 
of  the  cortls  and  to  avoid  the  little  cricothyroid  vessels. 

If  the  surgeon  have  more  leisure,  he  may  reach  the  cricothyroid 
membrane  more  gradually,  feeling  his  way,  using  retractors,  and  perhaps 
identifying  the  interval  between  the  sterno-hyoids.  The  only  advantage 
of  this  is  that  all  haemorrhage  can  be  arrested  before  opening  the  air- 
tube.     This  is  sometimes  severe,  and  has  led  to  fatal  dyspnoea. 


Fig.  250. 


Anatomy  of  the  neck  in  early  childhood,  to  show  the  relations  of  the 
thyroid  ^  and  thymus.     (Heath.) 


In  inserting  the  tube,  care  must  be  taken  that  both  the  cricothyroid 
membrane  and  the  subjacent  mucous  membrane  are  incised,  and  that  the 
tube  is  really  within  the  cavity  of  the  larynx,  not  pushed  down  into  the 
cellular  tissue  outside  it.  The  space  is  always  small,  and,  after  middle 
life,  increasingly  rigid.  The  cannula,  which  should  be  shorter  than  those 
used  for  tracheotomy,  of  uniform  bore  throughout,  and  oval  in  section,  is 
then  secured  with  tapes. 


TRACHEOTOMY 

This  operation  mil  be  carefully  considered  under  the  first  of  the 
following  indications,  and  more  briefly  in  its  relation  to  the  other  ones. 

Indications.     (1)  Diphtheria. 

(2)  Syphilitic  and  tuberculous  ulceration,  in  order  to  give  rest  to  the 
crippled  part  (p.  580). 

^  The  isthmus  of  the  thyroid  gland  is  too  large. 


564  OPERATIONS  OX  THE  HEAD  AND  NECK 

(3)  Malignant  disease  of  the  larynx  (p.  600). 

(4)  Papillomata  of  the  larynx.     By  itself  (p.  561)  or  as  a  part  of  the 
operation  of  thyrotomy  (p.  560). 

(5)  In  some  cases  of  acute  laryngitis  (p.  580). 

(6)  Certain  spasmodic  affections,  e.g.  tetanus,  or  aneurysm  of  the 
thoracic  aorta  (p.  581). 

(7)  Foreign  bodies  in  the  air-passage;-.  :    the  removal  of  those  which 
may  lodge  in  the  bronchi  are  treated  separately  (p.  608). 


TRACHEOTOMY,  WITH  SPECIAL  REFERENCE  TO  CASES  OF 
MEMBRANOUS  LARYNGITIS 

General  points  all  bearing  upon  a  successful  result  :  A.  The  age  of 
the  patient.  B.  Right  time  of  operating,  and  wise  selection  of  cases. 
C.  Skilful  operation.     D.  Painstaking  and  appropriate  ;<fter-treatment. 

A.  Average  of  Recoveries  after  Tracheotomy  for  Membranous 
Laryngitis.  Cases  of  laryngeal  diphtheria  requiring  tracheotomy  are 
the  most  severe  and  fatal  of  all  cases  of  diphtheria.  In  pre-antitoxin 
days  one  recovery  in  three  or  four  cases  was  a  very  good  average.  The 
percentage  of  recoveries  has  improved  in  the  most  striking  manner  since 
the  introduction  of  treatment  by  antitoxin.  Thus  the  statistics  of  the 
fever  hospitals  of  the  Metrop;)litan  Asylums  Board  show  the  following 
striking  figures.^  In  1894  there  were  261  cases,  of  which  184  died,  or 
70-4  per  cent.  In  the  nine  succeeding  years  there  were  2632  such  cases, 
the  numbers  lyinc  between  180  in  1903  and  390  in  1900. 

The  fatality  has  been  as  follows  : 

In  1895  it  was  49-4  In  1 898  it  was  38-0  In  1901  it  was  30-9 
In  1 896  it  was  41  -0  In  1 899  it  was  39 -1  In  1 902  it  was  32-5 
In  1897  it  was  40-0        In  1900  it  was  34-3        Li  1903  it  was  32-22 

B.  Right  Time  for  Operation.-  and  Wise  Selection  of  Cases.  The 
nature  of  the  dyspnoea  is  very  various,  and  on  this  account  the  above 
two  points  are  most  important. 

The  four  following  conditions  of  dyspnoea  are  met  with  : 
(i)  Dyspnoea  rapid,  urgent,  and  localised  to  the  larynx  ;  much 
anxiety  and  restlessness  ;  orthnopnoea  ;  stridor,  the  loudness  of  which  is 
probably  proportionate  to  the  degree  of  obstruction  in  the  larynx  and  the 
patency  of  the  small  tubes.  In  Prof.  Buchanan's  words,  it  points  to  a 
cavity  ready  to  receive  air  if  it  could  but  get  ^t,  and  to  a  passage  narrowed 

1  These  statistics  are  quoted  from  8ir  W.  P.  Herringhara's  article  in  Clifford  Allbufs 
System  of  Medicine,  vol.  i,  p.  1031. 

2  Those  surgeons  who  recommend  an  early  operation  rely  especially  on  the  existence 
of  much  sucking  in,  and  of  undoubted  dyspnrea.  With  regard  to  the  first.  Dr.  Passavant 
(Ann.  Surg.,  vol.  i,  p.  153)  holds  that  tracheotomy,  if  deferred  allows  prolonged  dyspnoea  to 
bring  about  simultaneously  with  retraction  of  the  epigastrium,  &c..  an  action  on  the 
lung  surfaces  analogous  to  that  of  a  cupping-glass  upon  the  skin,  viz.  hypersemia,  stasis, 
hypersecretion  of  mucus,  splenisation,  and  atelectasis.  With  regard  to  dyspnoea,  Dr. 
Ranke,  of  Munich,  lays  great  stress  upon  an  early  operation  :  "  If  a  child  with  pharyngeal 
diphtheria  has  become  hoarse,  and  shows  laryngeal  stridor  and  difficulty  in  breathing, 
which  has  already  led  to  ever  so  short  an  attack  of  real  dyspnoea,  that  child  ought  to  be 
operated  upon  at  once."  Another  practical  point  bearing  upon  the  right  time  for  opera- 
tion is  the  fact  that  at  night  time  children  often  get  worse.  If,  then,  a  case  is  advancing, 
and  parents  cannot  towards  the  day's  close  make  up  their  minds  to  .sanction  an  operation, 
they  should  be  warned  that  the  patient's  condition  may  call  for  an  operation  which  will 
be  of  necessity  hurried,  and  be  performed  under  much  less  favourable  circumstances  as 
to  light,  &c. 


TUACIIEOTOMY  565 

either  by  false  meinbiaiie  or  spasm  or  botli.  On  inspection  of  the  chest, 
the  extraordinary  muscles  of  respiration  are  seen  to  be  in  action,  there 
is  much  sucking-in  of  the  infracostal  and  epigastric,  and,  later  on,  of  the 
suprasternal  and  supraclavicular  regions.  While  this  sucking-in  is 
vigorous  and  well  marked,  the  lungs  are  pi'obably  free. 

Auscultation  and  percussion  are  difficult.  If  the  bases  are  resonant, 
and  show  vesicular  murmur,  it  is  of  good  omen.  So,  too,  if  the  eyes, 
though  starting,  are  bright,  the  face  suffused,  not  livid,  the  lips  of  fairly 
natural  colour,  the  cervical  veins  not  much  distended,  the  extremities 
not  cold  and  the  seat  of  stasis  :  in  such  cases  the  membrane,  if  present,  is 
limited  to  the  larynx,  and  the  tendency  to  death  is  by  laryngeal  apnoea. 

Tracheotomy  here  is  not  only  justifiable,  but  imperatively  called 
for,  if  previous  treatment  has  failed  ;  the  prognosis  is  favourable  if  the 
operation  is  not  too  long  deferred.  Hopeful  conditions  :  sudden  onset, 
previous  good  health,  absence  of  albuminuria,  evidence  of  toxaemia  little 
marked  or  absent. 

(ii)  When  the  dyspnoea  increases  more  slowly  though  continuously. 
The  restlessness  is  less  violent,  and  the  respiratory  effects  are  less  ex- 
aggerated. The  sucking-in  is  much  less  marked,  especially  above.  The 
chest  seems  to  be  impeded  in  its  movements,  puffing  or  heaving  out  en 
masse,  and  with  difficulty  ;  on  auscultation  and  percussion,  instead  of 
vesicular  murmur,  or  conducted  hoarse  laryngeal  rhonchus,  and  normal 
bases,  there  will  be  found  sibilant  rales,  small  crepitation,  and  deficient 
resonance.  These  point  to  the  exudation  being  no  longer  localised  to  the 
larynx,  but  more  probably  invading  the  finer  bronchial  tubes  and  air- 
vesicles,  the  former  being  swollen  and  infiltrated  with  membrane,  the 
latter  clogged  with  viscid  mucus.  The  tint  of  the  face  is  now  pale  or 
leaden.  The  operation  is  here  much  less  likely  to  be  successful,  from  the 
extension  of  the  membrane,  and  the  condition  of  the  lung  and  of  the  right 
heart.  Other  unfavourable  conditions  :  onset  with  much  asthenia, 
albuminuria,  evidence  of  toxaemia  well  marked. 

(iii  and  iv)  Dyspnoea,  intermittent  or  paroxysmal.  In  the  former 
case  it  is  due  probably  to  collections  of  viscid  mucus  or  membrane  in  the 
larynx  and  trachea.  Good  power  of  expectoration  is  here  very  import- 
ant. Paroxysmal  dyspnoea  means  spasm.  This,  very  common  in  all 
laryngeal  dyspnoea,  is  especially  so  in  children.  The  danger  of  this  is 
obvious,  and  the  question  of  tracheotomy  will  have  to  be  decided  according 
to  whether  the  spasms  are  increasing,  and  by  the  distance  of  the  medical 
man  from  his  patient. 

Dr.  A.  K.  Gordon  ^  puts  the  indications  for  operation  excellently. 
"  They  are  in  order  of  appearance  :  a  croupy  cough,  laryngeal  stridor, 
retraction  of  the  epigastrium  and  intercostal  spaces,  restlessness,  cyanosis  ; 
then  cessation  of  restlessness,  cessation  of  retraction,  followed  by  the 
apparent  comfort  which  precedes  death.  It  is  important,  however,  not  to 
take  any  one  of  them  by  itself,  except  apparent  cessation  of  respiration, 
as  an  indication  for  operation  ;  in  the  stage  of  active  discomfort,  where 
there  is  restlessness  and  dyspnoea,  so  long  as  there  is  no  cyanosis,  one 
should  nowadays  give  a  sufficient  dose  of  antitoxin  and  wait,  unless,  of 
course,  the  patient  cannot  be  watched,  in  which  case  it  may  be  best 
not  to  attempt  a  cure  without  operation.  It  is  when  the  stage  of 
active  discomfort  is  beginning  to  pass  into  that  of  diminishing  distress — 
and  this  is  invariably  heralded  by  blueness  of  the  lips — that  the  operation 

1  3Ie(J.  Chron.,  1902.  p.  96. 


566  OPERATIONS  OX  THE  HEAD  AND  NECK 

should  be  done.  The  sign  of  restlessness,  however,  deserves  some  mention, 
since  its  absence  is  occasionally  taken  as  a  sign  that  the  operation  is  not 
required  when  the  associated  cyanosis  should  really  demonstrate  that 
the  quietness  is  that  of  impending  death  ;  sometimes,  too,  its  presence  in  a 
marked  degree  is  the  cause  of  an  operation  which  is  really  premature, 
or  unnecessary.  It  is  well,  too,  to  remember  that  retraction  of  the 
epigastrium  during  inspiration  varies  with  the  age  of  the  patient.  In  a 
babv  it  is  present  in  health  when  there  is  crying  or  strugghng,  and  in  small 
children  a  slight  broncho-pneumonia  will  give  rise  to  retraction  when  the 
larynx  is  healthy.  In  adults,  and  occasionally  in  big  children,  there  is 
often  no  inspiratory  retraction  at  all,  though  there  be  much  laryngeal 
obstruction.  The  chief  occasion  in  which  tracheotomy  is  recjuired  in  the 
absence  of  cyanosis  is  when  repeated  attacks  of  dyspnoea  (especially  after 
the  first  forty-eight  hours  of  the  disease)  point  to  the  presence  of  loose 
membrane  in  the  trachea  or  lar}Tix,  in  which  case  tracheotomy  should  be 
done  in  a  quiet  interval." 

Three  Chief  Dangers  of  Deferring  the  Operation  too  long.  (1)  CEdema 
of  the  Imigs.^  Owing  to  the  deficient  entrance  of  air,  reflex  contraction 
of  the  pulmonary  arterioles  takes  place,  leading  to  distension  of  the  main 
trunk,  the  right  heart,  and  systemic  veins.  The  bronchial  veins  being  also 
engorged,  serous  exudation  takes  place  into  the  finer  tubes  and  vesicles  at 
the  bases,  and  respiration  is  thus  further  impeded. 

(2)  Exhaustion  of  the  heart.  Children  if  they  repair  quickly  are 
exhausted  quickly  also. 

(3)  Thrombosis  of  the  pulmonary  artery.  Owing  to  the  stagnation 
in  front,  the  blood  current  moves  more  and  more  slowly,  and  this  ob- 
struction by  thrombi  is  not  remediable  by  operation.  The  signs  of  this 
condition  are  increasing  dyspnoea,  a  very  feeble  pulse,  and  combined 
pallor  and  lividity. 

Recommendation  of  the  operation  to  the  friends,  (a)  In  reply  to 
questions  as  to  the  chance  of  cure,  the  surgeon  will  answer,  with  caution, 
that  the  operation  conduces  to  cure  by  removing  the  most  urgent  danger 
by  giving  relief  to  the  lungs,  and  thus  also  impro\'ing  the  strength  by  sleep 
and  quiet.  (6)  He  will  be  able  to  say  that  if  death  occm"  after  tracheotomy 
it  will  be  by  exhaustion  or  by  cardiac  failure,  not  by  apnoea,  most  distress- 
ing to  witness,  as  well  as  to  the  patient. 

C.  Points  to  be  noted  as  to  the  operation.  Question  of  anaesthetic.  In 
an  infant,  or  when  there  is  any  indication  of  cardiac  failure,  or  any  marked 
cyanosis,  or  unconsciousness,  an  anaesthetic  is  best  avoided.  These 
children  are  so  ill  that  they  often  scarcely  notice  the  incision  and  are  less 
adversaly  affected  by  it  than  by  the  administration  of  an  anaesthetic. 
If  these  more  serious  symptoms  are  not  present,  or  in  older  children, 
especially  when  there  is  a  tendency  to  struggle,  a  little  chloroform — i.e. 
just  enough  to  prevent  struggling  during  the  operation- — is  as  a  rule  safe 
and  advantageous.  It  allays  spasm  and  thus  improves  the  breathing. 
It  prevents  strugghng  and  promotes  sleep  after  the  operation.  The 
greater  the  experience  of  the  operator,  the  better  his  surromidings  as  to 
assistance,  the  greater  the  indication  to  dispense  \\\i\x  chloroform.  AVhen 
an  anaesthetic  is  given,  the  operator  should  be  close  at  hand,  with  every- 
thing ready,  in  case  the  dyspnoea  increases  suddenly.  The  question  of  the 
use  of  eucaiue,  with  or  without  chloroform,  is  referred  to  at  p.  582  ;  it  is 
obviously  more  adapted  to  adults. 

1  See  also  note,  p.  564. 


TRACHEOTOMY  567 

Site  of  Operation.  High  or  low,  i.e.  above  or  below  the  isthmus  of 
the  thyroid.  It  will  be  worth  while  just  to  consider  here  the  parts  met 
A\ith  in  the  middle  line,  (a)  above  and  (6)  below  the  thyroid  isthmus. 
{a)  Skin,  superficial  fascia,  branches  of  the  transverse  cervical  and  infra- 
maiidibular  (seventh)  nerves,  lymphatics,  cutaneous  arteries,  anterior 
jugular  veins — which  with  their  transverse  branches  are  smaller  here — 
deep  fascia,  cellular  tissue,  superior  thyroid  vessels,  the  isthmus,  usually 
over  the  second  and  third  rings,  and  pre-tracheal  layer  of  deep  cervical 
fascia.  The  importance  of  this  last  is  twofold  :  if  the  trachea  be  in- 
sufficiently opened  the  tube  may  be  passed  between  the  trachea  and  the 
fascia  overlying  it,  embarrassing  the  patient's  breathing  and  the  operator 
alike.  If  the  wound  become  septic  this  layer,  continuous  below  with 
the  pericardium,  may  conduct  pus  into  the  mediastinum,  {h)  The 
surface  structures  are  much  the  same,  but  the  anterior  jugular  vein  and 
its  transverse  branches  are  much  larger.  The  sterno-thyroids  are  here 
quite  close  together.^  The  inferior  thyroid  veins  are  larger.  A  thyroidea 
ima  artery  may  be  present,  and  the  innominate  artery  cross  as  high  as 
the  seventh  ring.  The  trachea  is  also  deeper,  smaller  and  more  mobile, 
having  no  steadying  muscles  here  as  higher  up.  The  thymus,  too,  in 
young  children  may  present  a  difficulty.  In  addition  to  the  above 
anatomical  objections  to  the  low  operation,  there  are  three  surgical  ones, 
viz.  (1)  pus  is  now  more  easily  conducted  into  the  mediastinum.  (2)  In 
the  same  way,  broncho-pneumonia  is  more  probable  from  a  wound  in 
the  trachea  low  down.  (3)  From  the  proximity  of  the  chest,  and  its 
suction  action,  the  tube  is  much  more  pulled  into  the  wound,  and  hence 
may  more  easily  become  displaced. 

Operation.  The  instruments  required  are — a  small  scalpel,  the  handle 
of  which  can  be  used  as  a  blunt  dissector,  two  or  three  pairs  of  Spencer- 
V/ells  forceps,  two  or  three  Lane's  tissue  forceps,  dissecting  forceps, 
scissors,  director,  sutures  and  ligatures  of  catgut  and  silkworm  gut,  and 
suitable  tubes  ^  and  pilots.  They  should  be  spread  out  ready  to  hand  on  a 
sterilised  towel,  as  in  an  instant,  moving  the  child  or  beginning  the 
anaesthetic  may  cause  the  most  urgent  dyspnoea.  The  question  of  an 
anaesthetic  has  already  been  discussed.  The  child's  neck  and  head,  at 
fii'st  raised  and  relaxed,^  are  stretched  over  a  sandbag  or  a  large  bottle 
wrapped  up  in  a  towel,  while  the  hands  are  secured  in  the  jack  towel  which 
firmly  encircles  the  body.     Three  assistants  at  least  are  desirable — one  to 

1  Above,  the  stemo-hyoids  are  almost  in  contact  in  the  middle  Une,  with  only  an  interval 
of  about  an  eighth  of  an  inch — a  strong  argument  in  favour  of  keeping  in  the  middle  line 
exactly  (Parker). 

2  The  best  tracheotomy-tubes  are  Parker's  and  Durham's.  If  the  latter  are  chosen, 
they  must  be  of  reliable  manufacture.  Whatever  tube  is  chosen,  it  should  have  a  movable 
shield  to  prevent  irritation  of  the  trachea,  and  it  should  just  fit  snugly  in  the  trachea, 
being  lightly  held  by  this.  Mr.  Parker  (loc.  supra,  cif.  p.  84)  argues  strongly  in  favour 
of  angular  tubes.  He  shows  that  the  usual  quarter-inch  tubes  impinge  with  their  lower 
extremity  on  the  anterior  wall  of  the  trachea,  thus  tending  to  produce  ulceration  and 
grave  risks  (p.  57.5).  Whatever  tube  is  chosen,  it  should  be  as  large  and  as  short  as  possible  ; 
it  should  be  of  the  same  size  throughout,  without  tapering  ;  the  inner  tube  should 
project  a  little  beyond  the  outer  one,  while  the  whole  tube  should  fit  snugly,  standing 
out  as  little  as  possible  in  the  neck.  As  to  the  size  of  the  tubes  needful,  Mr.  Parker 
recommends  a  series  running  from  Nos.  18,  20,  22.  24,  26.  and  28  for  the  outer  tube. 
Of  these  .sizes  the  following  are  the  most  useful :  No.  24  in  children  from  one  to  three, 
and  No.  26  in  tho.se  from  three  to  seven. 

^  Whenever  an  anaesthetic  is  being  given  in  cases  of  dy-spnoea,  the  patients,  what- 
ever the  age,  should  be  allowed  to  choose  their  own  position  at  first,  and  any  movements 
or  alterations  in  the  position  of  the  head  and  neck,  preparatory  to  the  commencement 
of  the  operation,  should  be  carefully  made. 


568  OPERATIONS  ON  THE  HEAD  AND  NECK 

support  the  head  and  give  the  anaesthetic,  another  to  sponge,  and  the  third 
to  prevent  any  strugghng  and  to  hold  a  Hght  if  needed.  It  is  almost  super- 
fluous to  add  that  the  light  should  be  the  best  possible.  The  surgeon  ^  with 
his  left  thumb  ^  and  forefinger  steadies  the  trachea  and  makes  it  a  little 
prominent  as  well,  without  any  compression  ;  he  then  incises  the  soft 
parts  in  the  middle  line  from  about  the  centre  of  the  cricoid  -^  downwards 
for  about  two  inches,  cutting  well  through  the  fat,  often  abundant  here, 
and  exposing  the  interval  between  the  sterno-hyoids  ;  he  incises  this 
interval  and,  if  he  has  reason  to  fear  haemorrhage,  with  the  point  of  a 
steel  director  placed  in  the  upper  part  of  the  wound,  he  slits  down  the 
remaining  soft  parts  in  the  middle  line  till  he  can  distinctly  feel  or,  with 
the  aid  of  retractors,  see  the  tracheal  rings.  The  point  of  the  knife 
is  often  required  here  to  inciEe  surely  the  pre-tracheal  fascia. 

Until  the  trachea  is  distinctly  exposed  the  left  forefinger  and  thumb 
must  not  be  removed  from  their  steadying  position  on  either  side.  With 
the  blade  of  the  knife  held  upwards,  the  middle  line  of  the  front  of  the 
trachea  is  then  punctured,  stab  wise,  and  two  or  three  rings  divided.  The 
sufficiency  of  the  opening  is  known  by  a  free  and  noisy  rush  of  air,  accom- 
panied often  by  the  expulsion  of  membrane,  which  should  be  sponged 
away  at  once.  On  the  other  hand,  an  inadequate  opening  will  be  indi- 
cated by  the  hissing  only  of  air  through  the  slit-like  opening,  without  any 
free  rush  and  with  no  escape  of  membrane  or  relief  of  the  dyspnoea.  In 
this  latter  case  the  first  opening  mu^'t  be  found  by  the  finger-nail  and 
carefully  enlarged.*  The  cannula  is  then  inserted  on  a  pilot,  and  secured 
with  tapes  in  situ.  Some  prefer  to  use  a  hook  to  steady  the  trachea,  and 
a  pair  of  dressing- forceps  or  dilators  to  separate  the  edges  of  the  incision  ; 
these  are  more  hkely  to  be  helpful  in  a  "  low  "  operation,  or  where  a  pilot 
is  not  used  to  insert  the  cannula.  If  it  be  desired  to  try  and  remove  any 
membrane,^  the  cannula  should  not  be  inserted  at  once,  but  the  opening 
dilated  with  dressing-forceps,  or  with  Golding-Bird's  or  Parker's  dilator. 
When  inserted,  the  cannula  nuist  be  in  the  middle  line,  otherwise  there 
will  be  troublesome  irritation  of  the  trachea  and  plugging  of  the  cannula. 
Several  sizes  of  tube  should  always  be  ready  and  sterilised.  The  larger  the 
tube  that  can  be  inserted,  the  more  snugly  it  rides  in  the  trachea,  the 
less  the  irritation  and  consequent  formation  of  granulations,  the  less 
risk  of  membrane  being  drawn  down  past  it  from  above,  and  lastly,  the 
less  frequently  will  it  need  changing.  The  wound  should  be  sutured, 
around  the  tube  closely,  with  silkworm  gut. 

Chief  Difficulties.     (I)  Insufficient  skin-incision,  giving  no  room  for 

1  He  first,  as  soon  as  the  head  and  nock  are  in  position,  marks  the  chief  spots  in  the 
middle  line,  viz.  centre  of  the  chin  and  manubrium,  and  (when  they  can  be  felt)  the 
hyoid  bone  and  the  thyroid  and  cricoid  cartilages,  especially  the  last. 

^  Dr.  Buchanan  considers  the  following  a  good  rule  :  "  Never  plunge  the  knife  into 
the  trachea  till  the  white  rings  are  clearly  seen  at  the  bottom  of  the  wound."  In  cases 
of  real  urgency  the  surgeon  must  be  satisfied  with  touch  and  not  with  sight. 

^  This  cartilage  is  often  accidentally  divided. 

*  If  the  opening  be  to  one  side,  as  well  as  too  small,  a  fresh  and  adequate  one  should  be 
made  in  the  middle  line. 

5  Mr.  Parker,  one  of  the  chief  authorities  on  this  subject,  strongly  advises  that  all 
membrane  as  well  as  mucus  be  got  rid  of,  on  account  of  its  impediment  to  respiration, 
its  infectiousness,  and  the  patient's  inability  to  get  rid  of  it  himself  by  coughing  after 
tracheotomy.  On  this  account  Mr.  Parker  recommends  gently  twirling  about  a  feather 
(the  shorter  and  finer  pheasant-tail  feathers  are  the  best)  soaked  in  a  solution  of  sodium 
carbonate,  and  passed  several  times,  not  only  down  into  the  trachea,  but  up  into  the 
glottis.  Mr.  Parker  condemns  attempts  to  suck  out  membrane,  by  putting  the  lips 
directly  to  the  wound,  as  of  no  service  to  the  patient,  and  as  possibly  very  disastrous 
to  the  operator. 


TRACHKOTOMY 


)69 


the  deeper  work.'  (2)  Not  keeping  to  the  middle  line,  the  alnindaiit  fat, 
and  the  indistinctness  of  landmarks,  e.g.  a  fiat  thyroid  in  a  little  child, 
aiding  this  mistake.  (3)  Not  steadying  the  trachea.  This  omission  leads 
to  missing  the  air-passage  altogether.  Cutting  to  one  side  of  it,  or  cutting 
into  it  laterally,  ijistead  of  centrally,  and  insufficiently.  (4)  Htonorrhage, 
the  chief  bugbear  of  the  operation,  varies  extremely.  Generally  it  is  not 
great.     The  greater  the  experience  of  the  operator,  the  more  strictly  he 


Fig.  2.")!.     Anatomy  of  the  neck  of  an  adult.     1,   ,Sterno-hyoid.     2,  Foreign 
body  in  the  oesophagus.    .3,  Onio-hyoid.    4,  Crico-thyroid  membrane.    5,  Sterno- 
ma.stoid.     6,  Tracheotomy  opening  in  the  trachea.     7,  I:iferior  thyroid  vein.s. 
8,  Isthmus  of  the  thyroid  gland.     (Heath.) 


keeps  in  the  middle  line,  the  more  rapidly  he  is  able  to  operate  safely,  the 
more  may  the  bleeding  be  disregarded.  Any  artery  which  spirts  should, 
of  course,  be  tied  at  once  or  caught  in  Spencer-Wells  forceps,  and  a  vein 
of  any  size  which  lies  in  the  way  should  be  caught  between  two  of  these 
forceps  before  it  is  divided.  Venous  haemorrhage,  as  a  rule,  stops  as  soon 
as  the  trachea  is  opened  and  respiration  established.  A  sufficient  median 
skin-incision  aids  the  meeting  of  haemorrhage.  With  regard  to  the 
isthmus  of  the  thyroid,  this  may  usually  be  neglected  by  the  surgeon  ; 
if  felt  by  the  finger  to  be  large,  it  may  be  depressed.^  If  encountered 
in  older  subjects,  or  if  large  in  children,  it  may  be  compressed  by  two  pairs 
of  Spencer-Wells  forceps  before  division,  or  ligatured  on  either  side  by 
passing  an  aneurysm-needle  beneath  it.  If,  as  rarely  happens,  the  venous 
bleeding  is  very  free,  and  the  patient's  condition  from  dyspnoea  critical, 

1  As  in  a  colotomy.  or  other  deep  incision,  the  wound  should  not  not  be  funnel- 
shaped. 

^  In  children  this  may  certainly  be  ignored.  If  the  knife  is  used  to  open  cleanly  and 
sufficiently  the  deep  fascia,  and  then  a  round-pointed  steel  director  to  clear  the  way  down 
to  the  trachea,  the  operation  will  be  almost  bloodless. 


570  OPERATIONS  ON  THE  HEAD  AND  NECK 

the  trachea  must  be  felt  for  and  opened  before  the  haemorrhage  is  arrested. 
The  urgency  of  the  case  must  here  come  before  the  amount  of  the  bleeding. 
In  these  cases  the  moment  the  trachea  is  opened  the  patient  must  be 
turned  well  over  on  to  his  side.  Entrance  of  blood,  to  any  amount,  into 
the  lungs  must  be  avoided ;  it  will  add  to  the  dyspnoea  now,  and,  later  on, 
may  set  up  broncho- pneumonia.  (5)  Insertion  of  cannula.  If  the  trachea 
has  not  been  steadied,  and  the  rings  not  clearly  made  out  by  sight  or 
touch,  the  opening  will  very  likely  be  made  inadequate  or  to  one  side. 
Another  difficulty  may  arise  here  from  the  tracheal  fascia  not  having  been 
sufficiently  cut,  or  from  the  tube  being  pushed  down  between  the  fascia 
and  the  trachea,  this,  of  course,  only  further  embarrassing  the  breathing. 
Lastly,  though  the  tracheal  rings  are  cut,  the  swollen  and  inflamed  mucus 
membrane  may  not  have  been  sufficiently  divided,  or  a  false  membrane 
may  have,  in  the  same  way,  been  carried  before  the  knife.  (6)  Little  or 
no  relief  after  insertion  of  the  cannula.  Though  this  may  have  been  well 
and  truly  done,  it  is  not  followed  by  the  relief  which  has  been  expected. 
This  may  be  due  (a)  to  the  tube  being  passed  between  the  trachea  and 
some  membrane  which  plugs  it  ;  (b)  to  the  trachea  and  bronchi  being 
blocked  with  membrane,  &c.,  (c)  to  the  child,  owing  to  the  operation  being 
performed  late,  being  practically  asphyxiated  before  the  completion  of 
the  operation.  The  indications  now  are  to  pass  a  long  narrow  feather 
down  the  tube,  to  remove  the  tube,  and  to  clear  out  the  trachea,  while 
artificial  respiration  is  vigorously  performed  and  kept  up,  the  opening 
into  the  trachea  being  kept  patent  by  dressing-forceps  or  by  one  of  the 
dilators  above  mentioned  (p.  568).  If  feathers  or  brushes  fail  to  reach 
and  remove  the  membrane,  trial  may  be  made  of  aspiration.  The  best 
means  of  effecting  this  is  by  Mr.  Parker's  tracheal  aspirator,  which  con- 
sists of  a  small  glass  cylinder,  three  or  four  inches  long,  to  one  extremity 
of  which  the  end  of  a  silk  catheter  is  attached,  and  to  the  other  an  india- 
rubber  tube  ending  in  a  mouthpiece.^  It  can  be  taken  to  pieces  to  facih- 
tate  cleaning.  Before  use  a  little  cotton-wool  is  packed  into  the  cylinder 
to  prevent  any  dangerous  membrane  reaching  the  operator's  mouth. 
Direct  suction  should  never  be  performed  in  membranous  laryngitis  ;  in 
other  cases  where  blood  alone  is  the  cause  of  the  dyspnoea,  it  may  of  course 
be  thus  removed. 

D.  After-treatment.  This  subject,  neglected  in  most  books,  is  often 
too  little  looked  to  in  practice.  The  question  of  the  most  suitable 
atmosphere  for  the  patient  will  first  arise.  By  many  a  tent  (readily 
improvised  by  converting  a  cot  into  a  four-poster,  by  fastening  on  four 
vertical  pieces  of  wood  at  the  corners,  joining  these  by  four  horizontal 
pieces,  and  throwing  a  sheet  over  all)  is  recommended,  and,  one  side  of  the 
cot  being  left  uncovered,  steam  is  conducted  thither  by  one  of  the  different 
forms  of  croup-kettles.  While  fully  aware  of  the  need  of  moisture  when 
the  atmosphere  is  dry,  when  the  membrane  tends  to  crust  and  become 
fixed,  Mr.  Jacobson  is  of  the  opinion  that  the  above  unvarying  rule  of 
cot-tenting  and  use  of  steam  is  disadvantageous.  The  weakly  condition 
of  children  with  membraneous  laryngitis,  and  all  that  they  have  gone 
through,  must  be  remembered.  Believing  that  such  seclusion  and  so  little 
admission  of  air  tend  to  increase  the  asthenia,  and  any  tendency  to 
infection  it  is  much  better  to  keep  off  draughts  by  a  screen,  which  allows 
of  the  escape  of  vitiated  air  above,  using  steam  only  if  needful,  according 
to  the  size  of  the  room,  fireplace,  &c.,  and  according  to  the  kind  of  ex- 
^  Loc: supra,  cit.,  Fig.  12,  p.  98. 


TKACIIKOTOMV  571 

pectoration,^  wlietlicr  easily  brouji;ht  u])  by  cougli  or  leathers,  or  viscid, 
quickly  drying,  and  causing  whistling  breathing.  The  inner  tube  must 
be  frequently  removed  and  cleansed,  every  hour  or  two  at  first.  If  the 
secretions  dry  on  and  cling  to  it,  they  are  best  removed  by  the  soda 
solution  mentioned  below.  At  varying  intervals  between  the  removals 
of  the  tube,  any  membrane,  &c.,  whicli  is  blocking  it,  appearing  for  a 
moment  at  its  mouth  and  then  sucked  back,  nmst  be  got  rid  of  by  in- 
serting narrow  pheasant  feathers,  and  twisting  them  round  before  remov- 
ing them.  If  the  exudation  is  slight,  moist,  and  easily  brought  up  by  a 
cough  or  featlier,  sponging  and  brushing  out  the  trachea  are  not  called  for, 
but  they  should  be  made  use  of  when  the\-e  is  much  flapping,  clicking 
or  whistling  breathing  ;  and  if  this  is  harsh,  dry  or  noisy,  instead  of 
moist  and  noiseless,  two  of  the  best  solutions  are  sodae  bicarb,  gr.  v-xx 
to  aq.  §j,  or  a  saturated  one  of  borax  with  soda.  These  maybe  applied 
by  a  hand  or  steam-spray  over  the  cannula  for  five  or  ten  minutes  at  a 
time,  at  intervals  varying  according  to  the  relief  which  is  given,  or  applied 
with  a  laryngeal  brush,  feather  or  a  bit  of  sponge  twisted  securely  into  a 
loop  of  wire.  When  any  of  these  are  used,  the  risk  of  excoriation  and 
bleeding,  and  the  fact  that  only  the  trachea  and  large  bronchi  can  be 
cleansed,  must  be  borne  in  mind  ;  and  with  regard  to  manipulations  for 
cleansing  the  trachea,  and  removing  the  inner  tube,  it  is  most  important 
to  remember  that  these  may  be  overdone,  and  a  weakly  child  still  further 
exhausted  by  meddlesome  interference.  This  point  requires  special 
attention  from  the  surgeon  in  the  case  of  some  nurses  who  should  be 
given  very  definite  instructions  as  to  this  most  important  point. 
There  is  often  much  difficulty  in  getting  sufficient  food  taken.  This 
and  the  amount  of  sleep  are  two  most  important  points. 

For  the  first  twenty-four  hours  the  child  should  be  disturbed  as 
little  as  possible.  The  pain  in  swallowing,  the  impairment  of  the  act  owing 
to  the  presence  of  the  tube,  &c.,  and  thus  the  facihty  with  which  liquids 
may  reach  the  lungs,  are  facts  to  be  duly  remembered.  It  will  usually 
be  better  to  pass  a  Jacques  catheter  (No.  4  or  6)  by  the  nose,  and  then  to 
feed  the  patient,  at  regular  intervals,  with  definite  amounts.  Care  must 
be  taken  to  see,  by  the  absence  of  irritation,  that  the  tube  is  not  in  the 
larynx,  and,  if  the  above  soft  tubes  are  used,  that  they  do  not  coil  up 
at  the  back  of  the  tongue. 

The  Removal  of  the  Tube  next  requires  consideration.  It  should  be 
dispensed  with  at  the  earliest  opportunity,  either  altogether,  or  replaced 
by  an  india-rubber  tube  between  the  fourth  and  ninth  days.  Quite 
apart  from  the  danger,  which  is  inseparable  from  a  metalfic  tube,^  of  irrita- 
tion and  ulceration  of  the  trachea,  there  is  this  object  in  getting  rid  of  the 
tube  as  soon  as  possible,  that  the  longer  the  child  is  allowed  to  breathe 
through  the  tube  the  more  is  the  act  of  breathing  through  the  natural 

1  CJ.  A.  Wright  {Dismsea  of  Children,  p.  164)  quotes  from  Cock's  {Arch.  Pcediat., 
January  1884)  that  sudden  obstruction  of  the  tube  is  most  often  due  to  inspissated  mucus, 
not  membrane  ;  this  thick  mucus  is  secreted  usually  about  twenty-four  hours  after  the 
operation,  and  after  three  or  four  days  the  discharge  becomes  thinner  and  more  puriform. 
But  blocking  of  the  tube  with  membrane  does  certainly  occur  ;  it  is  known  by  the  sudden 
cyanosis  and  struggles  of  the  child,  while  no  air  enters  the  tube.  The  whole^tube  must 
be  removed  ;  if  this  and  the  consecpient  coughing  does  not  expel  the  membrane,  the 
wound  m\ist  be  dilated,  and  the  membrane  extracted. 

2  Mr.  Parker  points  out  [loc.  supra,  cif.)  that  black  patches  seen  on  the  outer  tube 
when  removed  may  indicate  ulceration  of  the  trachea,  and  show  the  need  of  changing 
the  tube.  Such  discoloration  may  point,  here  and  in  intubation,  to  an  inferior  cxuaHty 
of  the  metal  of  the  tube. 


572  OPERATIONS  ON  THE  HEAD  AND  NECK 

passages  allowed  to  be,  as  it  were,  forgotten,  with  the  result  that,  on  the 
tube  being  removed,  asphyxia  is  threatened.  The  chief  points  to  go  by 
in  deciding  as  to  whether  the  tube  can  be  safely  dispensed  with  or  replaced 
by  one  of  india-rubber  is  the  freedom  of  entry  of  air  through  the  larynx, 
and  absence  of  any  sucking-in  below,  and  whether  some  f-killed  observer 
can  remain  present  and  decide  whether  sufficieiit  air  is  reaching  the  lungs 
through  the  larynx  and  through  the  wound  without  being  in  a  nervous 
hurry  to  replace  the  tube. 

Conditions  which  Impede  the  Removal  of  the  Tube.  (1)  Prolonged 
formation  of  membrane.  The  longest  possible  period  for  this  is  probably 
about  ten  days.  Patience  and  support  are  the  main  indications  here. 
(2)  The  larynx  is  crippled  like  any  other  inflamed  part.  (3)  The  air 
passage  is  closed  by  granulation,  usually  above  the  cannula.  More 
common  than  these  is  obstinate  swelling  of  the  mucous  membrane.  Here 
some  advise  that  the  tube  be  removed,  and  astringents  and  caustics  care- 
fully apphed  from  below,  with  the  aid  of  an  anaesthetic  if  necessary.  It 
has  often  been  found  more  satisfactory  to  reinsert  a  tube  of  large  size,  with 
a  hole  on  its  convexity,  and  to  leave  it  in  for  a  week  or  two,  thus  giving 
further  rest  to  the  parts.  Needless  resort  to  caustics  will  certainly  risk 
the  occurrence  of  stenosis  later  on.  (4)  Closure  of  larynx  by  deep  ulcera- 
tion cicatrising  after  detachment  of  membrane.  In  such  a  case,  with  the 
aid  of  anaesthetics,  the  larynx  must  be  opened  up  by  probes  of  increasing 
size  and  laminaria  tents  introduced  from  below,  and  later  on  by  the  use  of 
Macewen's  tubes  (p.  573).  (5)  Paralysis  of  the  dilating  crico-arytenoidei 
postici,  from  fear,  excitement,  or  during  effort.^  (6)  The  commonest 
cause  of  inability  to  dispense  with  the  tube  is  probably  due  to  the  rapidity 
with  which  the  larynx  falls  into  abeyance  when  a  child  is  allowed  to 
breathe  through  a  tracheal  cannula,  the  patient  at  this  age  not  being 
intelligent  enough  to  understand  the  importance  of  dispensing  with  the 
tube,  and  perhaps  too  young  to  care  to  talk,  or,  if  older,  not  realising  the 
need  of  again  using  its  voice  while  all  its  wants  are  supplied.  With  the 
above  condition  are  coupled  a  nervous  dread  of  having  the  tube  removed, 
and  paroxysms  of  temper  and  struggling  which  rapidly  produce  em- 
barrassed breathing.  Any  organic  mischief,  such  as  adhesions  in  the  larynx, 
is  extremely  rare,  and  granulations  above  or  below  the  tube  are  more 
often  talked  of  and  given  as  a  reason  for  inability  to  dispense  with  the 
tube  than  really  seen. 

But  while  real  organic  mischief  is  rare  and  the  usual  cause  is*  due 
to  conditions  which  would  seem  to  be  only  temporary,  it  is  well  known 
that,  in  some  cases,  getting  a  little  child  to  dispense  with  the  tube  is  a 
most  baffling  and  prolonged  affair.  The  following  points  are  worthy  of 
attention  :  Early  attempts  to  remove  the  cannula,  whether  metal  or  india- 
rubber.  A  reliable  nurse.  Ability  on  the  part  of  the  surgeon  so  to 
arrange  his  time  as  to  be  himself  frecpiently  present  at  first,  and,  in  the 
intervals,  to  be  represented  by  an  assistant  who  will  not  replace  the  tube 
before  it  is  absolutely  necessary  to  do  so,  and  who  can  dilate  the  opening 
with  a  pair  of  dressing-forceps  and  perform  artificial  respiration  if  these 
steps  are  required.     Shortening  the  india-rubber  tube,  till  eventually  little 

^  In  a  case  in  which  tracheotomy  had  been  performed  by  Vir.  Jacobson.  and  while 
the  child  was  being  watched  for  the  first  few  hours  after  the  tube  had  been  dispensed  with, 
most  urgent  symptoms  came  on  during  the  slight  straining  which  accompanied  an  action 
of  the  bowels,  the  patient  falling  off  the  bed-pan  on  to  the  floor  apparently  lifeless.  Arti- 
ficial respiration  restored  the  child,  and  the  case  did  well. 


THAt  IIKOTOMV  573 

more  than  tlie  shield  is  worn,  the  rhild  bciii*,'  coiuloitc  d  by  the  apparent 
presence  of  the  tube.  Encouraging  the  chikl  to  make  use  of  his  larynx 
by  breathing  through  the  tube  and  expiring  through  the  larynx  while  the 
tube  is  closed.  Patiently  persevering  efforts  to  get  a  child  to  talk,  or, 
in  the  case  of  a  younger  one,  to  use  his  larynx  by  blowing  out  a  spirit- 
hunj)  or  using  a  penny  trumpet.  All  this  time  every  attempt  should 
be  made  to  im})rove  the  general  health  :  wise  feeding  (too  frequent  or  too 
large  meals  provoke  dyspnoea),  attention  to  the  bowels,  tonics  such  as 
Easton's  syrup,  proper  clothing,  cold  or  tepid  sponging  followed  by 
friction,  change  of  scene  and  air  in  every  possible  way,  especially  at  the 
seaside. 

In  a  large  majority  of  cases  the  above  treatment,  aided  by  patience, 
tact,  and  time,  which  allows  of  development  of  the  air  passages,  will 
suffice.  In  a  few  the  attempts  at  removing  the  tube  will  still  fail.  Where 
this  is  so,  and,  in  fact,  in  any  case  where  the  use  of  the  tube  seems  likely 
to  be  protracted,  the  larynx  should  be  dilated- — a  step  which  is  brought 
al)out  by  sinij)1e  means,  as  the  larynx  is  usually  merely  functionk.'-s  from 
disuse,  not  blocked  up,  or  the  glottis  closed — by  a  tube  through  which 
the  child  is  made  to  breathe. 

In  a  recent  case  the  simplest  way  of  effecting  this  is,  after  chloroform 
has  been  given,  to  remove  the  tracheotomy-tube,  dilate  the  wound  if 
needful,  and  pass  upwards  from  it  a  drainage-tube  or  catheter  with  a 
double  silk  web  ;  the  upper  end  of  this  is  drawn  out  of  the  mouth  (with 
the  aid  of  a  gag  if  needful),  and  tied  to  the  lower  end  which  projects  through 
the  wound. 

The  tracheotomy-tube  is  then  replaced  for  a  day  or  two,  and  on  the 
withdrawal  of  the  tube  from  the  larynx  it  can  usually  be  dispensed  with 
altogether.  Another  very  simple  and  efficient  means  is  thus  given  by 
G.  A.  Wright  ^  :  "  A  flexible  probe  should  be  passed  up  through  the  glottis 
from  below,  and  a  piece  of  silk  carrying  a  small  sponge  be  attached  to  it  ; 
the  probe  should  then  be  drawn  out  through  the  mouth,  and  the  sponge, 
carried  through  the  larynx,  sweeps  it  out,  breaks  down  any  adhesions,  and 
clears  away  mucus  or  any  granulations." 

Occasionally,  in  cases  of  longer  standing,  the  above  simple  treatment 
may  not  be  sufficient,  and  here  intubation  with  vulcanite  tubes  (pp.  576 
et  seq.),  or  the  use  of  Mace  wen's  tubes  passed  through  the  larynx  -  and 
into  the  trachea  below  the  wound,  should  be  made  use  of.  If  intubation 
tubes  are  not  available,  chloroform  ha^ang  been  given,  one  of  Mace  wen's 
tubes — they  resemble  stout  gum-elastic  catheters  with  terminal  carefully 
bevelled  openings — is  passed  from  the  tracheal  opening  ^  up  through 
the  larynx  into  the  mouth.  Having  hooked  this  end  out  of  the  mouth,^ 
the  surgeon  now  passes  the  other  end  down  the  trachea  beyond  the  wound, 
a  step  sometimes  accompanied  with  difficulty.  The  object  of  the  surgeon 
should  be  to  place  this  lower  end  of  the  tube  only  just  below  the  tracheal 
opening,  so  that  air  is  drawn  in  from  the  end  projecting  through  the 
mouth  into  the  trachea,  without  leaving  any  needless  length  of  the  tube 
here  or  in  one  bronchus  for  fear  of  setting  up  irritation  or  secretion.  To 
prevent  the  child  pidling  out  the  tube,  the  hands  should  be  secured  for  the 

^  Loc.  supra,  cif.,  p.  165. 

-  See  paper  by  Mr.  Bilton  Pollard  {Lancet.  1887)  on  thi.s  subject. 

'  It  is  more  easy  to  pass  the  tube  this  way  owing  to  the  facility  with  which,  when 
passed  from  above,  it  finds  its  way  into  the  tesophagus. 

''  The  tube  will  be  found  to  pass  readily  behind  the  soft  palate. 


574  OPERATIONS  OX  THE  HEAD  AND  NECK 

first  few  hours,  and  to  prevent  the  tube  being  bitten  it  is  well  to  pass  a 
piece  of  drainage-tube  ^  over  the  first  few  inches.  This  end  is  then  secured 
with  tapes  around  the  head.  The  tube  may  be  left  in  from  twelve  to 
eighteen  hours,  according  to  the  amount  of  secretion  and  the  facility  with 
which  the  tube  is  blocked. 

While  this  treatment  is  being  carried  out  it  is  well  to  isolate  the  child 
in  a  separate  room,  as  the  breathing  through  the  tube  is  very  noisy,  being 
often  accompanied  by  very  loud  bubbling  sounds,  and  the  aspect  of  the 
child  while  this  necessary  dilating  of  the  larjmx  is  going  on  is  one  of 
apparently  great  distress. 

When  it  is  evident  that  the  tube  is  clogged  it  must  be  withdrawn 
and  cleansed,  and,  a  little  anaesthetic  having  been  given,  again  inserted. 
At  any  time,  if  needed,  the  cannula  must  be  re-inserted  and  artificial 
respiration  performed.  It  vaW  be  readily  understood  that  during  this 
time  the  presence  of  the  surgeon,  and  reliable  assistants  who  will  not 
lose  their  heads,  and  nurses  with  much  tact  and  temper,  are  pre- 
eminently required.  Even  when  laryngeal  breathing  has  been  restored 
and  the  tube  has  been  dispensed  with,  the  child  must  be  carefully  watched, 
especially  at  night.  If  natural  breathing  fails,  it  is  better,  whenever  there 
is  time,  to  replace  the  Macewen's  tube  in  the  trachea  rather  than  re-insert 
the  tracheotomy-tube  into  the  old  wound,  a  mode  of  relief  which  is  too 
likely  to  be  resorted  to  on  account  of  its  facility,  but  one  which  tends  to 
keep  up  the  sinus-Uke  nature  of  the  wound  in  the  trachea,  and  brings  back 
that  mo.st  pernicious  tendency  of  the  child  to  prefer  and  confide  in  this 
mode  of  breathing. 

Complications  during  the  After-treatment,  (a)  Haemorrhage.  This  is 
not  uncommon  ;  if  immediate,  it  is  due  to  some  vessel  having  been  left 
unsecured.  Later  on,  it  may  be  brought  about  by  ulceration  of  the 
trachea  set  up  by  the  pressure  of  the  cannula  ^  ;  through  separation  of 
false  membrane  by  sloughiiig  ;  a  velvety  and  swollen  condition  of  the 
mucous  membrane  ;  or  by  prominent  granulations.  The  treatment  is 
clearly  preventive — to  dispense  with  a  tube,  especially  a  metal  one,  as 
soon  as  possible,  and  from  the  first  to  use  one  of  appropriate  length  and 
curve  (footnote,  p.  567). 

(b)  A  Sloughing  Condition  of  the  Wound.  If  this  is  threatening,  atten- 
tion must  be  paid  to  the  tightness  of  the  tapes,  so  that  the  cannula  be  not 
needlessly  buried  in  the  wound,  and  to  the  wearing  of  a  collar  of  boric  lint 
under  the  shield.  The  tube  must  be  removed  at  intervals,  or  replaced 
by  an  india-rubber  one,  air  tending  to  enter  without  a  tube  as  soon  as 
the  edges  of  the  wound  are  heahng.  If  the  wound  be  not  only  sloughy 
but  gangrenous  and  diphtheritic,  in  addition  to  frequent  cleansing 
with  a  camel's-hair  brush,  the  use  of  hot  boracic  or  zinc  chloride  lotions, 
stronger  measures,  such  as  the  application  of  silver  nitrate  or  pure 
carbolic  acid,  will  be  called  for.  The  general  treatment  will  not,  of 
course,  be  neglected  in  these  cases. 

(c)  Emphysema.^   This  is  usually  the  result  of  a  faulty  operation.  The 

^  This  simple  means  is  much  better  borne  by  the  child  than  the  gag.  Its  suggestion 
was  made,  some  years  ago,  by  Dr.  Arthur  E.  Poolman. 

^  Some  undoubted  cases  of  ulceration  into  the  innominate  after  low  tracheotomies 
in  children  are  on  record,  r.g.  Path.  Soc.  Trans.,  vol.  xi,  p.  20. 

■^  On  this  subject  the  reader  should  consult  the  full  and  detailed  papers  of  Sir  F. 
Champneys,  in  vols.  lxv,lxvi,  andlxviii  of  the  iled.  Chi'r.  Trans.,  and  his  work  on  Artificial 
Respiration.  The  following  are  amongst  the  practical  conclusions  with  which  his  pages 
abound  :     (Ij  Emphysema  of  the  anterior  mediastinum,  often  associated  with  pneumo- 


INTl  HATIOX  OF  THE  LARYNX  575 

incision  into  the  trachea  is  either  wrongly  placed — i.e.  it  is  not  in  the  same 
line  with  that  in  the  soft  parts — or  it  is  too  small  ;  perhaps  two  small  ones 
have  been  made  ;  very  rarely  is  the  emphysema  due  to  too  large  an 
incision  in  the  trachea.  Or,  the  incision  may  have  been  correctly  made, 
but  some  fault  connected  with  the  tube  may  produce  the  emphysema  ; 
thus  it  may  have  been  originally  too  short,  or  have  been  pushed  out  of 
the  wound  by  swelling  of  the  soft  parts  or  by  coughing.  As  a  rule  tliis 
complication  is  not  dangerous  unless  it  be  extreme  in  very  young  children, 
or  unless  it  travel  deeply. 

(d)  Ulceration  of  the  Trachea.  This  is  usually  due  to  the  pressure  of 
a  cannula  faulty  in  length,  or  curve,  much  more  rarely  to  separation  of 
membranes  or  sloughs.  There  are  no  definitely  characteristic  signs  of 
this  complication  ;  the  following  point  to  it  :  Streaks  of  blood  expector- 
ated a  day  or  two  after  the  operation,  and  perhaps  discoloration  of  the 
lower  end  of  the  tube.  This  accident  is  especially  likely  to  occur  in  cases 
of  diphtheria,  where  antitoxin  has  not  been  given  or  delayed,  as  the 
vitality  of  the  tissues  is  here  much  lowered.  The  tube  should  be  left 
out  if  possible,  or  an  india-rubber  one  substituted,  worn  as  short  as 
possible,  and  cut  obliquely  so  that  the  end  does  not  impinge  upon  the 
anterior  wall  of  the  trachea.  If  it  is  necessary  to  dispense  with  all  tubes, 
attempts  may  be  made  to  keep  the  edges  of  the  tracheal  womid  stitched 
to  that  in  the  soft  parts  for  a  few  hours,  or  Mr.  Golding-Bird's  dilator 
may  be  worn. 

(e)  Suppi(rat{o7i  in  Mediastina.  This  is  a  rare  complication.  When 
it  does  occur  it  is  liable  to  be  very  rapid.  It  results  from  a  descending 
cellulitis  from  the  wound.  The  only  treatment  is  prevention  by  a  well- 
performed  operation,  and  by  attention  to  the  wound. 

Other  complications  which  are  not  surgical  may,  of  course,  be 
present,  \"iz.  extension  of  the  exudation  doAvnwards,  general  infection, 
paralysis,  albuminuria,  broncho-pneumonia- — a  ver)^  frequent  one, 
known  by  a  rise  of  temperature  with  frequent  respiration  and  dyspnoea, 
dulness  on  percussion,  bronchial  breathing,  with  bubbling  and  crepitant 
rales.  The  discharge  becomes  scanty,  the  child  is  restless  with  a  tendency 
to  lividity,  and  there  is  a  return  of  the  sucking-in  in  the  supra-cla\dcular 
and  epigastric  regions,  while  no  obstruction  is  foimd  in  the  tube.  The 
antitoxin  treatment  has  very  largely  lessened  the  frequency  of  the  above- 
mentioned  difficulties  and  complications  of  the  after-treatment. 

INTUBATION  OF  THE  LARYNX  AS  A  SUBSTITUTE  FOR  TRACHEO- 
TOMY   IN     MEMBRANOUS     LARYNGITIS    OR    STENOSIS     OF    THE 

LARYNX 

Attention  was  first  called  to  this  subject  by  Sir  W.  Macewen.^     The 

tubes  he  used  have  been  alluded  to  at  p.  573.     It  was,  later  on,  more 

prominently  brought  forward  in  America. ^ 

thorax,  occurs  in  a  certain  number  of  tracheotomies.  (2)  The  conditions  favouring  this 
are,  division  of  the  deep  cen-ical  fascia,  obstraction  to  the  air  passages,  and  inspiratory 
efforts.  (3)  The  incision  in  the  deep  cerAncal  fascia  downwards  should  not  be  longer  than 
needful.  (4)  The  frequency  of  emphysema  probabh'  depends  much  on  the  skill  of  the 
operator,  especially  in  inserting  the  tube.  (5)  The  dangerous  period  during  tracheotomy 
is  the  interval  between  the  division  of  the  deep  cervical  fascia  and  the  inefficient  intro- 
duction of  the  tube.  (G)  If  artificial  respiration  is  necessary,  the  tissues  should  be  kept 
in  apposition  with  the  trachea,  and  any  manipulations  performed  without  jerks. 

1  Brit.  Med.  Journ..  July  24  and  31,  1880. 

^  Especially  by  the  late  Dr.  O'Dwyer,  whose  paper  appeared  in  the  Neiv  York  Med. 
Journ.,   August   1885.      Amongst   many  more   recent  papers   are — O'Dwyer,    Arch,   of 


576 


OPERATIONS  OX  THE  HEAD  AND  NECK 


The  Advantages  claimed.  The  chief  of  these,  the  easy  and  rapid 
introduction  of  a  tube,  has  been  substantiated  of  recent  years,  -when  the 
favourable  conditions  of  special  skill  and  experience  are  granted.  On  the 
presence  of  these  conditions  the  whole  question  turns  (p.  578). 

(1)  The  consent  of  the  friends  will  be  more  quickly  obtained  than 
in  the  case  of  tracheotomy.  (2)  Intubation  requires  no  angesthetic. 
(3)  The  tubes  are  easily  and  quickly  introduced,  and  thus  the  operation  is 


Fig.  252. 


0'Dwycr"s  intubation  instruments.  con.sisting  of  tu)>es,  introrlucer, 
extractor,  mouth-gag  and  measuring  scale. 


much  more  rapidly  performed.  (4)  There  is  no  severe  or  difficult 
operation  as  in  tracheotomy.  (5)  The  inspired  air  is  drawn  warm  and 
moist  through  the  natural  passages  ;  thus  the  depressing  effects  of  a 
steam-tent  are  avoided.^  (6)  There  is  no  open  wound  requiring  careful 
treatment,  and  there  is  not  the  same  difficulty  in  getting  rid  of  the  tube. 
(7)  The  after-treatment  is,  therefore,  much  less  prolonged.  This  advan- 
tage is  not  to  be  expected  invariably.  It  occasionally  happens  that  after 
the  original  trouble  for  which  intubation  was  done  has  disappeared,  it  is 
impossible  to  remove  the  tube  from  the  larynx  without  dyspnoea  returning, 
necessitating  the  return  of  the  tube.  Such  a  condition  is  termed  "  retained 
tube."  O'Dwyer,  the  authority  upon  all  matters  pertaining  to  intubation, 
in  a  paper  read  before  the  American  Pediatric  Association  in  May  1897, 
said  that  "  the  cause  of  persistent  stenosis  following  intubation  in  laryn- 
geal diphtheria  can  be  summed  up  in  a  single  word — '  traumatism.' 
Paralysis  of  the  vocal  cords  may  possibly  furnish  an  occasional  exception 
to  this  rule."  The  reason  of  the  traumatism  may  be  a  tube  that  does  not 
fit,  one  that  is  imperfect  in  its  construction,  or  injury  to  the  tissues  by 
unskilled  operators.     Undoubtedly  most  of  the  cases  of  retained  tube 

Poediat.,  1897..  xiv,  p.  481  ;  those  by  Dr.  F.  Wright,  of  ,Xew  Haven;  Dr.  Lovett,  of 
Boston;  Dr.  Codd  and  Dr.  E.  W.  GoodaU,  of  this  country  (Edin.  Med.  Journ.,  1902,  voL  i, 
p.  223).  The  last-mentioned  writer  is  an  authority  not  only  on  intubation  but  also 
on  those  di.seases  which  may  call  for  it.  A  paper  by  Dr.  Ba.san  (Lancet,  .July  13.  1901, 
p.  76)  will  also  be  found  helpful  with  its  cases  and  practical  details.  See  also  Fairbank, 
Lancet,  1903,  vol.  i,  p.  1724. 
^  Codd.  loc.  infra  cit. 


INTUBATION  OF  TIIK  LARYNX  577 

are  due  to  the  tube  being  too  large,  notwithstanding  the  size  for  the  age 
has  been  used.  This  condition  has  most  frequently  happened  when  the 
3  to  -i  size  has  been  used.  If  the  pressure  is  great  enough  seriously  to 
inteifere  witii  the  circulation,  even  if  it  does  not  cause  ulceration,  there 
will  be  an  cedenia  of  the  surrounding  tissues.  The  tube  being  withdrawn, 
the  pressure  is  suddenly  removed,  and  the  submucous  tissue  becomes  in- 
filtrated, and,  being  surrounded  with  cartilage,  can  swell  in  but  one 
direction,  thus  obstructing  respiration  by  narrowing  the  lumen  of  the 
larynx.  Sometimes  the  head  of  the  tube,  by  making  undue  pressure  upon 
the  parts  on  which  it  rests,  causes  an  abrasion  from  which  granulations 
spring,  and,  as  the  tube  is  removed  these  drop  down  into  the  chink  of  the 
glottis  and  obstruct  respiration.  Dr.  Goodall,  who  only  met  with 
ulceration  of  the  larynx  four  times  in  101  cases  of  intubation,  concludes 
as  follows  :  "  Be  very  careful  in  the  introduction  of  the  tube.  Do  not 
intubate  when  the  larynx  is  very  much  swollen.  If  in  any  case  intubation 
is  found  to  be  difficult,  do  not  persist  too  much  in  your  efforts,  especially  if 
your  experience  of  the  operation  is  limited.  Lastly,  do  not  intubate  the 
same  case  more  than  three  times.  If  these  rules  are  adhered  to,  I  believe 
that  ulceration  of  the  larynx  will  occur  no  more  frequently  after  intubation 
than  it  does  after  tracheotomy."  ^  Intubation  may  fail,  and  its 
failure  on  any  of  the  following  grounds  may  necessitate  tracheotomy 
(Goodall).  (1)  Intubation  may  not  relieve.  (2)  Some  time  after  the 
removal  of  the  tube  dyspnoea  may  recur,  and  the  patient's  condition  be 
too  serious  to  allow  of  re-intubation.  (3)  The  tube  may  become  suddenly 
blocked  {vide  mfra).  (4)  Failure  may  follow  an  attempt  at  re  intubation. 
(5)  The  medical  man  called  to  the  patient  may  have  had  no  experience  of 
intubation.     (G)  The  larynx  may  be  ulcerated. 

Disadvantages,  Difficulties,  and  Dangers.  (1)  In  Dr.  Codd's  words, 
"The  epiglottis  may  be  very  turgid,  and  the  parts  generally  oedematous, 
and  the  point  of  the  tube,  though  entering  the  upper  part  of  the  larvnx, 
may  fail  to  get  through  the  glottis  or  even  to  get  as  far  as  it.  This  can  be 
got  over  by  thrusting  the  left  index-fuiger  firmly  down  to  the  glottis.  I 
have  nearly  always  found  this  to  succeed,  and  it  is  not  a  bad  plan  to 
follow  systematically.  The  inexperienced  sometimes  enter  the  ventricles 
of  the  larynx  if  they  diverge  from  the  middle  line.  (2)  In  introducing 
the  tube,  membrane  may  be  dislodged  into  the  trachea,  causing  fatal 
dyspnoea  unless  tracheotomy  be  performed  at  once."  Dr.  Goodall  admits 
that  the  displacement  of  false  membrane  before  the  tube  mav  occur,  and 
that  tracheotomy,  requiring  rapid  execution,  under  these  circumstances 
may  be  required.  (3)  There  may  be  great  difficulty  in  getting  children 
to  take  sufficient  food,  as  swallowing  is  lor  the  first  few  davs  much 
embarrassed.  The  importance  of  sufficient  food  being  taken  has  already 
been  alluded  to  (p.  571).  (4)  Parts  of  the  liquids  taken  find  their  way 
into  air-passages.  Dr.  Codd  considers  the  latter  "  a  theoretic  objection." 
The  difficulty  in  feeding  can  be  met  by  the  Casselbury  method  :  '  The 
child  is  placed  on  the  nurse's  lap,  the  head  being  down,  and  fed  with  a 

1  Bokay  {Dent.  Med.  Woch.,  1901.  Xo.  47)  reports  five  eases  in  which  removal  of  the 
intubation  tube  at  the  end  of  periods  var\nng  from  107  to  294  hours  led  to  alarming 
symptoms,  attributed  to  ulceration  from  pressure.  In  one  case  this  diagnosis  was  con- 
firmed by  the  subsequent  development  of  stenosis.  He  advises  that  the  portion  of  the 
tube  between  the  neck  and  the  body  be  coated  with  gelatine,  into  which,  while  it  is  still 
soft,  powdered  alum  is  pressed.  This  proves  simple  and  effective,  and  is  recommended 
in  all  cases  where  the  intubation  has  lasted  over  a  hundred  hours,  and  where  pressure 
ulceration  is  suspected.  He  considers  that  by  following  this  rule  secondary  tracheotomy 
will  usually  be  avoided. 

SURGERY   I  37 


578  OPERATIONS  ON  THE  HEAD  AND  NECK 

.spoon  so  that  it  swallows  uphill."  In  Dr.  Goodall's  opinion,  ample 
nutriment  can  be  given  either  by  a  tube  passed  through  the  nose 
into  the  stomach  or  by  rectal  feeding.  (5)  1  he  tube  may  be  coughed 
out.  In  such  cases,  if  the  medical  man  is  absent,  death  may  occur  in  a 
few  minutes.  Dr.  Goodall  found  that  the  tube  was  coughed  up  or  pulled 
out  by  the  patient  in  28  per  cent,  of  his  cases.  "  Dyspnoea  by  no  means 
always  returns  at  once,  and  when  it  does  there  is  ample  time  for  the 
medical  officer  to  reach  the  patient  and  re-insert  the  tube  or  perform 
tracheotomy.  Intubation  cases  doubtless  require  the  medical  officer  to 
be  more  at  their  beck  and  call  than  do  tracheotomy  cases  ;  but  this  cannot 
be  claimed  as  a  serious  objection."  (6)  The  tubes  are  liable  to  become 
plugged  with  membrane.  In  Dr.  Goodall's  cases  sudden  blocking  of 
the  tube  occurred  in  12  per  cent.  He  considers  that  in  hospital  practice 
there  appears  always  to  be  time  for  a  medical  man  to  reach  the  patient 
early  enough  to  remove  the  tube,  and,  if  needful,  open  the  trachea  success- 
fully. Recently  special  patterns  of  wider  tubes  have  been  recommended 
for  use  in  cases  where  there  is  much  loose  membrane  or  discharge.  Dr. 
Codd  recommends  "  short  cylinders.  The  largest  possible  size  should  be 
used  and  wedged  into  the  larynx,  and  retained  only  a  few  hours  at  the 
most.".i 

Dr.  Goodall  in  discussing  the  indications  for  intubation  and  tracheo- 
tomy considers  that  even  cases  with  abundant  faucial  membrane  are  not 
necessarily  excluded  from  intubation,  "provided  that  there  are  no 
symptoms  of  profound  toxaemia,  and  no  oedema  of  the  fauces  to  obstruct 
the  upper  opening  of  the  tube  in  situ."  With  regard  to  the  number  of 
insertions  of  the  tube  that  may  be  made  before  tracheotomy  is  resorted 
to,  he  would  rule  that  "  if  three  insertions,  each  of  several  hours'  duration, 
fail  to  cure  the  obstruction,  tracheotomy  should  be  performed." 

While  Dr.  Codd,  in  his  candid  and  helpful  paper, ^  has  no  hesitation  in 
declaring  that  intubation  is  by  far  a  better  operation  than  tracheotomy — 
emphatically  so  in  hospitals,  and,  he  believes,  also  in  private  practice — 
his  results  scarcely  bear  this  out.  Of  twenty-six  cases  of  intubation  for 
diphtheria,  fourteen  were  fatal.  All  were  treated  with  antitoxin.  With 
regards  to  these  results,  which  cannot  be  compared  with  those  given  by 
tracheotomy,  combined  with  serum-treatment,  in  a  large  hospital  at  the 
present  day,  it  is  noteworthy  that  the}^  are  the  outcome  of  the  work  of  an 
operator  who  has  evidently  taken  up  the  subject  with  much  zeal  and 
ability. 

It  is  probable  that  while  in  those  institutions  where  a  special  knowledge 
of  the  diseases  which  call  for  intubation  exists,  and  where  a  mastery  of 
the  details  needed  can  be  obtained  owing  to  the  staiY  changing  at  long 
intervals,  intubation  at  the  present  day  will  give  as  good  results  as 
tracheotomy,  as  shown  by  those  obtained  by  Dr.  Goodall  and  Dr.  Wax- 
ham  {vide  infra) ;  this  is  not  the  case  in  those  hospitals  where  the  service 
changes  more  frequently.  In  private  practice  it  is  not  likely  to  be  em- 
ployed.   It  is  only  fair  to  add  that  the  introduction  of  antitoxin  has  led  to 

1  The  question  of  traumatism  has  already  been  referred  to  at  ]).  570..  and  Dr.  Coodairs 
opinion  given.  It  is  obvious  that  in  hands  less  skilled  than  his  ukeration  and  stenosis  may 
occur,  especially  if  the  practitioner  be  prevented  from  visiting  his  ])atient  at  the  time 
required.  A  case  of  fatal  ulceration  is  candidly  recorded  by  Dr.  i\  W.  Carr  {Lancet, 
vol.  i.,  1891,  p.  713).  The  tube  here  was  "  somewhat  large,"  a  smaller  one  having  been 
coughed  out. 

2  "  Intubation  of  the  Larynx,"  Binuiwjham  Med.  Rev.,  August  and  September 
1898. 


TECHNIQUE  OF  INTUBATION  570 

the  same  impiovoineiit  in  the  results  of  intubation  for  diphtheria  as  it  has 

in  those  of  tracheotomy  (p.  5()i). 

TECHNIQUE  OF  INTUBATION 

O'Dwyer's  method.  To  prevent  movements  of  the  child, ^  it  is  wrapped 
securely  in  a  blanket,  and  placed  in  an  upright  position  on  the  lap  of 
a  nurse,  the  head  resting  on  her  left  shoulder.  The  nurse  holds  the 
upper  limbs  securely  with  her  hands,  and  the  lower  ones  with  her  knees. 
An  assistant  standing  behind,  and  to  the  left  of  the  nurse,  holds  the  head 
of  the  child  inclined  somewhat  backwards,  perfectly  steady,  and  towards 
the  operator.  The  latter,  seated  so  as  to  face  the  patient,  opens  the 
mouth  widely  with  a  gag.  At  this  stage  the  struggles  of  the  child  may 
so  increase  the  respiratory  distress  that  instant  performance  of  tracheo- 
tomy is  demanded.  Cardiac  syncope  is  now  especially  to  be  feared. 
The  operator  next,  while  his  right  hand  holds  an  introducer  with  the 
tube  of  appropriate  size  fitted  on  and  threaded,  with  his  left  index 
finger,  protected  with  a  finger-stall  or  a  sealed  gauze  dressing,  hooks 
up  the  epiglottis.  The  position  of  the  glottis  being  thus  localised, 
the  tube  is  carried  along  the  inner  side  of  the  left  index,  and  then 
downwards  and  forwards  by  raising  the  handle  of  the  introducer,  which 
must  be  carefully  kept  in  the  middle  line.  When  the  tube  is  in  place 
the  left  iuiex  finger  gently  pushes  it  down,  and  at  the  same  time  the 
introducer  is  withdrawn,  the  handle  being  gradually  depressed.  Any 
difficulty  in  introducing  the  tube  may  be  got  over  by  waiting  for  an 
inspiratory  efiort  on  the  part  of  the  patient,  and  then  slipping  in  the 
tube.  With  his  left  index  the  operator  then  makes  sure  that  the  tube 
is  in  place,  by  feehng  the  posterior  wall  of  the  larynx  between  his  finger 
and  the  tube.  If  this  is  not  the  case  the  tube  will  be  found  to  be  iu 
the  upper  part  of  the  oesophagus,  it  can  be  removed  by  the  string,  and  the 
operation  repeated. ^  Expulsive  coughing  and  a  peculiar  ratthng  of  mucus 
which  immediately  follow  the  introduction  of  the  tube  and  the  withdrawal 
of  the  finger  usually  denote  that  the  tube  is  safely  in  situ.  The  gag  is  now 
withdrawn,  and  the  child  allowed  to  breathe  quietly  for  a  few  minutes. 
If  there  be  no  obstruction  to  respiration  the  gag  is  again  inserted,  and  the 
left  index  fijiger  being  placed  on  the  head  of  the  tube,  so  as  to  prevent 
its  being  displaced,  the  thread  is  withdrawn.  George  Wright  ^  is  of  the 
opinion  that  "  it  is  much  better  not  to  withdraw  the  thread,  so  as  to 
facilitate  extraction  ;   usually  it  sets  up  little  or  no  irritation." 

Withdrawal  of  the  Tube.  Two  points  call  for  consideration  here  : 
(a)  the  date  at  which  the  tube  may  be  dispensed  with  ;  (6)  the  mode  of 
withdrawal  of  the  tube. 

(a)  The  date  at  ivhich  the  tube  may  he  dispensed  with.  No  hard  and 
fast  rule  can  be  laid  down  here.  The  following  data  will  help  to  a 
decision  :  (1)  The  earlier  antitoxin  has  been  administered,  the  earlier 
will  the  membrane  be  loosened,  and  the  sooner  may  the  tube  be  removed. 
(2)  k  temperature  falling  to  99"  or  lower.  (3)  A  generally  satisfactory 
condition  of  the  child.     (4)  If,  in  spite  of  every  care  in  feeding  the  child, 

^  Dr.  Codd,  to  prevent  syncope,  introduces  the  tube  with  the  child  in  the  recumbent 
position. 

^  Dr.  Codd's  advice  here  is  to  be  remembered  :  "  If  you  fail  to  hook  up  the  epiglottis 
or  get  the  tube  into  the  larj-nx  at  the  first  effort,  \\-ithdraw  the  finger,  and,  after  a  short 
interval,  re-insert  it.     Do  not  make  prolonged  efforts." 

^  Loc.   supra   cit. 


580  OPERATIONS  ON  THE  HEAD  AND  NECK 

both  in  the  recumbent  and  the  erect  position,  food  is  badly  taken,  this, 
cseteris  paribus,  is  an  indication  for  removal  of  the  tube.  Dr.  Codd  ^  says 
on  this  point,  "  As  a  general  rule  four  days  suffice  to  leave  the  tube  in, 
though  re-intubation  is  often  necessary."  Carefully  drawn-up  tables 
by  Dr.  Goodall  "  point  to  the  advisability  of  not  removing  the  tube  till 
the  lapse  of  from  thirty-six  to  sixty  hours." 

(b)  The  mode  of  withdrawal  of  the  tube.  This  is  somewhat  more 
difficult  than  intubation.  In  the  latter  the  operator  has  the  tube  under 
his  command  ;  in  its  withdrawal  he  has  to  get  command  of  it. 
The  position  of  the  patient  being  the  same,  the  surgeon  hooks  up  the 
epiglottis  with  his  left  index,  and  rests  the  tip  of  the  finger  on  the  posterior 
part  of  the  head  of  the  tube.  The  curved  extracting  forceps  is  passed 
along  the  palmar  aspect  of  the  finger,  being  kept  strictly  in  the  middle 
line  until  it  reaches  the  tube  just  in  front  of  the  finger.  The  handle  of  the 
extractor  being  gently  raised,  its  point,  aided  by  gentle  movements  of  the 
left  index  finger,  now  finds  the  entrance  into  the  tube  and  is  dropped  into 
it.  The  right  thumb  now  presses  on  the  spring,  separates  the  blades, 
and  the  tube  is  withdrawn.  Previous  to  introducing  the  extractor, 
the  amount  to  which  its  point  can  be  opened  out  must,  by  means  of  a 
sc/ew  on  the  under-surface  of  the  instrument  be  carefully  adjusted  to  the 
size  required  for  the  removal  of  the  tube,  otherwise  much  injury  may  be 
inflicted  on  the  soft  parts  about  the  upper  orifice  of  the  larynx. 

Stenosis.  The  tubes  for  the  treatment  of  this  condition  are  made  in 
vulcanite  as  well  as  in  metal.  Intubation  by  means  of  these  tubes,  if 
obtainable,  will  be  found  preferable  to  the  use  of  the  gum-elastic  ones 
of  Macewen  in  the  case  of  adults.  The  full  account  already  given  above 
will  suffice  here  also. 


OTHER  INDICATIONS  FOR  TRACHEOTOMY 

(i)  Syphilitic  and  Tuberculous  Ulceration.  Of  these  tracheotomy  is 
the  more  frequently  called  for  in  syphilis,  in  which  also  it  is  decidedly 
more  useful.  The  conditions  which  demand  it  temporarily  are,  oedema  of 
the  glottis,  setting  in  on  old  mischief  ;  fibroid  thickening,  which  may 
later  yield  to  treatment  ;  and  more  fermanently ,  probably,  deep  ulcera- 
tion, necrosis,  and  cicatricial  contraction. 

In  tuberculous  mischief,  tracheotomy  rarely  gives  much  relief, 
dyspnoea  being  now  a  rarer  misery  than  cough  and  difficulty  of  swallowing, 
both  of  which  are  conditions  which  may  be  intensified  by  the  presence  of 
a  tube. 

(ii)  Malignant  Disease  of  the  Larynx.  This  subject  is  considered 
below  (p.  600). 

In  all  cases  of  tracheotomy  where  dyspnoea  is  present  or  likely  to  be 
brought  on  by  the  anaesthetic,  save  in  little  children  (p.  567),  local  anal- 
gesia, by  means  of  eucaine  and  adrenalin,  should  be  employed  (p.  582). 
This  especially  applies  to  tracheotomy  for  disease  of  the  larynx,  malignant 
bronchocele,  and  other  growths  which  have  caused  narrowing  of  or  a 
liability  to  spasm  in  the  air-passages. 

(iii)  Acute  Laryngitis.  The  rapidity  with  which  this  may  run  a  fatal 
course,  especially  after  exposure  to  cold  in  reduced  constitutions,  is  well 
known.     If  treatment,  including  scarification  of   the   aryteno-epiglotti- 

*  Loc.  siijira.  cit. 


TRACHEOTOMY  581 

dean  folds  and  adjacent  parts,  fail  to  relieve  tlie  dyspnoea,  tracheotomy 
shonld  be  performed  at  once  to  meet  the  increasing  exhaustion. 

(iv)  Certain  Spasmodic  Affections,  c.f/.  Thoracic  Aneurysm  and 
Tetanus.  Owing  to  these  diseases  destroying  life  usually  in  other  ways, 
tracheotomy  is  rarely  called  for  here.  Occasionally,  however,  the 
laryngeal  dyspnoea  which  they  may  bring  about  calls  for  this  operation. 

Probably  there  is  no  form  of  dyspnoea  more  agonising  to  the  patient, 
or  more  distressing  to  the  friends,  than  that  which  may  accompany 
thoracic  aneurysm.  The  surgeon,  however,  when  called  upon  to  perform 
tracheotomy  in  one  of  these  terrible  cases,  must  remember  that  the 
dyspnoea  may  be  due  to  direct  pressure  upon  the  trachea  as  well  as  to 
pressure  or  irritation  of  the  laryngeal  nerves,  that  it  is  in  the  latter  only 
that  operation  will  give  relief,  and  that  the  difficulty  of  distinguishing 
between  the  two,  though  much  diminished  by  the  laryngoscope,  is  not 
entirely  removed. 

With  regard  to  tracheotomy  in  tetanus,  the  same  warning  has  to  be 
given.  In  the  rarer  cases  in  which  tetanus  threatens  life  by  asphyxia 
and  not  by  exhaustion,  the  surgeon,  before  performing  tracheotomy,  must 
decide  where  lies  the  seat  of  the  asphyxia.  Asphyxia  will  probably  be 
due  to  spasm  of  the  muscles  of  respiration,  including  both  those  of  inspira- 
tion and  expiration,  i.e.  the  abdominal  muscles  also.  The  fatal  spasm 
thus  usually  not  lying  in  the  larynx,  tracheotomy  seems  contra-indicated, 
unless  it  were  done  with  the  object  of  reheving,  with  the  aid  of  artificial 
respiration,  that  congested,  gorged  condition  of  the  lungs  which  is  due  to 
the  continued  spasm  of  the  muscles  of  respiration.  And  it  is  to  be  feared 
that  if  these  steps  were  taken,  the  gentle  violence  of  artificial  respiration 
would,  as  has  happened  with  tracheotomy  itself  in  this  disease,  only  bring 
on  further,  and  perhaps  final  and  fatal,  spasms. 

(v)  Scalds  of  the  Upper  Aperture  of  the  Larynx.  Tracheotomy  is 
here  usually  deferred  until  late,  and  its  want  of  success  is  well  known. 
This  is  not,  however,  an  instance  of  cause  and  effect,  the  mortality  in  these 
cases  being  rather  due  to  the  shock,  pain,  and  inability  to  take  sufficient 
food.  Unless  the  patient  is  seen  late,  tracheotomy  should  not  be  per- 
formed in  these  cases  till  a  trial  has  been  made  of  scarification,  or  rather 
of  acupuncture,  by  means  of  a  guarded  bistoury  point,  of  the  mucous 
membrane  of  the  epiglottis  and  the  glosso-epiglottidean  and  aryteno- 
epiglottidean  folds,  the  left  forefinger  guiding  the  point  of  the  instrument. 
In  doing  this  the  surgeon  must  remember  the  amount  of  dyspnoea  which 
is  already  present,  and  the  certainty  that  this  will  be  increased  by  the 
struggles  of  the  child,  by  the  finger  coming  in  contact  with  the  inflamed 
parts  ;  at  any  moment  the  child  must  be  turned  on  its  side,  artificial 
respiration  performed,  or  tracheotomy  at  once  resorted  to. 

(vi)  Foreign  Bodies  in  the  Air-Passages.  The  treatment  of  these 
serious  accidents  and  the  indications  for  tracheotomy  are  discussed  on 
p.  603. 

Tracheotomy  under  Local  Analgesia.  Before  leaving  the  subject  of 
tracheotomy,  the  above  must  be  referred  to,  especially  in  its  reference  to 
cases  of  chronic  stenosis  of  the  larynx.  In  some  of  these  cases  the  risk 
of  the  operation  is  greatly  increased  by  the  use  of  a  general  anaesthetic, 
especially  where  a  patient  who  has  been  obliged  to  keep  in  one  position  in 
order  to  facilitate  his  breathing  has  a  sudden  attack  of  urgent  dyspnoea 
when  he  is  placed  in  the  position  for  tracheotomy.  Again,  in  some  cases 
of   marked   stenosis,    general   anaesthesia,  by  abolishing  the  voluntary 


582  OPERATIONS  ON  THE  HEAD  AND  NECK 

respiratory  movements,  may  render  it  impossible  for  sufficient  air  to  be 
drawn  through  the  narrowed  larynx. 

Sir  St.  Clair  Thompson  called  attention  to  the  advantages  of  local  anaesthesia 
by  cocaine  and  adrenalin.^  Another  useful  solution  for  producing  local  anaesthesia 
for  this  and  other  operations  is  Schleich's  solution  which  has  the  following  composi- 
tion:  Cocain  hydrochlor.  -2  grm.,  morphia  hydrochlor.  -025  grni.,  sod.  chlorid. 
•2  grm.,  aq.  dest.  steril.  ad  100  cc.  This  solution  may  be  injected  freely.  Mr.  Barker  ^ 
recommends  a  solution  of  eucaine  which  has  the  advantage  that  it  is  practically 
non-toxic.  The  following  solution  may  be  injected :  Eucaine  lactate,  gr  i,  adrenalin 
hydrochloride  soln.  (1  in  1000)  Tl\  v,  sod.  chlorid.  soln.  (-75  per  cent.)  ad  3  x. 

Novocain  is  also  a  very  satisfactory  drug  for  the  production  of  local  anaesthesia.^ 
It  is  much  more  effective  if  combined  with  adienine.  A  •.')  per  cent,  solution  of 
novocain  with  1  milligram  of  adrenine  added  to  each  200  cc.  will  be  found  very  satis- 
factory. As  much  as  20  or  30  cc.  may  be  used  if  necessary.  If  a  1  per  cent,  solution 
of  novocain  be  used,  1  milligram  of  adrenine  should  be  added  to  each  100  cc. 

Another  drug  which  is  employed  for  local  anaesthesia  is  quinine  and  urea  hydro- 
chloride. A  -25  or  -1  per  cent,  solution  may  be  used.  The  solution  may  be  sterilised 
by  boiling,  but  if  freely  used  it  may  cause  sloughing  of  the  subcutaneous  tissues. 

EXTRA-LARYNGEAL  OPERATIONS  FOR  REMOVAL  OF  GROWTHS 
OF  THE  LARYNX,  EXCISION  OF  THE  LARYNX,  PARTIAL  AND 

COMPLETE 

It  will  be  seen  from  the  remarks  made  below  that  the  value  of  some 
of  these  operations  is  still  sub  judice  ;  much  of  the  following  will,  therefore, 
require  confirmation. 

Indications.  Carcinoma  and  sarcoma  of  the  larynx,  especially  if  intra- 
laryngeal  in  origin,  and  remaining  so.  This  being  the  chief  and  almost  the 
only  indication  for  operative  interference,  any  others  will  be  very  briefly 
alluded  to  (p.  601).  The  following  cpiestions  call  for  an  answer  when  the 
question  of  operative  interference  arises  in  cases  of  growths  of  the  larynx  : 
A.  Is  the  disease  malignant  ?  B.  How  far  has  it  advanced  ?  Is  it  now 
intra-  or  extra-laryngeal,  and  where  did  it  originate  ?  C,  Which  of  the 
following  operations  is  the  wisest  to  be  prepared  for  when  the  local  condition 
of  the  growth  and  the  general  condition  of  the  patient  are  duly  weighed, 
thyrotomtj,  removal  of  the  larynx,  partial  or  complete,  trans-hyoid  pharyn- 
gotomy,  or  a  palliative  tracheotomy  ?  To  give  any  helpful  answer  here, 
(1)  the  results  of  these  operations  and  (2)  the  after-condition  of  the 
patients  have  to  be  duly  weighed.  There  is  scarcely  any  decision  in 
surgery  which  is  so  beset  with  difficulties. 

A.  7s  the  case  one  of  malignant  disease  ?  and,  if  so,  B.  Hoiv  far  has  it 
advanced?  The  impossibility  of  always  deciding  early  and  positively 
whether  a  growth  in  the  larynx  is  malignant  by  the  laryngoscope  alone 
is  well  known.  As  in  the  case  of  the  tongue,  in  a  certain  proportion  of 
cases  it  is  impossible  to  say  whether  the  trouble  is  papillomatous  or 
epitheliomatous,  if  the  former  whether  it  is  in  the  pre-cancerous  con- 
dition, i.e.  its  base  richly  cellular  ;  in  other  occasional  cases,  as  in  the 
tongue,  whether  an  ulcer  is  carcinomatous,  syphilitic,  or  tuberculous.'* 
This  difficulty  raises  the  question  of  the  value  of  previous  intra-laryngeal 

1  Brit.  Med.  Journ.,  October  14,  1905.  2  /^^v;^  1904,  vol.  ii.  p.  1682. 

^  For  further  information  on  the  subject  of  local  anaasthesia  reference  should  be 
made  to  Local  Ancesthesia,  by  Prof.  Braun,  1914.  Here  will  be  found  an  account  of 
the  various  drugs  which  may  be  employed,  and  full  instructions  as  to  the  technique  of 
the  injection  for  the  various  operations. 

*  In  Sir  H.  Butlin's  words,  "  There  are  three  classes  of  cases,  the  first  in  which  every 
one  can  make  a  diagnosis,  the  second  in  which  the  more  experienced  can  make  it,  and  the 
third  class  in  which  the  conditions  are  so  obscure  that  no  one  can  make  a  diagnosis  un- 
less the  larynx  is  opened,  and  in  some  of  which  it  is  even  then  difficult  to  say  what  the 
nature  of  the  disease  is." 


KXTHA-LARYNGEAL  OPERATIONS  583 

removal  of  portions  of  the  growth  for  examination.  As  in  the  tongue, 
there  are  certain  cases  in  which  this  step  will  not  clear  up  the  doubt, 
either  because  the  incision  does  not  happen  to  have  been  made  deep 
enough  to  reach  the  part  where  malignancy  is  present,  or  because  it  has 
entered  a  ])art  adjacent  to  it.  Moreover,  this  nxxle  of  intra-laryngeal 
removal  of  bits  of  growth  is  not  without  its  risks. 

Dr.  Newman,  of  Glasgow,  sounded  the  following  note  of  warning  :  '- 
"  Intra-laryngeal  excision  for  microscopic  purposes  exposes  the  patient 
to  very  serious  dangers  by  increasing  the  rapidity  of  secondary  new 
formations.  The  incision  of  a  cancerous  growth,  or  its  partial  removal, 
has  justly  been  regarded  as  a  most  dangerous  procedure,  probably  because 
the  absorption  of  the  infective  material  takes  place  rapidly  from  a  wounded 
surface.  For  instance,  judging  from  my  own  experience  of  other  similar 
cases,  I  should  say  that  neither  in  case  2  nor  3  would  the  lymphatic  glands 
have  become  involved  for  months  had  T  not  removed  portions  of  the 
growth  with  forceps.  In  both  cases  the  tumour  was  limited  in  size,  and 
in  both,  within  a  very  short  time  of  the  intra-laryngeal  operation,  the 
lymphatic  glands  became  involved.  .  .  .  While  conscious  of  the  value 
of  removing  portions  of  a  laryngeal  neoplasm  for  diagnostic  purposes,  I 
desire  to  express  my  strong  conviction  that  it  should  not  be  resorted  to  in 
cases  suspected  to  be  cancer  unless  the  patient  is  willing  to  have  a  radical 
operation  performed  immediately  after  the  diagnosis  is  completed." 

This  difficulty  should  be  faced  in  the  same  way  as  elsewhere.  Where 
a  patient  has  suspicious  symptoms,  especially  at  a  suspicious  age,  e.g. 
alteration  in  the  voice,  "  soreness,"  pain,  cough,  hsemorrhage,  interference 
with  breathing  or  swallowing- — the  same  steps  should  be  adopted  which 
stand  in  such  good  stead  in  cases  of  doubtful  malignant  disease  elsewhere 
and  explore.  Where  such  interests  are  at  stake,  there  should  be  no 
hesitation  in  advising  opening  of  the  thyroid  cartilage  and  examination 
of  the  larynx,  at  any  rate  in  cases  where  endo-laryngeal  examination 
and  treatment  are  unsuccessful  or  inconclusive.  If  the  growth  is  mahg- 
nant,  one  of  the  operations  mentioned  above  should  be  proceeded  with 
at  once,  or  a  preliminary  tracheotomy  alone  performed  at  this  stage. 
If  the  disease  is  not  malignant,  it  will  very  likely  be  the  better  for  local 
treatment,  which  can  now  be  effectually  applied.  If  the  thyroid  cartilage 
be  very  carefully  divided  in  the  middle  Hne,  and  no  further  operation 
done,  it  is  known  from  experience,  in  adopting  a  similar  step  for  the 
removal  of  certain  foreign  bodies,  that  no  harm  will  happen  to  the  cords, 
while  the  relief  to  the  patient's  mind  will  be  enormous.  It  is  only  by 
this  early  and  complete  exploration  that  the  disease  can  be  attacked  in 
a  stage  when  it  can  be  entirely  removed. 

B.  How  far  is  the  disease,  if  malignant,  advanced  ?  In  recent  years 
the  method  of  direct  examination  of  the  larynx  by  Killian's  or  Briining's 
tubes  has  rendered  this  question  easier  of  solution.  It  must  be  remem- 
bered, however,  that  when  the  growth  is  exposed  during  an  operation,  it 
is  almost  always  found  to  be  more  advanced  than  was  supposed  at  a 
preliminary  examination. 

C.  Is  the  disease  intra-  or  extra-laryngeal  ?  The  importance  of  this 
distinction — one  not  always  possible  to  make — is  enormous,  owing  to  its 
bearing  on  the  severity  of  the  operation  and  its  results  immediate  and 
later. 

Under  the  term  intrinsic  carcinoma  should  be  included  those  cases 
^  Clin.  Soc.  Trans.,  vol.  xxii. 


584  OPERATIONS  ON  THE  HEAD  AND  NECK 

in  which  the  disaase  has  begun  in  and  is  confined  to  the  cavity  of  the 
larynx  proper  from  the  cords  downwards.  The  extrinsic  group  should 
include  these  cases  where  the  growth  has  started  in  the  epiglottis,  or 
aryteno-epiglottidean  folds,  or  cricoid, ^  or  when  having  begun  in  the 
pharynx,  it  has  invaded  the  larynx,  or  vice  versa.  Here  another  warning 
is  needed.  In  some  cases  it  may  be  only  possible  to  clear  up  this  point  at 
the  operation. 

It  was  shomi  by  Krishaber  and  Frankel  that  the  intra-laryngeal  form 
of  carcinomata  remains  limited  to  the  larynx  for  some  time,  and,  while  so 
limited,  is  comparatively  slow  in  affecting  the  glands. ^  Extrinsic  car- 
cinomata, on  the  other  "hand,  affect  the  glands  at  an  early  stage.  The 
laryngeal  sarcomata,  though  rapid  in  growth  and  with  marked  power  of 
infiltration,  have  no  marked  tendency  to  spread  by  the  lymphatics  and 
affect  the  glands,  thus  affording  an  instance  of  the  well-known  variable- 
ness of  sarcomata  in  this  respect. 

In  deciding  whether  ths  disease  is  extra-laryngeal,  the  surgeon  may  be 
help  3d  by  a  history  of  dysphagia,  the  passage  of  a  bougie,  by  noting  the 
mobility  of  the  larynx  laterally  on  manipulation  and  in  deglutition,  the 
involvement  of  lymphatic  glands,  and  the  date  at  which  this  involvement 
has  taken  place, ^  and  by  information  gained  by  the  passage  of  a  finger 
from  the  mouth  with  the  aid  of  eucaine.  Dr.  Newman,  in  his  instructive 
book,^  writes  :  "  When  the  disease  is  intrinsic,  the  prominent  symptoms 
are  aphonia  and  dyspnoea.  The  lymphatic  glands  are  seldom  affected  ; 
as  a  rule,  cachexia  is  not  a  prominent  feature  during  the  earlier  stages  of 
the  disease,  and  dysphagia  is  not  a  common  symptom.  In  patients 
suffering  from  extrinsic  growth,  on  the  other  hand,  aphonia  is  not  usually 
present  at  the  commencement  of  the  disease,  and,  indeed,  there  may  be 
only  slight  alteration  in  the  voice,  while  dysphagia  is,  as  a  rule,  present 
as  soon  as  the  growth  has  reached  any  considerable  size.  Pain  in  larynx 
and  pharynx,  extending  round  the  neck  and  to  the  ear  of  the  affected 
side,  is  more  characteristic  of  extrinsic  than  of  intrinsic  new  formations. 
In  the  former  the  glands  are  also  involved  at  an  early  period,  and  cachexia 
is  usually  pronounced." 

While  the  subject  of  extrinsic  malignant  disease  of  the  larynx  is  being 
referred  to,  the  question  of  how  far  operations  in  these  cases  are  justifiable 
arises.  Interference  here  is  one  of  those  instances  in  which  the  surgeon 
may  have  a  difficulty  in  deciding  where  to  stop,  o^^^ng  to  the  extent  of  the 
disease.  Where  the  pharynx,  epiglottis,  and  surrounding  soft  parts  have 
been  extensively  extirpated,  the  patient  usually  gains  a  prolongation  of 
life,  rarely  a  cure,  at  the  cost,  to  put  the  matter  moderately,  of  great 
discomfort. 

Reference  may  be  made  to  the  illustrations  accompanying  Prof.  Gluck's 
article,-^  and  more  particularly  Figs.  19,  22,  23,  24,  25. 

1  Of  those  extrinsic  carcinomata  which  begin  in  the  laryngeal  region,  but  not  in  the 
larynx  proper.  Dr.  Chevahcr  Jackson  (Trans.  Amer.  Lar.  Soc,  1904,  p.  165)  finds  that 
the  posterior  surface  of  the  cricoid  is  by  far  the  most  frequent  site. 

-  U'hile  those  who  have  worked  at  this  subject  are  not  agreed  as  to  the  exact  lymphatic 
supply  of  the  larynx,  they  are  unanimous  in  declaring  that  the  vocal  cords  are  less  richly 
supplied  than  the  vestibular  regions,  and  that  the  lymphatics  of  each  half  of  the  larynx 
are  relatively  independent  of  each  other.  Further,  there  is  reason  to  believe  that  carcinoma 
is  somewhat  slow  in  destroying  the  cartilage. 

*  Dr.  C.  Jackson,  in  his  remarks  on  infiltration  of  the  glands  (loc.  supra.  cU.),  warns  us, 
"  If  no  adenopathy  can  be  made  out,  even  deep  along  the  trachea  and  oesophagus,  it  does 
not  exclude  carcinoma,  even  if  the  growth  be  ulcerating." 

*  Loc.  supra,  cit. 

5  Brit.  Med.  Journ.,  October  31,  1903,  p.  1122. 


KXTliA  LARYNGEAL  OPERATIONS  585 

'I'hc  results  cU'inoiustratc  what  especial  experience  may  achieve  with 
especial  operative  skill,  but  this  is  only  half  the  picture.  Such  figures  as 
the  above,  showing  the  steps  in  the  technique  by  which  such  results  may 
be  attained,  show  also  inevitable  nmtilat-ions  by  which  the  patient's  future 
nuist  be  rendercnl  a  sad  one.  I'rof.  (JIuck's  woids  (p.  I  12."}),"  Fiist  save 
and  prolong  the  life  of  your  patient,  aiul  do  not  trouble  yourself  too  much 
about  the  post-operative  state  ;  the  restitution  of  function  will  be  a 
secondary  care,  the  imminent  danger  once  dissipated,"  are  justified 
as  far  as  they  go,  but  they  do  not  go  far  enough.  His  success  seems  to 
have  begotten  an  enthusiasm  leading  him  to  foi'get  that  it  is  the  patient, 
and  not  the  surgeon,  who  will  have  reason  "  to  trouble  about  the  post- 
opiM-ative  state,"  and  that  the  degree  of  "  restitution  of  function,"  the 
organs — for  it  is  not  only  the  larynx  which  is  concerned — being  most 
essential  for  the  daily  comfort  of  the  patient,  is,  in  the  great  majority 
of  those  who  survive,  very  incomplete.  Any  one  familiar  with  the  litera- 
ture of  this  subject  will  agree  that  this  aspect  of  the  case  does  not 
receive  its  rightful  prominence  with  many  writers.  Without  the  least 
exaggeration,  the  fact  remains  that  of  all  the  mutilations  inflicted  by 
surgery  that  for  extrinsic  malignant  disease  is  one  of  the  most  terrible. 
The  most  that  can  be  said^ — and  it  is  only  fair  to  give  both  sides — is 
that  if  the  patient  survive  he  will  be  freed  from  pain,  especially  pain  in 
the  ears,  from  much  of  his  cough,  from  toxaemia,  and  he  will  put 
on  flesh.  How  far  he  can  follow  any  occupation  must  depend  upon  the 
nature  of  this,  and  how  far  it  requires  the  ordinary  voice  which  has 
been  lost. 

While  the  decision  here  must  be  left  to  the  patient,  and  while  especial 
indications  for  running  the  necessary  risks  will  occasionally  arise,  e.g.  in 
the  case  of  a  pension,  annuity,  &c.,  there  is  scarcely  any  question  in 
surgery  which  is  so  beset  by  difficulties. 

D.  Which  of  the  operations  open  to  the  surgeon  is  it  wisest  to  perform 
in  cases  of  intrinsic  malignant  disease  ?  ^  Here,  in  addition  to  the  conditions 
presented  by  the  growth  in  each  individual  case,  (a)  the  state  of  the 
patient  as  to  general  vitality  and  the  condition  of  his  viscera,  especially 
the  lungs,  (b)  the  results  of  the  operation,  and  (c)  the  after-condition  of 
the  patient,  have  to  be  considered. 

The  operations  are  the  following  :  (i)  thyrotomy  ;  (ii)  unilateral 
removal  of  the  larynx  ;  (iii)  complete  removal  ;  (iv)  trans-hyoid  pharyn- 
gotomy  ;    (v)  palliative  tracheotomy. 

(i)  Thyrotomy.  While  this  term  is  retained  for  the  sake  of  con- 
venience, it  is  here  an  incomplete  one.  Not  only  is  the  thyroid  cartilage 
and,  if  needful,  the  cricoid  divided  as  in  removal  of  certain  foreign  bodies, 
but  the  growth,  and  with  it  a  varying  part  of  the  larynx,  is  removed  as 
well,  the  framework  of  the  larynx  itself  not  being  taken  away.  The 
statistics  and  value  of  the  operation  have  been  much  in  dispute.  In 
this  country,  owing  to  the  support  which  it  has  received  from  authorities 
like  Sir  H.  Butlin,^  Dr.  Moure,  of  Bordeaiix,^  and  Sir  F.  Semon,^  thyro- 
tomy has  been  strongly  advocated.  By  many  Continental  surgeons,  on 
the  other  hand,  this  operation  has  been  condemned,  owing  to  its  rate  of 

^  See  a  paper  by  Dr.  G.  Emerson  Brewer  (An7i  of  Surg.,  1909,  vol.  1,  p.  820)  on  the 
operative  treatment  of  cancer  of  the  larynx.  Thyrotomy  and  total  laryngectomy  are 
discussed  with  a  number  of  illustrative  cases. 

^  Clin.  Soc.  Trans.,  vol.  xxii,  p.  94,  and  Oper.  Sur.  of  Mai.  Dis.,  p.  196. 

»  Ibid.,  p.  1148. 

*  Brit.  Med.  Journ.,  October  31,  1903,  p.  H14. 


580 


OPERATIONS  ON  THE  HEAD  AND  NECK 


mortality  being  much  higher  than  has  been  found  to  be  the  case  in  this 
country,  and  also  because  the  permanent  results  have  proved  themselves 
to  be  less  favourable. 

While  thyrotomy  is,  when  all  the  conditions  affecting  these  operations 
are  taken  into  account,  at  present  the  one  most  justifiable,  it  is  doubtful 
whether  for  any  cases  save  the  very  earliest,  which  will  be  few,  it  can  be 

considered  a  sound  operation,  i.e.  one 
based  on  those  principles  which  guide 
us  in  our  attempts  to  exterminate 
malignant  disease  elsewhere. 
Amongst  these  the  most  important 
are  to  include  at  the  time  of  operation 
not  only  the  growth  itself,  but  a  wide 
margin  of  healthy  parts  around,  and, 
further,  what  is  sometimes  forgotten 
in  the  stress  of  an  operation,  a 
sufficient  depth  of  healthy  tissue  beneath 
the  grovjth.  This  step,  always  diffi- 
cult, must  be  especially  so  with  the 
subjacent  cartilages.^  Time  alone 
will  show  whether  on  sound  surgical 
principles  the  only  operations  before 
us  are  not  partial  and  complete 
removal  of  the  framework  itself  of  the 
larynx. 

Indications  for  Thyrotomy.     Dr. 
C.    Jackson  -  gives    the    following  : 

(1)  an  intrinsic  growth,  that  is,  one 
limited  to  the  ventricular  bands,  the 
ventricle,  the  cords,  and  the  parts 
below  to  the  limits  of  the  larynx  ; 

(2)  a    limited    extent    of    disease  ; 

(3)  malignancy,  or  a  suspicion  of  ma- 
lignancy justifying  exploratory  thy- 
rotomy ;  (4)  no  extrinsic  disease,  not 
even  involvement  of  the  arytenoids 
or  inter-arytenoid  folds ;  (5)  no 
perforation  of  the  thyroid  cartilage  ; 
(6)  no  glandular  involvement.  Others 
limit  the  disease  farther.  Thus,  Dr. 
Moure,  of  Bordeaux,^  holds  that 
thyrotomy  "  should  be  reserved  espe- 
cially for  tumours  of  one  or  other  of 
the  vocal  cords.  When  one  of  the 
ventricular  bands  is  affected,  when 

there  is  a  peripheral  infiltration,   still   more   when   the  corresponding 
arytenoid  is  fixed,  or  when  there  are  signs  of  perichondritis,  it  is  unsuit- 

^  "  The  operation  must  be  thorough.  No  sentimental  considerations  concerning  the 
amount  of  vocal  power  to  be  retained  by  the  patient  must  interfere  with  the  imperative 
necessity  of  removing  a  sufficient  area  of  healthy  tissue  around  the  new  growth  in  all 
directions.  A  violation  on  one  single  part  of  the  periphery  of  the  new  growth  of  this 
rule  may  frustrate  the  entire  purpose  of  the  operation."     (Semon.) 

^  Lor.  supra,  cif. 

3  Brit.  Med.  Journ.,  October  31,  1903,  p.  1148. 


Fig.  2.53.  Thyrotomy.  The  larynx  has 
been  opened,  and  the  halves  of  the 
thyoid  cartilage  separated.  1,  Hyoid. 
2,  Thyro-hyoid  membrane  partially 
divided  and  separated.  3,  One  half  of 
the  thyroid  cartilage.  4,  C'rico-thyroid 
membrane  opened.  6,  Cricoid.  6,  Left 
ventricular  band.  7,  Ventricle  of  Mor- 
gagni.  8,  Left  vocal  cord.  9,  Growth 
upon  the  right  vocal  cord.     (Moure.) 


EXTUA-LARYNGEAL  OPERATIONS       587 

able."  The  same  authority  ^  considers  the  total  laryngectomy  is  indicated 
in  cases  not  hmited  to  the  cords  and  tending  to  become  diffuse. 

Dr.  J.  N.  Mackenzie,  of  Baltimore,  who  holds  that  early  extirpation  of 
the  larynx,  with  its  lympliatics  and  glands,  is  here,  as  elsewhere,  the  safest 
step,  considers  that  very  small  growths,  distinctly  circumgcribed,  remote 
from  the  middle  line,  and  not  of  an  es[)ecially  malignant  type,  may  possibly 
be  removed  with  safety  by  extirpation  of  half  the  larynx  and  lymphatics 
on  the  corresponding  side,^  Dr.  Mackenzie's  advice  was  almost  the  same  : 
"'  He  did  not  believe  that  any  other  than  the  most  radical  operation  should 
be  undertaken  in  cases  in  which  disease  was  medially  situated.  An 
incomplete  operation  would  be  especially  hazardous  where  the  disease 
appeared  as  an  infiltration."  The  next  step  will  be  to  consider  the 
results  of  thyrotomy  (I)  as  to  the  risks  of  the  operation,  and  (2)  the 
probability  of  a  reappearance  of  the  disease,  and  the  amount  of  voice 
regained. 

There  is  probably  no  operation  about  the  statistics  of  which  so  much 
care  is  needed  as  in  those  for  malignant  disease  of  the  larynx.  The  chief 
fallacies  arise  from  the  way  in  which  cases  are  grouped  together,  both 
those  in  which  the  disease  has  been  intrinsic  and  extrinsic,  those  where 
an  operation  appears  to  have  been  strongly  indicated,  and  those  in  which 
it  seems,  owing  to  the  condition  of  the  patient,  to  have  been  equally 
unsuitable,  the  frequent  absence  of  important  details,  and  the  tendency 
to  publish  only  successful  cases,  often  prematurely.  If  the  results  of  one 
operator,  a  man  of  especial  experience,  are  taken,  another  difficulty  arises. 
Such  results  have  only  been  gained  as  the  authority  passed  through 
different  stages  of  increasing  experience. ^  Men  who  have  had  very 
different  opportunities  must  bear  this  in  mind  when  patients  or  their 
friends,  as  is  increasingly  their  wont  nowadays,  ask  what  are  the  risks 
of  an  operation. 

And  this  tends  to  a  statement  with  which  many  will  disagree.  Until 
these  operations — and  especially  laryngectomy  partial  and  complete — 
are  placed  upon  a  more  satisfactory  basis,  they  should  only  be  performed 
whenever  this  is  possible,  and  it  usually  is  so,  by  those  who  combine  a 
thorough  mastery  of  general  surgical  technique  and  an  especial  training 
in  laryngology. 

Returning  to  the  subject  of  the  results  of  thyrotomy,  as  to  the  risks 
of  the  operation,  and  a  probability  of  a  reappearance  of  the  disease, 
Dr.  D.  B.  Delavan,  of  New  York,*  puts  the  permanent  cures  as  high 
as  44  per  cent.,  while  the  death-rate  can  be  placed  at  about  11  per  cent. 
Of  the  patients  operated  upon  by  Sir  H.  Butlin  66*6  per  cent,  lived  for 
more  than  three  years  after  operation,  while  his  death-rate  was  9-5  per 
cent.  As  to  the  term  "  permanent  cure  "  one  half  and,  in  some  instances, 
two-thirds,  of  the  patients  reported  ahve  and  well  at  the  end  of  the  first 
year  have  died  within  three  years.  Statistics  based  upon  alleged  cures 
of  less  than  three  years'  duration  are  therefore  worthless. 

Sir  F.  Semon's  results  are  given. ^    He  states  that "  my  oldest  successful 

1  Ann.  de  Mai.  de  I'Oreille,  &c.,  1904,  t.  xxx..  p.  407. 

^  Trans.  York.  Med.  Eec,  November  4,  190u. 

^  On  this  point  the  reader  is  especially  referred  to  Prof.  Gluck's  results,  earlier  and 
later,  candidly  given  {Brit.  Med.  Journ.,  October  .31,  190.3). 

*  Trajis.  Amer.  Lar.  Soc.,  June  1904  ;  Neio  York  Med.  Rec.,  September  17,  1904, 
p.  442. 

^  Brit.  Med.  Jotcrn.,  loc.  supra,  cit.,  and,  with  more  detail.  New  York  Med.  'Rec., 
November  5,  1904. 


588  OPERATIONS  ON  THE  HEAD  AND  NECK 

thyrotomy  dates  back  to  thirteen  years  ago,  and  I  have  other  patients 
in  good  health  in  whom  the  operation  was  performed  twelve,  ten,  and  nine 
years  ago." 

As  to  the  amount  of  voice  regained,^  Sir  Felix  states  :  "  The  great 
majority  have  regained  a  surprisingly  good,  although,  of  course,  more 
or  less  husky,  voice  :  in  a  few  cases  only  have  their  vocal  powers  been 
reduced  to  a  whisper." 

Operation  of  Thyrotomy  and  Removfd  of  the  Diseased  Parts  (Fig.  253). 
The  points  in  the  examination  of,  and  the  preparation  of,  the  patient 
locally  and  generally  (p.  594),  must  be  attended  to  here. 

The  patient  having  been  anaesthetised  ^^^th  chloroform, ^  is  placed 
in  the  tracheotomy  position,  with  a  firm  support  under  the  shoulders. 
A  vertical  incision  is  made  in  the  middle  line  from  the  hyoid  bone  to  a 
point  just  above  the  sternum.^ 

As  the  incision  is  deepened  precisely  in  the  middle  line,  in  the  upper 
part  the  thyro-hyoid  membrane  and  angle  of  the  thyroid  should  be 
exposed,  in  the  lower  the  septum  between  the  sterno-hyoids.  This  is 
opened,  the  muscles  gently  retracted,  any  superficial  veins  tied,  and  the 
thyroid  isthmus  divided,  between  two  ligatures  if  necessary.  The  angle 
of  the  thyroid  cartilage  is  now  exactly  defined,  the  soft  parts  being 
gently  peeled  and  pushed  aside.  The  next  step  is  to  open  the  trachea 
low  down.  A  trial  of  the  position  of  Rose  or  Trendelenberg  should 
now  always  be  made.  Hahn's  sponge-cannula  has  been  the  one  chiefly 
employed,  but  many  authorities  advocate  an  ordinary  tube.  This  does 
away  with  any  need  of  wasting  ten  or  more  precious  minutes  until  the 
sponge  has  sufficiently  expanded,  and  avoids  the  risk  of  over-distension 
of  a  slender  trachea,  and  syncope  with  arrest  of  breathing  (Moure).  By 
means  of  india-rubber  tubing  with  a  curved  mouthpiece  to  fit  into  the 
cannula  at  one  end,  and  a  gauze-covered  funnel  at  the  other,  on  which  the 
chloroform  is  dropped,  the  anaesthetist  is  kept  to  one  side.  The  crico- 
thyroid membrane  is  next  opened  in  the  middle  line,  and  this  structure 
and  the  thyroid  cartilage  divided  completely,  with  one  stroke  if  possible, 
by  a  pair  of  stout  scissors  or  a  pair  of  slender  shears  if  the  process  of 
calcification  is  advanced.  In  these  cases  the  use  of  a  fine  Gigli's  saw 
has  been  recommended,  this  instrument  being  passed  through  openings 
in  the  crico-thyroid  and  thyro-hyoid  membranes.  It  will  require  to  be 
kept  most  steadily  in  the  middle  line,  or  needless  laceration  of  the  mucous 
membrane  and  faulty  union  will  be  the  result.  The  alse  of  the  cartilage 
are  next  pulled  apart,  and  held  so  with  hooks  or  retractors.  This  step 
is  not  an  easy  one  where  the  cartilage  is  much  calcified.  No  force  whatever 
is  allowable,  or  a  fracture  may  occur.  If  it  be  impossible  to  obtain  a  com- 
plete inspection^ — an  absolutely  essential  point — by  the  above  steps,  the 
median  incision  in  the  larynx  should  be  continued  through  the  cricoid  and 
upper  two  rings  of  the  trachea.     Transverse  division  of  the  thyro-hyoid 

^  See  a  case  recorded  by  Sir  Felix  Scmon  (Proc.  Roy.  Soc.  Med.,  Laryng.  Sec,  vol.  ii, 
1909,  p.  78),  in  which  the  right  vocal  cord  was  replaced  by  a  cicatricial  ridge,  the  patient 
subsequently  having  a  remarkably  good  voice. 

^  Local  anaesthesia  throughout  (p.  582)  is  jDref erred  by  some.  The  position  of  Rose 
or  1  rendelenberg  has  also  been  advocated.  Local  anaesthesia  throughout  would  be 
indicated  in  patients  of  sufficient  self-control  who  have  had  bronchitis. 

^  This  incision  would  a])])ear  needlessly  long  for  a  thyrotomy,  but  the  trachea  requires 
to  be  opened  low  down  for  two  reasons  :  (1)  to  jjlace  the  anaesthetist  as  much  as  possible 
out  of  the  operator's  way  ;  (2)  where  advanced  calcification  of  the  thyroid  cartilage 
is  present,  the  cricoid  and  upper  two  rings  of  the  trachea  may  require  division,to  enable 
an  adequate  inspection  of  the  inside  of  the  larynx  to  be  made. 


EXTRA-LARYNGEAL  OPERATIONS  589 

membrane  affords  additional  room,  but  impci'iLs  the  iinnujljility  of  the 
two  halves  of  the  thyroid  cartilage  later  on. 

When  the  larynx  is  opened  the  entrance  of  mucus  and  blood  into 
the  air-passages,  especially  if  an  ordinary  tracheotomy  cannula  has  been 
employed,  and  if  the  breathing  is  much  embarrassed  at  this  moment, 
must  be  guarded  against.  The  anaesthetist  should  follow  Dr.  C.  Jackson's 
advice,  and  allow  the  patient  to  cough  up  nnicus  occasionally.  Infection 
of  the  wound  nnist  now  be  prevented  by  gauze.  The  chloroform  should 
also  be  discontinued  towards  the  close  of  the  operation,  so  that  the  patient 
recovers  consciousness  by  the  time  that  the  last  sutures  have  been  put  in. 
A  sterihsed  sponge  or  gauze  tampon,  attached  to  silk,  may  be  introduced 
into  the  pharynx  above,  and  a  smaller  one  into  the  lower  angle  of  the 
wound,  above  the  cannula. 

As  soon  as  the  interior  of  the  larynx  has  been  thoroughly  exposed, 
and  any  fluids  dealt  with,  local  analgesia  should  be  employed.  The 
proportions  vary  with  different  operators. 

Prof.  Gluck  prefers  cocaine  and  antipyrin  (5  per  cent.),  and  carbolic 
acid  (1  per  cent.), in  distilled  water;  Dr.  Moure  uses  20  per  cent,  cocaine 
and  1  in  10,000  adrenalin.  If  local  analgesia  is  employed  throughout, 
useful  information  will  be  found  in  the  reference  at  p.  582.  The  solution 
used  by  Mr.  Barker  will  be  found  here.  Any  fluid  used  will,  of  course,  be 
sterile,  and  applied  on  sterile  gauze  or  camel's-hair  brushes.  After  a  lapse 
of  a  few  minutes  the  actual  removal  of  the  growth  is  proceeded  with. 
Here  Sir  F,  Semon's  caution  that  the  growth  will  always  be  found  to  be 
more  extensive  than  was  shown  by  the  laryngoscope  may  be  repeated. 
He  thus  describes  the  actual  removal  of  the  growth  :  "  The  operator 
ought  to  make  two  semicircular  or  elliptical  cuts,  uniting  in  front  and 
behind,  through  the  whole  of  the  soft  tissues  and  down  to  the  perichon- 
drium round  the  diseased  area,  and  at  a  distance  of  about  half  to  one  inch 
from  the  periphery  of  the  growth.  .  .  .  The  area  to  be  removed  having 
been  thus  circumscribed,  the  removal  ought  to  take  place  by  the  growth 
itself  being  held  with  dressing-forceps  and  the  whole  area  being  cut  out 
with  curved  scissors,  the  points  of  which  are  firmly  pressed  against  the 
inner  aspect  of  the  cartilage  the  mucous  covering  of  which  is  to  be  removed. 
Unfortunately,  it  will  be  found  that  it  is  hardly  ever  possible  to  remove 
the  whole  of  the  growth  in  one  piece,  and,  as  a  rule,  the  diseased  portions 
will  have  to  be  removed  piecemeal.  The  entire  growth  and  part  of  its 
healthy  neighbourhood  if  necessary,  including  portions  of  cartilage,  having 
thus  been  removed,  the  base  ought  to  be  firmly  scraped  with  a  sharp 
spoon.  In  very  rare  cases  only  will  it  be  found  necessary  to  apply  the 
galvano-cautery."  Sir  Henry  Butlin  "  cuts  out  the  included  area  right 
down  to  the  cartilage,  which  is  laid  bare  and  finally  scraped  absolutely 
bare  with  Volkmann's  spoon." 

Dr.  C.  Jackson  condemns  the  use  of  the  curette  as  likely  to  cause  infec- 
tion at  the  time  of  the  operation  and  so  reappearance  of  the  disease. 
"  The  curette  may  be  likened  to  the  harrow  that  buries  the  seed  in  the 
soil  to  ensure  germination."  He  emphasises  the  need  of  cutting  far  out 
into  healthy  tissue,  but  does  not  specify  how  to  meet  the  chief  difficulty 
of  ensuring  removal  of  a  sufficient  depth  of  tissue  beneath  the  growth. 
Dr.  Moure  uses  both  curette  and  thermo-cautery.  The  bleeding  can 
usually  be  checked  by  very  fine  ligatures  of  catgut  and  pressure  with 
gauze,  wrung  out  of  very  hot  water  or  adrenalin  solution.  Hot  sterile 
saline  solution  having  been  applied  to  the  surface  operated  upon,  the 


590  OPERATIONS  ON  THE  HEAD  AND  NECK 

alee  of  the  thyroid  cartilage  are  now  accurately  united  with  salmon-gut  or 
silver  wire,  the  sutures  not  entering  the  cavity  of  the  larynx.  The  trache- 
otomy tube  can  be  removed  as  a  rule  at  the  conclusion  of  the  operation  ; 
in  these  cases  where  the  framework  of  the  larynx  and  thus  a  sufficient  air- 
way is  left,  there  does  not  appear  to  be  any  risk  of  subsequent  oedema  of 
the  glottis.  The  upper  half  of  the  skin  incision  is  closed  with  sutures  of 
gossamer  salmon-gut  and  horsehair  :  any  sutures  inserted  in  the  lower 
half  should  not  be  tied  for  the  first  few  days.  Gauze  dressings  to  be  fre- 
quently changed  as  they  become  soiled,  or,  better,  a  boracic  acid  fomen- 
tation applied. 

After-treatment.  The  patient  is  placed  upon  the  side  operated  on, 
with  the  chin  downwards  and  forwards,  and  only  a  low  pillow  under  the 
head,  to  promote  the  escape  of  any  fluids  by  the  mouth  and  miclosed 
part  of  the  wound.  For  the  first  forty-eight  hours  the  oj^erator  or  a  skilled 
assistant  should  be  at  hand,  so  that,  if  needful,  the  tracheotomy  tube 
may  be  replaced  at  once.  Nutrient  enemata  are  given,  and,  if  the 
patient's  condition  require  it,  feeding  by  a  tube  must  be  resorted  to.  For 
the  first  twenty-four  hours  only  sips  of  sterilised  water  or  ice  should 
occasionally  be  allowed  by  the  mouth.  "  On  the  follo\nng  morning  the 
first  attempt  is  made  to  swallow.  The  patient  leans  far  forwards,  with 
the  head  down,  and  the  dressing  is  taken  off  the  wound,  under  which  a 
basin  is  placed.  Cold  water  is  drmik  out  of  a  glass.  If  the  experiment  is 
successful,  all  the  water  passes  into  the  stomach.  If  it  is  only  partially 
successful,  some  escapes  into  the  larynx.  But  the  posture  of  the  patient 
ensures  that  it  runs  through  the  wound,  and  does  not  pass  into  the  air- 
passages.  As  soon  as  water  can  be  readily  swallowed  milk  and  other 
liquids  may  be  drunk.  The  wound  is  generally  closed  within  ten  or 
twelve  days  "  (Butlin). 

Removal  of  half  the  Larynx  (Figs.  254,  255).  This  operation  may  be 
strongly  recommended  for  cases  of  intrinsic 
disease  which  are  not  suitable  for  th}Totomy, 
i.e.  where  the  growth  has  extended  widely, 
but  is  still  confined  to  one  half  of  the  larynx. 
The  epiglottis  should  always  be  preserved  : 
indeed,  Chevafier  Jackson  advises  that  if  the 
growth  has  extended  so  far  upwards  as  to 
call  for  removal  of  this  cartilage,  a  complete 
laryngectomy  is  to  be  preferred.  The  reason 
for  this  is  the  very  strong  probability  of 
aspiration-pneumonia  when  the  epiglottis  is 
removed  as  well  as  half  the  larynx. 

The  operation  of  hemi-laryngectomy  is 
much  less  severe  than  complete  lar\Tigec- 
tomy,  and  the  mortality  is  much  less.  The  results  as  regards  voice 
and  breathing  are  nearly  as  good  as  after  a  thyrotomy.  In  one  of 
Schede's  cases  ^  the  patient  was  a  dentist  ;  he  could,  after  a  while, 
dispense  with  any  cannula  and  follow  his  calling,  his  speech  not 
attracting  notice.  As  a  result  of  cicatricial  contraction,  a  prominent 
fold  of  mucous  membrane  had  formed,  immovable,  but  capable  of 
performing  many  of  the  functions  of  the  right  cord,  the  left  moving  up  to 
it,  and  thus  forming  a  rima  glottidis.^ 

1  German  Surg.  Congr.,  April  1884  ;  Lond.  Med.  Rec.  1884,  p.  358. 

*  See  also  a  case  reported  by  Sir  F.  Semon  {Clin.  Soc.  Trans.,  vol.  xx,  p.  44). 


Fig.   254. 
left  cord 


Epithelioma  of  the 
(Lennox  Browne.) 


EXTRA-LARYNGEAL  OPERATIONS 


591 


Sir  H.  Butlin,  writing  in  1900/  puts  the  mortality  at  2()-3  per  cent., 
or  nearly  three  times  greater  than  that  of  thyrotomy.  About  three  years 
later  Prot.  Gluck,-  as  an  instance  of  his  improving  results,  said  :  "  In  one 
series  of  thirty-five  hemi-laryngectomies  I  had  three  deaths,  one  twenty- 
four  days  after  operation  of  heart  failure,  when  the  wound  was  already 
healed  ;  another,  independently  of  the  operation,  of  phlegmon  of  the 
right  gluteal  muscle  ;  the  third  of  pneumonia  five  days  after  operation." 
When  unilateral  laryngectomy  is  performed  these  two  points  must  be 
remembered.  Carcinoma  may  reap})ear  in  the  lialf  left  even  after  such  a 
long  interval  as  to  suggest  a  fi-esh  outbreak  of  the  disease.  Prof.  Gluck  ^ 
mentioned  a  case  in  which,  nine  years  after  the  operation,  "  recurrence 

\..CART.O»-\A/RlSBERC>  tOLD 

LSURC0R»4U  '         ' 

«40T  REMOV*         ^  CAPlT"* 

SANTO  R  IN  I 


V  ITER- ARYTENOID. 
FOLD 


VENTI^ICt.f 


AKTERIORPORT" 
OF  CRICOIO 


Fig.  255.     Inner  aspect  of  the  portion  removed.     (Lennox  Browne. 


took  place  in  the  other  half  of  the  larynx,  and  in  the  glands  ;  after 
the  second  operation  he  lived  over  two  years,  and  died  at  76.  The 
operations  lengthened  his  life  for  eleven  years."  The  second  point  is 
that,  after  removal  of  one  half  of  the  framework  of  the  larynx,  cicatricial 
contractions  may  bring  about  a  degree  of  stenosis  which  necessitates  the 
permanent  use  of  a  tracheotomy  tube. 

Operation  of  Removal  of  half  the  Larynx.  The  points  which  are 
insisted  on  as  essential  in  the  preliminary  examination  of  the  patient  in 
the  account  of  complete  laryngectomy  (p.  593)  should  be  referred  to, 
and  several  of  the  details  of  this  operation,  e.g.  the  position  of  the  patient, 
cocainisation  of  the  nerves,  apply  here  also.  The  anaesthetic  should  be 
chloroform,  and  the  advice  given  at  p.  589  is  to  be  remembered.  A 
preliminary  tracheotomy  is  performed,  as  at  p.  593.  A  vertical  incision 
is  made  from  the  hyoid  bone  to  the  cricoid  cartilage,  to  which  transverse 
ones  must  be  added  if  the  glands  are  to  be  removed  at  the  same  time.  The 
soft  parts  are  raised  from  the  larynx  either  en  masse  or  by  separation  in 
detail  according  to  the  extent  to  which  they  may  be  infiltrated. 

Mr.  Lennox  Browne  **  in  his  case  of  removal  of  half  the  larynx,  one 

^  O-per.  Surg,  of  Malig.  Dis.,  p.  198. 

2  Brit.  Med.  Jonrn.,  October  31,  190.3,  p.  1123. 

3  Loc.  .suprd  cit. 

*  Brit.  Med.  Joiirn.,  February  5,  1887. 


592  OPERATIONS  ON  THE  HEAD  AND  NECK 

of  the  few  at  that  time  reported  in  this  country  ^  (Figs.  204,  255), 
having  exposed  it  by  subperichondrial  raising  of  the  soft  parts  divided  the 
thyroid  cartilage  with  cutting-forceps,  removed  the  half  by  (a)  thorough 
separation  of  the  attachments  to  the  pharynx  with  the  raspatory  aided 
by  the  knife-handle  and  finger-nail ;  (6)  division  of  the  thyro-hyoid 
membrane  as  close  as  possible  to  its  thyroid  attachment ;  (c)  division  of 
the  left  superior  horn  of  the  thyroid  cartilage  at  its  root  by  cutting- pliers  ; 
{d)  division  in  the  middle  line  of  the  cricoid  cartilage,  in  front  and  behind  ; 
(e)  the  divided  half  of  the  larynx  was  then  separated  from  the  first  ring  of 
the  trachea,  and  a  few  nicks  only  were  necessary  to  remove  it  entire.  The 
very  shght  oozing  which  ensued  after  the  removal  of  the  diseased  part  was 
checked  by  a  light  application  of  the  galvano-cautery,  which,  it  was 
thought,  would  also  destroy  any  possible  fragments  of  diseased  tissues  not 
removed.  The  left  arytaeno-epiglottic  fold  was  divided  close  to  the 
cartilage  of  Wrisberg,  and  the  thyro-hyoid  membrane  close  to  its  thyroid 
attachment,  with  the  view  of  impairing  as  little  as  possible  the  action  of 
the  epiglottis.  An  ordinary  tracheotomy  cannula  must  be  retained  for 
some  days.  Whether  the  glands  are  dealt  with  now  or  later,  as  has 
been  advised  in  the  case  of  the  tongue,  must  depend  on  the  difficulties  of 
the  previous  operation  and  the  state  of  the  patient. 

Prof.  Gluck's  method  ^  in  hemi-laryngectomy  is  as  follows  :  He  raises 
a  skin  flap  on  the  affected  side  by  a  median  and  two  transverse  incisions. 
The  larynx  is  exposed,  split  in  the  middle  line,  and  the  affected  half 
loosened  out.  "  The  defect  thus  created  is  so  covered  with  the  skin  flap 
that  its  edges  are  sewn  above  to  the  mucous  membrane  of  the  sinus 
pyriformis  and  below  to  the  trachea,  and  in  the  middle  line  to  the  plate 
of  the  cartilage.  A  large  tampon  of  iodoform  gauze  is  introduced  into  the 
cavity  of  the  larynx.  It  must  press  tightly  against  the  under-surface  of 
the  skin  flap,  and  prevent  the  passage  of  food  particles  into  the  air 
passages." 

Complete  Laryngectomy.  The  progress  that  has  been  made  in  opera- 
tions on  the  larynx  in  the  last  fifteen  years  by  the  few  who  have  had 
opportunities  for  gaining  a  special  mastery  over  the  needful  details  is 
nowhere  shown  better  than  by  Prof.  Gluck's  details.^  "  In  my  first  series 
of  ten  cases  only  two  were  successful,  and  in  nine  cases  of  another  series 
I  had  four  deaths.  .  .  .  My  most  recent  results  show  a  series  of  twenty- 
two  complete  laryngectomies  with  one  death — that  of  a  man  of  seventy, 
who  died  on  the  eleventh  day  of  iodoform  poisoning.  Of  partial  extirpa- 
tion of  the  larynx  and  pharynx,  generally  combined  with  removal  of 
infected  glands,  I  can  point  to  a  series  of  twenty-seven  cases  with  only 
one  death.  This  was  a  case  in  which  the  carotid  had  been  tied,  and  death 
occurred  from  hemiplegia  five  days  after  the  operation.  ...  At  present 
I  could  show  you  thirty-eight  living  patients  who  have  been  cured  by 
these  operations.  The  oldest  case  was  operated  on  thirteen  years  ago. 
Of  those  already  dead,  a  number  have  lived  11,8,  GJ,  5|,  4i,  and  Si  years 
after  the  operation  in  good  health,  and  some  have  died  of  other  illnesses, 
not  of  recurrence." 

Other  authorities  who  have  been  candid  enough  to  pubHsh  their  results 

^  See  also  an  interesting  case  recorded  by  Mr.  Arthur  Evans  (Proc.  Roy.  Foe.  Med., 
Laryng.  Sec,  December  1908).  Sir  F.  Semon  has  described  a  case  (Proc.  Roy.  Soc.  Med., 
Laryng.  Sec,  Dec.  1908)  in  which  an  epithelioma  of  the  left  vocal  cord  treated  by 
thyrotomy  was  followed  by  a  recurrence ;  a  hemi-laryngectomy  was  then  performed  with 
a  satisfactory  result. 
2  Loc.  supra  cit. 


EXTRA-LARYNGKAL  OPERATIONS  593 

— uiul  the  siuall  iiuiiihcr  of  hiryMjj^ectoinics  publislicd  by  those  who  have 
special  opportunities,  and  avail  themselves  of  these  opportunities,  carries 
its  own  tale — have  met  with  dill'ereut  success,  'i'he  after-condition  of 
the  patients  is  referred  to  at  p.  585.  In  estimating  the  value  of  the  above 
conclusions,  and  in  deciding  upon  an  operation  where  a  doubt  is  present, 
the  tendency  to  make  the  best  of  cases  must  be  remembered  ;  and,  further, 
when  malignant  disease  rea})pears  in  situ 
two  to  four  months  after  an  operation 
even  by  skilled  hands,  the  question  arises 
whether  such  interference,  necessarily  in- 
complete, may  not  have  hastened  this 
result. 

Indications  for  Complete  Laryngectomy. 
Here  both  the  local  stage  of  the  disease  and 
the  general  condition  of  the  patient  have  to 
be  considered.  The  first  has  already  been 
referred  to  under  the  headings  of  the  opera-     f"'-  256.    Laryngoscopic  view 

P    , ,  ,  1  i  •    1    1  from    the     samb     patient    lour 

tions  of  thyrotomy  and  partial  laryngec-  „ioath«  after  operation.  (Lennox 
tomy.      To    put    the    indications    on    this  Browne.) 

point    briefly,  it    may   be    said    that    the 

complete  operation  is  indicated  in  cases  of  malignant  disease  of  the 
larynx  unsuitable  for  thyrotomy,  partial  laryngectomy,  orpharyngotomy, 
cases  in  which  the  operator  has  grounds  for  believing  that  he  can  get 
away  all  the  disease,  including  infiltrated  glands,  cases,  finally,  in  which 
the  general  condition  of  the  patient  is  favourable.  Here  the  age  of 
the  patient  (not  only  to  be  recognised  by  years),  his  power  of  meeting 
and  recovery  after  an  operation  in  which  a  peculiar  form  of  shock  will 
probably  always  be  present  (p.  596),  the  existence  of  any  liability  to 
bronchitis,  broncho -pneumonia,  asthma,  his  capability  of  assimilating 
food,  the  condition  of  his  viscera,  e.g.  the  presence  of  any  albuminuria, 
or  arteriosclerosis,  the  history  of  emaciation,  and,  by  no  means  least,  the 
temperament  of  the  patient— have  all  to  be  most  carefully  considered. 

Operation  of  Complete  Laryngectomy.  The  first  question  that 
arises  is  the  advisability  of  performing  a  preliminary  tracheotomy. 
Of  late  years  the  use  of  a  tube  has  been  largely  dispensed  with  during 
the  operation.  From  what  follows  most  will  allow  that  the  advantages  of 
taking  this  preliminary  step  are  considerable,  and  that  in  some  cases  its 
adoption  is  strongly  called  for.  Advantages.  (1)  It  gives  great  relief  to 
any  laryngeal  stenosis  and  its  results  on  the  lungs.  In  cases  of  dyspnoea 
it  is  strongly  indicated.  (2)  While  it  is  probable  that  the  diniinished 
congestion  of  the  lungs  will  lessen  the  risk  of  broncho-pneumonia,  it  is 
certain  that  when  bronchitis  is  already  present,  and  other  treatment 
does  not  avail,  this  step  should  be  taken  (Bilroth).  (3)  If  it  is  intended 
to  perform  tracheotomy,  and  this  step  is  employed  beforehand,  less 
time  will  be  taken  up  at  the  operation,  and  no  blood  will  enter  the  trachea 
from  this  source.  (4)  The  trachea  will  have  become  adherent  to  the  skin. 
In  several  cases,  as  in  those  mentioned  by  a  French  writer  at  p.  598,  the 
necessarv  adhesions  have  not  taken  place.  Dr.  Delavan  ^  adds  the  follow- 
ing :  (5)"  By  the  rest  given  to  the  larynx  and  adjacent  parts  their  conges- 
tion is  lessened,  and  it  becomes  easier  to  •distinguish  between  diseased  and 
healthy  parts.  (6)  The  operation  being  done  while  the  patient  is  in  a 
quiescent  state,  he  is  less  disturbed  by  the  sudden  change  in  his  mode  of 

^  hoc.  supra  cit. 
SURGERY   I  38 


594 


OPERATIONS  ON  THE  HEAD  AND  NECK 


^/<r%^^ 


V- 


^^^ 


s^ 


breathing,  and  he  is  in  a  better  condition  to  acquire  experience  in  the 
management  of  the  tube.  The  objections  brought  against  this  preliminary 
step  are  (1)  that  it  is  not  necessary,  which  is  certainly  true  of  many  cases 
in  the  hands  of  experienced  operators  ;  (2)  that  it  exposes  the  patient  to 
the  risk  of  septic  infection  and  broncho-pneumonia.  These  are  rare 
after  tracheotomy  in  patients  in  fair  condition  ;  they  might  certainly 
follow  in  patients  whose  vitality  is  much  lowered,  but  it  is  doubtful  if  in 
these  the  major  operation  is  justifiable.  As  to  the  date  of  the  pre- 
liminary tracheotomy,  this  should  be  at  least  ten  days  before  the  laryn- 
gectomy, for  the  reasons  already  given. 
These  outweigh  the  advantages  claimed  for 
performing  it  immediately  before  the  main 
operation,  viz.  that  the  patient  is  thus 
saved  two  separate  operations. 

If  it  be  important  to  avoid  giving  an 
anaesthetic  twice,  local  analgesia  (p.  582) 
should  certainly  be  tried.  The  site  of  the 
tracheotomy  should  always  be  low,  for,  if 
performed  high  up,  the  lower  end  of  the 
excision  wound  will  come  into  parts  infil- 
trated and  altered,  and  thus  difficult  to 
distinguish  at  a  critical  stage  of  the  opera- 
tion, and  likely  to  lead  to  needless  haemor- 
rhage. The  tracheotomy  may  be  too  near 
to  the  disease,  and,  further,  bring  the  anaes- 
thetist in  the  way  of  the  operator. 

The  preliminary  preparation  of  the 
patient  as  regards  tbe  general  state  of 
the  lungs,  power  of  assimilating  food,  &c.,  should  be  of  the  most 
careful  kind.  Not  only  is  the  area  of  the  operation  to  be  sterilised,  but 
the  mouth,  teeth,  and  nose  should  be  disinfected  as  far  as  possible.  The 
temperature  of  the  operating-room  should  be  attended  to  and  every  pre- 
caution taken  for  preventing  shock.  An  electric  head-light  will  be  found 
very  useful.  The  means  for  administering  oxygeji  should  be  at 
hand.  Chloroform  is  administered  with  the  precautions  already 
detailed  at  p.  589.  If  tracheotomy  has  been  performed  it  is  given  by  the 
tracheotomy  tube.  If  no  tracheotomy  has  beeii  employed,  the  anaesthetic 
is  given  as  long  as  possible  in  the  ordinary  way,  and  later  on,  when  the 
trachea  is  severed,  by  tubing  fitting  the  inner  tube  of  the  tracheotomy 
cannula  exactly.  Whether  the  operation  is  performed  from  above  down- 
wards or  vice  versa,  the  Trendelenberg  or  Rose's  position  (p.  474)  should 
be  tried  as  soon  as  the  larynx  and  trachea  are  well  exposed.  Removal  from 
above  downwards,  by  leaving  the  division  of  the  trachea  to  the  last,  is 
held  b}  some  to  avoid  the  risk  of  the  escape  of  blood  and  lotions  into  the 
trachea,  and  thus  to  avoid  any  need  of  using  expensive  and  sometimes 
unreliable  tampon  cannul  ae.  Sterilised  sponges  or  gauze  tampons  attached 
to  silk  must  be  at  hand  to  be  placed  in  the  trachea  above  the  tracheotomy 
cannula  and  in  the  pharynx.  If  no  tracheotomy  is  performed  either  some 
time  previously  or  immediately  before  the  operation,  the  median  incision 
being  made,  the  trachea  is  usually  first  isolated  and  divided,  and  then  a 
large  tube  inserted.  The  plan  of  the  operation  must  be  carried  out 
according  to  the  conditions  found  when  the  interior  of  the  larynx  has 
been  thoroughly  well  exposed.     We  will  suppose  at  first  that  the  disease 


Fig.   257.     A,   Incision    for    ex- 
cision of  larynx.      B,   Kocher's 
"  high  "   collar  incision  for   ex- 
cision of  the  larynx. 


KXT1?A  LARYNGP:AL  operations  595 

is  too  ditluse  to  allow  of  a  unilateral  laryngectomy,  but  that  it  has  not 
infiltrated  the  framework  of  the  larynx  deeply.  If  the  operation  be 
begun  from  above  an  incision  is  first  made  from  the  lower  border  of  the 
hyoid  bone,  exactly  in  the  middle  line,  vertically  down  to  the  level 
of  the  first  or  second  ring  of  the  trachea,  and  a  second  at  right  angles 
to  the  first,  either  at  the  level  of  the  hyoid  bone,  or  below,  in  either  case 
passing  outwards  to  the  sterno-mastoids. 

The  lower  transverse  incisions  may  give  more  room  and  prevent 
any  need  of  prolonging  the  longitudinal  wound  down  to  the  tracheotomy 
incision  if  this  preliminary  operation  has  been  performed,  a  step  which  it 
is  difficult  to  avoid  in  short  necks. ^  The  vertical  incision  should  go  down 
to  the  thyroid  and  cricoid  cartilages  and  trachea,  the  thyroid  and  cricoid 
cartilages  being  carefully  severed  in  the  middle  line  with  stout  scissors 
or  cutting  forceps,  the  two  halves  separated  with  retractors  and  the 
interior  examined.  The  soft  parts  over  the  thyroid  and  cricoid  are  then 
raised  en  masse  by  inserting  a  blunt  dissector  or  raspatory  so  close  to  the 
cartilage  that  the  perichondrium  itself  is  lifted  up,  with  its  relation  to  the 
soft  parts  over  it  undisturbed.  This  separation  is  carried  bacl<:  as  far 
as  the  middle  of  the  junction  of  the  larynx  and  pharynx.  The  thyroid 
isthmus  is  drawn  downwards  or,  better,  divided  between  two  ligatures  ; 
the  larynx  is  pulled  to  either  side  with  sharp  hooks,  and  the  attachments 
of  tlie  inferior  and  lower  part  of  middle  constrictors  and  stylopharyngeus 
divided.  All  vessels,  especially  the  superior  laryngeal  and  superior 
thyroids,  must  be  carefully  secured.  The  trachea,  separated  from  the 
oesophagus  by  the  careful  use  of  a  blunt  dissector,  a  curved  periosteal 
elevator,  or  snips  of  curved  blunt-pointed  scissors,  is  cut  through  between 
the  first  and  second  rings.  If  no  tracheotomy  has  been  performed,  two 
stout  sutures  of  silk  are  passed  through  the  whole  thickness  of  the  trachea, 
one  on  either  side  ;  and  by  these  the  tracheal  stump  is  drawn  downwards 
and  forwards  and  secured  by  most  careful  suturing  in  the  lower  angle  of 
the  wound,  or  in  a  separate  incision  made  for  this  purpose  just  above  the 
sternum.2  Two  precautions  are  needed  here.  In  freeing  the  trachea 
sufficiently  to  allow  of  its  being  brought  downwards  and  forwards  so  as  to 
diminish  the  risk  of  entrance  of  fluids,  care  must  be  taken  not  to  bare  it 
too  much,  and  thus  cut  off  its  blood-supply.  The  sutures  employed  to 
keep  it  firmly  and  snugly  in  position  should  be  of  reliable  catgut  or 
kangaroo  tendon.  If  of  salmon-gut  they  must  be  left  long,  to  facilitate 
their  removal.  Two  stout  silk  sutures  are  now  passed  through  the  upper 
cut  end  of  the  trachea,  and  by  traction  on  these  the  larynx  is  carefully 
separated  from  the  oesophagus  and  pharynx  from  below  upwards.  The 
excision  is  completed  by  division  of  the  thyro-hyoid  ligament  and  the 
mucous  membrane  at  the  entrance  of  the  larynx.  The  epiglottis  and 
its  folds  should  be  left  intact,  if  possible. 

The  above  method  of  working  very  close  to  the  cartilages  with  a  blunt 
instrument  only,  has  the  conspicuous  advantages  of  disturbing  but  little 
the  soft  parts  and  of  causing  but  trifling  haemorrhage.^ 

1  The  operator  can  use  a  T-shaped  incision,  a  vertical  one  with  transverse  cuts  at  either 
end,  or  a  flap  with  its  base  upwards.  This  last  method,  used  by  Durante  and  Crile.  is 
referred  to  below  (p.  598).  It  is  especially  adapted  to  those  cases  where  it  is  not  possible 
to  suture  securely  the  pliarynx  and  oesophagus.  Other  flap  methods  are  given  by  Prof. 
Gluck  {Brit.  Med.  Journ.,  October  31,  1903,  p.  1119). 

-  Gluck,  vide  infra. 

^  In  thus  raising  the  soft  parts  by  keeping  close  to  the  cartilages  of  the  larynx,  care 
should  be  taken  not  to  separate  needlessly  the  soft  parts  from  the  trachea.     Some  of 


596  OPERATIONS  ON  THE  HEAD  AND  NECK 

Where  the  parts  do  not  admit  of  the  above  step^ — for  instance,  where 
the  cartilages  are  infiltrated  or  where  the  parts  outside,  e.g.  glands.,  are 
found  involved,  and  the  operator  decides  to  go  on  with  the  operation 
(p.  584) — much  severer  steps  are  necessary.  The  larynx  must  now  be 
treated  in  the  same  way  as  a  mahgnant  growth  elsewhere.  Flaps  of  skin 
and  fascia  are  reflected,  and  the  larynx  exposed  as  freely  as  possible.  Any 
enlarged  glands  now  seen  should  be  removed,  and  superficial  vessels 
secured.  The  sterno-hyoids,  sterno-thyroids,  and  thyro-hyoids  are  next 
severed  near  the  thyroid  cartilage,  and  the  lateral  lobes  of  the  thyroid 
gland  carefully  separated  in  the  same  way  {vide  infra),  ligatures  being 
tied  at  their  junction  with  the  isthmus  if  needful.  The  soft  parts  at  the 
sides  which  contain  the  large  vessels,  &c.,  are  now"  carefully  retracted,  and 
the  larynx  being  drawn  first  to  one  side  and  then  to  the  other,  the  inferior, 
lower  part  of  middle  constrictor  and  stylo-pharyngeus  muscles  are  divided 
very  close  to  their  attachments  to  the  cricoid  and  thyroid  cartilages.  The 
introduction  of  an  oesophagus  bougie  may  facihtate  this  step,  and  save 
needless  "  button-holing  "  now  and  in  the  separation  of  the  oesophagus 
from  the  trachea.  The  superior  laryngeal  vessels  are  secured  and  divided 
as  they  enter  the  thyro-hyoid  membrane.  To  produce  anaesthesia  of  the 
nerves  which  may  carry  inhibitory  cardiac  impulses,  Dr.  Crile  injected 
cocaine  into  the  superior  laryngeal  nerve  before  dividing  it  in  two  of  his 
cases  published  by  Dr.  Lincoln.^  Information  on  this  point  has  been 
given  at  p.  238.  Further  experience  is  needed  before  we  can  rely  on  this 
step  for  preventing  the  serious  respiratory  and  cardiac  disturbances 
w^hich  have  followed  during  the  raising  up  and  dissection  out  of  the 
larynx,  and  also  for  diminishing  the  shock  afterwards. 

The  larynx  is  next  severed  from  the  trachea  at  the  second  ring,  the 

stump  of  the  trachea  being  dealt  with  in  the  manner  already  given.     The 

detachment  of  the  larynx  from  the  oesophagus  is  then  carried  out  from 

below  upwards,  with  the  precautions  given  above  not  to  buttonhole  it. 

As  the  dissection  is  carried  upwards  to  the  laryngo-pharyngeal  junction  the 

anterior  and  lateral  walls  of  the  pharynx  will  require  partial  removal 

in  these  more  advanced  cases.     At  this  stage  the  following  details  given 

by  Mr.  Harvey  will  be  found  useful. ^     After  the  stump  of  the  trachea  has 

been  stitched  to  the  skin  "  the  next  step  will  be  to  dissect  off  the  upper 

portion  of  the  trachea  from  the  oesophagus  and  the  muscles  from  the 

lateral  surface  of  the  cricoid.     The  inferior  cornu  of  the  thyroid  is  next 

bared  by  detaching  and  reflecting  the  crico-thyroid  and  inferior  constrictor 

muscles.     The  muscles  and  perichondrium  in  front  of  the  thyroid  will 

now  be  separated  and  reflected  as  far  back  as  the  superior  cornu,  which 

latter  will  next  be  freed  by  dividing  the  periosteum  on  its  surface,  and 

pushing  it  along  mth  the  lateral  wall  of  the  pharynx  and  the  loose  areolar 

tissue  backwards  mitil  the  posterior  lateral  border  of  the  cricoid  is  reached. 

The  outer  two-thirds  of  the  lateral  portion  of  the  thyro-hyoid  ligament 

will  then  be  divided  transversely  and  cautiously  at  the  junction  of  its 

middle  and  upper  thirds  ;   and  when  the  adjacent  mucous  membrane  is 

reached  this  must  be  picked  up  with  forceps  and  divided,  whereby  the 

upper  portion  of  the  epiglottis  can  be  seized  and  drawn  forwards.     The 

anterior  wall  of  the  pharynx  is  thus  opened,  and  by  pulling  the  epiglottis 

these,  e.g.  the  lateral  masses  of  the  thyroid  gland,  which  are  now  also  detached  with 
a  blunt  dissector,  are  useful  in  preventing  descent  of  the  trachea.  Sloughing  of  the  tracheal 
stump  and  failure  of  union  to  the  skin  has  followed  in  several  cases  (jjp.  598  and  .599). 
1  Trans.  Amer.  Lnr.  Soc,  1903,  p.  54.  Dr.  Lincoln  relates  the  results  in  seven  cases 
operated  on  by  Dr.  Crile.  ^  Lancet,  September  21,  1901. 


EXTRA-LARYNGEAT.  OPERATIONS  597 

strongly  forwards,  and  with  it  the  wliolc  hnviix.  the  knif(^  ran  be  placed 
on  tlu^  posterior  surface  of  the  cricoid,  and  by  cutting  (h)wnwards  the 
anterior  wall  of  the  esophagus  will  be  opened.  Care  nuist  be  taken  at 
this  point  to  limit  the  cut  to  the  parts  which  are  covered  in  front  by  the 
posterior  surface  of  the  cricoid  ;  if  this  is  not  done,  the  lateral  wall  of  the 
pharynx  and  oesophagus  will  be  unnecessarily  encroached  upon,  thus 
rendering  it  difhcult  to  approximate  their  edges.  The  whole  larynx  is 
thus  compK'tely  detached,  and  the  defect  in  the  pharyngeal  mucous 
membrane  nnist  now  be  made  good  by  inserting  sutures  (piite  close  to  the 
cut  edges,  and  so  preventing  in-turning  of  the  epithelial  surfaces. 

"  The  sewing  up  must  be  water-tight,  with  fine  catgut  sutures,  so 
as  to  form  a  Y-shaped  stitched  line  ;  then  a  row  of  Lembert's  sutures 
must  be  added,  transfixing  the  muscular  and  cellular  coats  of  the  oeso- 
phagus and  pharynx.  The  third  layer  unites  the  stumps  of  the  pharyngeal 
constrictors,  and  the  fourth  brings  together  the  divided  sterno-hyoid 
and  thyro-hyoid  muscles."  If  closure  of  the  pharynx  be  found  impossible 
its  cut  edges  must  be  united  by  numerous  sutures  of  sterilised  catgut  to 
the  soft  parts  about  the  base  of  the  tongue  and  hyoid  bone,  secure  union 
here,  as  in  the  case  of  the  sutured  stump  of  the  trachea,  being  of  the 
utmost  importance  to  prevent  infection  of  the  wound  by  fluids  from  the 
mouth. 

All  haemorrhage  having  been  carefully  arrested,  drainage  is  supplied 
by  securely  packing  any  pockets  in  the  wound  with  strips  of  iodoform 
gauze,  which  are  led  out  above  and  below.  The  wound  is  sewn  together 
over  these  strips,  and  a  boracic  acid  fomentation  supplied.  A  soft 
tube  may  be  passed  by  the  nose  into  the  oesophagus  at  the  time  of  the 
operation.  If  this  occasion  retching  and  coughing  it  must  be  passed  as 
required. 

As  to  the  removal  of  glands,  Prof.  Gluck  carries  this  out  at  the  time  of 
the  laryngectomy.  By  most,  considering  the  severity  of  the  first  opera- 
tion a;id  the  thoroughness  and  time  required  if  epitheliomatous  glands 
in  the  neck  are  to  be  attacked  to  any  purpose  (p.  539),  this  proceeding 
will  be  deferred  to  a  later  stage. 

The  after-treatment  is  considered  at  p.  600. 

Numerous  modifications  have  been  introduced  in  the  technique  of 
laryngectomy  with  a  view  especially  of  diminishing  the  risk  of  broncho- 
pneumonia. 

Gluck  1  does  not  perform  a  preliminary  tracheotomy.  After  the  usual  incision, 
exposure  of  the  sides  of  the  larynx,  division  of  the  muscles,  separation  of  the  thyroid 
gland,  and  ligature  of  the  suj^erior  laryngeal  artery,  the  patient  is  placed  so  that 
the  head  hangs  over  the  end  of  the  table,  the  thyro-hyoid  membrane  is  divided  and 
the  pharjnix  plugged  with  gauze,  so  as  to  prevent  the  descent  of  saliva.  The  larynx 
is  then  drawn  steadily  forward  as  it  is  separated  from  the  pharjTix  and  oesophagus 
until  the  lower  margin  of  the  cricoid  is  reached,  when  the  whole  larynx  can  be  drawn 
out  of  the  wound.  A  transverse  incision  is  now  made  above  the  episternal  notch, 
and  from  this  the  skin  is  loosened  upwards  into  the  upper  wound  so  as  to  leave  a 
bridge  of  skin  4  to  5  cms.  vnde.  Two  strong  threads  are  then  passed  through  the 
trachea,  the  larynx  is  cut  away  close  above  the  threads,  and  the  stump  of  the  trachea 
drawn  by  the  threads  under  the  bridge  of  skin  into  the  buttonhole-like  opening  above 
the  episternal  notch.  It  is  here  fixed  by  sewing  its  edges  all  round  to  the  edges  of  the 
skin  wound.  The  opening  in  the  pharynx  is  closed  by  one  or  more  rows  of  sutures, 
and  all  the  different  pockets  of  the  wound  and  mouth  are  packed  tightly  with  iodo- 
form gauze.  The  skin  is  sewn  together  over  this  packing.  The  patient  is  fed  by  an 
india-rubber  tube  passed  through  the  nose. 

1  Brit.  Med.  Jottrn.,  loc.  supra  cit. 


598  OPERATIONS  OX  THE  HEAD  AND  NECK 

The  advantage  of  thus  separating  the  opening  in  the  trachea  by  considerable 
distance  from  the  wound  is  obvious,  but  nothing  is  said  as  to  the  difficulties  which 
are  apjoarently  certain  to  arise  in  the  administration  of  an  anaesthetic  if  the  above 
technique  is  followed.     It  is  not  stated  that  local  analgesia  is  emploj'ed. 

Le  Bee  ^  has  followed  Chiari  in  dividing  larjaigectomy  into  two  stages.  In  the 
first,  the  trachea  is  detached  from  the  larynx  and  sutured  to  the  skin.  In  the 
second,  performed  eight  to  fourteen  days  later,  the  larynx  is  removed.  He  claims 
that  by  tliis  method  shock  is  diminished,  and  the  risk  of  broncho-pneumonia  greatly 
lessened.  The  trachea  is  exposed  by  an  excision  extending  from  below  the  cricoid 
to  the  sternum  and  isolated  laterally,  with  care  to  preserve  sufficient  cellular  tissue 
to  ensure  its  nutrition.  The  tube,  severed  below  the  cricoid,  is  drawm  downwards 
and  forwards,  and  fixed  to  the  skin  by  sutures  which  take  up  the  trachea  between 
its  second  and  third  rings.  A  tracheotomy  tube  is  placed  in  the  opening,  and  the 
wound  closed  with  drainage.  At  the  second  operation  the  larynx  is  removed  by  the 
steps  already  fully  given  (p.  595).     Dr.  Le  Bee's  patient  recovered. 

Dr.  Canzard  ^  states  that  in  the  above  case,  after  the  removal  of  the  silk  sutures 
by  which  the  stump  of  the  trachea  had  been  united  to  the  skin,  union  failed  to  take 
place,  but  as  this  wound,  by  the  adoption  of  the  two-stage  method,  had  become  shut 
off  from  that  of  the  major  operation,  re-insertion  of  a  few  sutures  was  sufficient.  He 
mentions  another  case  operated  upon  in  one  stage  in  which  the  patient  was  very 
restless.  Sloughing  of  the  di\ided  trachea  was  followed  by  a  fatal  result  two  weeks 
after  the  laryngectomy. 

Dr.  Durante,  the  well-known  surgeon  at  Rome,  in  order  to  prevent  the  risk  of 
lung  troubles,  makes  use  of  a  flap  intended  to  close  the  pharj-ngeo-oesophageal 
opening  so  that  mucus  and  saliva  shall  be  conveyed  directlj'  into  the  cesophagus,  and 
the  large  wound  remaining  after  lar^nigectomy  be  reduced  to  a  minimum.  An 
account  of  his  operation,  with  excellent  photographs,  is  given  in  a  brief  paper,  in  the 
International  Clinics,  1905,  p.  122.  A  large  horseshoe-shaped  flap  consisting  of  skin 
and  su])erficial  fascia  is  raised  by  an  incision  Avhich,  starting  at  the  right  angle  of  the 
mandible,  descends  along  the  sterno-mastoid  to  a  point  3  cms.  above  the  episternal 
notch  ;  thence,  cur%nng  across  to  the  left  side,  it  ascends  along  the  sternomastoid  to 
end  at  the  left  angle  of  the  jaws.  The  flap  is  raised  as  high  as  the  hyoid  bone,  the 
larynx  exposed,  and,  after  the  jierforraance  of  a  low  tracheotomy,  removed  by  the 
steps  already  given.  When  all  bleeding  has  been  arrested  the  flap  is  sutured  "  from 
above  doTvnwards  to  the  edges  of  the  pharj'ngeo-cesophageal  mucous  membrane,  in 
such  a  manner  that  the  rete  ]Malpighii  comes  into  more  or  less  direct  contact  with  the 
cut  edge  of  the  mucous  and  submucous  coats  of  the  phar3Tix  and  cesophagus.  The 
lower  end  of  the  flap  remains  behind  the  tracheal  stump,  and  is  fixed  to  it  with  stitches 
so  as  to  render  it  immobile.  The  whole  bleeding  surface  is  thus  reduced  to  two 
lateral  clefts  which  should  be  jiacked  with  gauze." 

Both  the  patients  on  whom  Dr.  Durante  employed  this  method  recovered  rapidly, 
one  being  able  to  swallow  milk  and  water  on  the  second  day  after  the  operation, 
The  first  died  two  months  later  with  infiltration  of  the  glands  and  ha?morrhage 
from  the  carotid  artery.  In  the  second  an  enlarged  gland  and  "  all  the  objective 
evidence  of  carcinomatous  cachexia  "  appeared  eight  months  after  the  oj^eration.  In 
this  case  it  is  to  be  noted  that  at  the  time  of  the  lar}^lgectomy  "  the  carcinoma  was 
rather  circumscribed,  and  there  was  no  evidence  of  metastasis." 

F('iderl  endeavours  to  meet  the  dangers  of  pneumonia  by  restoring  the  lumen  of  the 
air  tube.  On  the  cadaver,  and  in  one  case  of  tracheal  stenosis  in  which  he  operated 
with  striking  success,  he  found  that  the  severed  trachea  was  sufficiently  mobile  to 
admit  of  its  being  pulled  up  and  united  to  the  j^arts  left  about  the  hyoid  bone. 

A  preliminary  tracheotomy  is  performed.  The  larynx  is  removed  by  the  steps 
already  given,  it  being  essential  to  retain  the  epiglottis  and  arj'teno-epiglottidean 
folds.  All  ha-morrhage  having  been  completely  arrested,  the  mucous  membrane 
on  the  posterior  aspect  of  the  severed  trachea  or  the  cricoid  cartilage,  according  to 
the  site  of  division,  is  united  to  the  aryteno-epiglottidean  folds.  Anteriorly  some 
of  the  sutures  taking  up  the  air  tube  below  pass  around  the  hyoid  bone,  beneath 
the  mucous  membrane,  and  also  the  base  of  the  epiglottis,  in  order  to  prevent  re- 
traction. The  sutures,  mostly  of  sterilised  catgut,  are  introduced  from  behind 
forwards,  and  none  are  tied  until  all  are  inserted.  Tension  on  the  deep  sutures  is 
relieved  by  drawing  together  the  soft  part  with  silk  sutures  where  this  is  practicable. 
Two  iodoform  drains  are  emplo3"ed,  and  the  skin  wound  is  sutured.  Immobilisation 
of  the  head  was  not  found  necessary. 

1  Ann.  de  Mai.  de  VOreille,  d-c,  1905,  t.  xxxi,  p.  375. 
^  Loc.  supra  cit.,  pt.  ii,  p.  165. 


EXTRA-LARYKGEAL  OPERATIONS  590 

In  ii  caso  in  which  \'.  Hippcl  tried  (his  metliod  the  upper  end  of  the  trachea 
sloughed  from  ulceration  and  infection  ;   the  ])atient  ultimately  recovered. 

Operation  in  Cases  o£  Extrinsic  Malignant  Disease  involving  the 
Pharynx  extensively.  If,  aftci-  ciucl'iil  coiisidciatioii  of  the  ca.se,  the 
vitality  of  the  patient  aiul  his  (k'cisioii  justify  resort  to  such  an  operation, 
the  following  are  the  hnes  on  which  Prof.  Gluck  ^  carried  it  out  : 

"  In  order  to  extirpate  the  larynx  with  the  pharynx,  I  expose  first  the  whole 
larynx,  and  ])lace  the  patient  so  that  the  head  hangs  down  over  the  edge  of  the 
table.  1  then  divide  the  mtMubrane  between  the  hyoid  bone  and  the  larynx,  and 
draw  the  larynx  forward  in  front  of  the  wountl.  The  inner  surface  of  the  ])harynx  is 
now  well  seen,  and  one  can  divide  without  diiticulty  the  side  walls  and  anterior  edge 
of  the  pharynx  straight  through  above  the  tumour.  Next  1  push  forward  into  the 
loose  tissues  between  the  pharynx  and  a>soj)hagus  and  the  vertebral  column,  and 
detach  the  pharynx  from  the  vertebral  column  till  I  have  reached  the  lower  pole  of 
the  tumour.  I  cut  the  oesophagus  straight  oif,  as  far  as  possible  below  the  tumour, 
and  then  loosen  the  oesophagus  from  the  trachea  for  a  short  distance.  The  larynx 
is  then  divided  from  the  trachea  as  in  laryngectomy,  and  the  tracheal  stump  pulled 
mider  the  skin-bridge  and  into  the  buttonhole  above  the  ejiisternal  notch,  where  it  is 
firmly  stitched.  The  wound  is  closed  towards  the  mouth  by  sewing  the  pharynx 
walls,  or,  if  one  has  cut  oif'  the  pharynx  very  high,  by  packing  with  iodoform  gaute. 
An  india-rubber  tube  is  placed  in  the  ajsojihagus."  Prof.  Gluck  draws  tlaj)s  of 
skin  together  by  sutures  over  gauze  ;  other  surgeons  leave  the  wound  open. 

The  edges  of  this  gradually  become  inverted,  and  the  granulating  surface  slowly 
covered  by  epithelium  until  a  deep  furrow  leads  fi'om  the  pharynx  above  to  the 
ffisophagus  below.  Narath  ^  advises  the  closure  of  this  by  a  plastic  operation  by 
double  tlaps,  as  in  Duplay's  operation  for  hypospacUas  (q.v.),  some  months  later 
to  convert  the  above  furrow  into  a  tube.  Two  flaps  are  marked  out  and  dissected 
upon  either  side  of  the  furrow.  They  are  then  turned  inwards  and  sutm-ed  in  the 
middle  line.  They  should  not  contain  any  hair  follicles.  Over  the  raw  surface 
of  these,  if  the  tissues  of  the  neck  are  sufficiently  lax,  two  other  flaps  are  guided 
inwards.  Further  operations  may  be  needed  for  iistulse  dating  to  failure  of  complete 
union. 

Mr.  W.  S.  Handley  has  recorded  a  case  of  complete  transverse  resection  of  the 
pharynx  with  laryngectomy  for  a  carcinoma  of  the  posterior  wall.^  The  patient 
was  a  woman  aged  44  years.  There  was  a  mass  of  fungating  growth  filling  up  the 
lower  outlet  of  the  j^harynx.  A  preliminary  gastrostomy  was  performed  and  a 
week  later  a  low  tracheotomy  was  done,  the  trachea  being  plugged  with  gauze 
above  the  tube.  An  incision  was  made  along  the  anterior  border  of  the  left  sterno- 
mastoid,  and  the  upj^er  end  of  the  oesophagus  was  exposed  :  at  the  root  of  the  neck 
it  was  free  from  growth.  The  left  lateral  incision  was  then  prolonged  to  the  mastoid 
process,  and  from  the  angle  of  the  jaw  on  the  right  side  a  second  incision  was  carried 
downwards  and  inwards  to  join  the  first  one  at  right  angles.  After  identifying  and 
freeing  the  two  superior  larjaigeal  nerves  the  jihai-jTix  was  opened  by  dividing  the 
thyro-hyoid  membrane.  The  insertion  of  a  finger  then  showed  that  it  would  be 
impossible  to  separate  the  growth  from  the  larjoix.  The  pharynx  was  then  divided 
above  the  level  of  the  growth.  The  whole  mass  could  now  be  pulled  forward,  and 
was  removed  by  cutting  through  the  trachea  and  oesophagus  as  low  down  as  possible, 
after  ligature  and  division  of  the  isthmus  of  the  thyi-oid.  The  infiltrated  left  lobe 
of  the  thyroid  was  removed  in  one  piece  with  the  larynx  and  pharynx.  The  trachea, 
the  oesoj^hagus,  and  the  remaining  upper  part  of  the  pharynx  were  respectively  closed 
by  sutures.  A  drainage-tube  was  inserted,  lying  in  the  line  between  the  right  and 
left  angles  of  the  mandible.  The. flaps  were  replaced  and  the  wound  sewn  up.  As 
Mr.  Handley  remarks,  the  operation  is  a  terrible  one,  and  is  to  be  offered  not  urged. 
This  is  true  of  this,  and  of  many  of  the  other  operations  described  in  this  and  the 
preceding  chapters. 

Trans-hyoid  Pharyngotomy.  This  operation  is  indicated  in  a  few 
cases  of  extrinsic  malignant  disease,  e.g.  those  where  the  mischief  originates 

^  Loc.  supra  cif. 

2  Arch.f.  Klin.  Chir.,  Bd.  Iv,  S.  840. 

'  Proc.  Roy.  Soc.  Med.,  Clin.  Sec,  vol.  i,  p.  60. 


600  OPERATIONS  ON  THE  HEAD  AND  NECK 

in  the  region  of  the  epiglottis,  aryteno-epiglottidean  folds,  and  is  limited 
to  these  parts.     The  operation  is  described  at  p.  558). 

Palliative  Tracheotomy.  This  may  be  indicated  in  cases  unsuited  to 
attempts  at  extirpation,  or  where  a  patient  declines  these,  with  the  object 
of  retarding  the  rate  of  the  disease  and  preventing  or  relie\"ing  dyspnoea. 
The  chief  guides  are  the  general  condition  and  vitality  of  the  patient  (p. 
593)  and  the  extent  of  the  disease, e.gr.  to  the  pharynx  widely,  epiglottis  and 
back  of  tongue,  with  evidence  of  infiltration  and  involvement  of  glands. 
While  the  rehef  given  at  first  may  be  decided,  the  closing  scene  is  often 
distressing,  as  when  ulceration  of  the  soft  parts  takes  place,  or  when,  owing 
to  the  downward  extension  of  the  growth,  the  tracheotomy  tube  becomes 
a  source  of  constant  irritation  and  distress,  though  absolutely  necessary 
for  respiration.  In  such  cases,  where  the  suffocative  cough  and  dyspnoea 
cannot  be  reheved  by  other  means,  the  question  of  laryngectomy  may 
arise  after  a  palliative  tracheotomy  has  been  performed.^ 

After-treatment.  As  the  best  of  all  positions,  the  prone,  is  rarely 
endured,  the  foot  of  the  bed  may  be  raised  for  a  day  or  two.  The  inspired 
air  should  be  kept  moist  by  means  of  a  steam  kettle.  Discharges  must 
be  prevented  from  entering  the  trachea  by  packing  gauze  round  the  tube. 
Nourishment  must  be  supplied  for  the  first  week,  or  mitil  the  deeper  part 
of  the  wound  is  consolidated,  by  a  soft  tube  passed  either  from  the  nose 
or  mouth.  If  the  repairing  sutiures  in  the  pharynx  give  way,  the  use  of 
the  tube  will  be  more  prolonged.  Feeding,  save  for  the  first  few  hours, 
by  enemata  alone  is  not  reliable,  considering  the  debilitated  condition 
of  these  patients  and  the  profound  shock  which  accompanies  the  operation. 
When  the  wound  is  consolidated,  the  patient  should  be  encouraged  to 
take  some  semi-solid  food  by  the  mouth,  liquid  food  thus  taken  having 
a  greater  tendency  to  get  into  the  womid.  Thirst  must  be  met  by  ice 
in  the  mouth  and  sips  of  sterile  water.  The  temperature  of  the  room 
should  be  from  65-70°.  Morphia  should,  if  possible,  be  avoided.  Se- 
cretion and  coughing  may  be  diminished  by  giving  small  doses  of  bella- 
donna . 

An  artificial  larynx  has  been  tried  but  has  met  with  but  indifferent  success. 
It  consists  of  three  parts,  a  lower  tracheal  and  an  upper  or  laryngeal  tube,  which 
lies  in  the  phar^Tix  and  contains  some  form  of  vibrator  or  reed.  As  a  rule  the  artificial 
lar^^lx  has  been  found  to  be  liable  to  the  followiiig  objections.  Irritation  is  produced 
bj^  pressure  at  a  spot  where  all  pressure  is  especially  to  be  avoided  ;  the  vocal 
vibrator  is  liable  to  produce  a  sound,  often  noticeable  and  "^vhistling  with  every 
respiration.  It  often  becomes  obstructed  with  mucus  and  saliva,  and  prolonged 
attempts  at  talking  with  such  apparatus  prove  exhausting  from  difficulty  in  breathing. 
The  patient  is  better  content  with  a  whispered  voice,  and  the  use  of  a  writing 
pad. 

Dangers  and  Causes  of  Death.  These  will  have  been  gathered  from 
the  details  already  given.  It  may  be  well  to  recapitulate  the  chief  ones  : 
(1)  Shock.  (2)  Exhaustion.  (3)  Broncho-pneumonia,  abscess  and  gan- 
grene of  the  lung,  and  empyema.  The  first  two  weeks  are  said  to  consti- 
tute the  chief  period  of  danger  from  lung  complications.  (4)  Infective 
conditions,  e.g.  septicaemia,  toxaemia,  cellulitis,  mediastinitis.  (5)  Second- 
ary haemorrhage.  (7)  Displacement  of  the  tracheotomy  tube.  (7)  In 
some  cases  a  rapidly  fatal  result  has  followed  when  all  has  seemed  to  be 
doing  well,  perhaps  from  impulses  conveyed  along  the  cardiac  fibres  of  the 
vagus,  from  changes  in  the  cut  superior  laryngeal  nerves,  or  in  branches 
between  the  sj^mpathetic  and  vagus  of  which  but  httle  is,  at  present, 
^  See  a  ease  rejjorted  by  Sir  H.  Morris  {Trans.  Clin.  Soc,  vol.  xx,  p.  37). 


EXTRA-LARYNGEAL  OPERATIONS  COl 

known.  (8)  Stenosis  from  cicatricial  contraction.  (9)  Other  risks  in- 
separable from  operations  in  which  an  attempt  is  made  to  extirpate  in- 
filtrated and  adherent  epitheliomatous  glands  in  the  neck.  Finally 
other  dangers  inseparable  from  laryngectomy  in  some  patients  must  be 
remembered,  viz.  the  visceral  and  vascular  changes  usually  present,  and 
the  mental  misery  from  the  isolation,  the  discomfort,  and,  at  times,  the 
degree  of  inanition  daily  from  the  escape  of  liquids  where  the  pharynx  has 
been  extensively  extirpated,  and  where  the  repairing  sutures  have  not 
held,  or  where  a  plastic  operation  has  failed. 

Otlior  Indications  for  Laryngectomy.  These  will  be  extremely  rare.  The 
operation  has  however  been  performed  for  tertiary  syphilitic  disease,  for  necrosis 
of  the  laryngeal  cartilages,  for  an  enormous  myxotibrochondroma  of  the  hyoid  and 
larynx,  and  also  in  the  course  of  an  operation  for  a  recurrent  carcinoma  of  the  thyroid 
gland. 


CHAPTER   XXVIII 

REMOVAL  OF  FOREIGN  BODIES  FROM  THE  UPPER  AIR 
PASSAGES  AND  FROM  THE  (ESOPHAGUS 

It  is  no  exaggeration  to  say  that  Avdthin  the  last  ten  years  this  branch 
of  surgery  has  been  completely  revolutionised  by  the  introduction  of  direct 
vision  tubes  for  diagnosis  and  treatment  by  Killian,  of  Bonn  :  the  original 
tubes  have  been  considerably  modified  and  improved  by  Briinings  and 
others.  Before  the  introduction  of  these  methods  the  death-rate  was 
extremely  high  :  as  a  result  of  their  use  the  mortality  has  been  strikingly 
reduced. 

FOREIGN  BODIES  IN  THE  AIR-PASSAGES 

The  variety  of  foreign  bodies  which  may  be  met  with  is  great.  Among 
these  may  be  mentioned  pins,  portions  of  tracheotomy  tubes,  especially 
ill-made  ones  and  tubes  worn  for  too  long  a  time,  beans,  pebbles,  fruit- 
stones,  parts  of  toy  whistles,  pieces  of  nutshell,   &c. 

Site  of  lodgment.  In  the  pharynx  foreign  bodies  may  be  caught  in 
the  vallecula  (the  fossse  bounded  by  the  glosso-epiglottidean  folds,  between 
the  tongue  and  the  epiglottis),  and  the  sinus  pyriformis  ;  in  the  larynx, 
between  the  vocal  cords  ;  in  the  trachea  ;  and  in  the  right  bronchus,^ 
rather  than  the  left,  owing  to  the  larger  size  of  the  former,  and  the  fact 
that  the  septum  is  a  little  to  the  left  of  the  mid-line. 

Evidence  of  a  Foreign  Body  having  lodged  in  a  Bronchus.  Perhaps 
there  may  be  a  history  of  a  foreign  body  having  been  held  in  the  mouth, 
though  in  the  case  of  a  child  no  history  may  be  obtainable  ;  there  may  be 
dull  heavy  pain  behind  the  sternum  at  about  its  junction  with  the  right 
costal  cartilage.  There  will  also  be  shortness  of  breath,  cough,  and 
expectoration.  On  examining  the  chest  there  \\ill  be  more  or  less 
diminution  of  breath  sounds  over  a  portion  of  the  chest  wall  ;  -  increased 
breath  sounds  on  the  opposite  side,  rales,  and  later  on  evidence  of  in- 
flammation and  destruction  of  lung  tissue.^ 

An  X-ray  examination  should  always  be  carried  out,  though  the 
foreign  body  may  be  transparent  to  the  rays  and  hence  not  show  on 

1  While  this  is  the  rule.  Dr.  Cheadle  and  Sir  T.  Smith  reported  {Lancet.  January  14, 
1888)  a  case  of  occlusion  of  the  left  bronchus  by  a  metal  pencil  cap  in  a  girl  aged  9.  Urgent 
dysjanoea  followed  at  once,  there  was  great  pain  at  the  time  and  violent  cough.  By  the 
eleventh  day  there  was  evidence  of  almost  complete  collapse  of  the  left  lung,  this  having 
commenced  on  the  fourth  day.  There  was  no  dyspnoea  but  occasional  short  cough.  The 
cap  was  believed  to  have  lodged  in  the  left  bronchus.  Tracheotomy  was  performed  and 
the  trachea  freely  opened.  A  long  probe  detected  the  cap  in  the  position  diagnosed,  with 
the  open  end  uppermost.  It  was  easily  extracted  with  suitably  curved  forcei^s.  A  good 
recovery  followed. 

^  Obstruction  of  the  left  bronchus  usually  produces  absence  of  breath  sounds  over  the 
entire  left  lung,  but  occlusion  of  the  right  bronchus  usuallj'  produces  absence  of  breath 
sounds  over  the  right  lower  lobe  only,  the  division  of  that  bronchus  taking  place  much 
nearer  the  bifurcation,  and  the  foreign  body  rarely  lodging  above  the  point  of  division. 

^  In  the  case  of  a  foreign  body  in  the  trachea  there  will  veiy  hkely  be  spasmodic  attacks 
of  coughing  during  which  the  body  may  be  felt  to  be  forcibly  driven  against  the  under- 
surface  of  the  vocal  cords. 

602 


FOREIGN  BODIKS  IN  AIR-PASSAGES  603 

screen  or  plate.  It  must  be  renieinbered,  too,  that  a  small  opacjiu;  b<Kly, 
such  as  a  piece  of  bom*  or  tlie  root  of  a  tooth,  may  not  show  owing  to  its 
small  size  and  deep  situation.  Another  important  point  to  bear  in  mind  is 
that  though  the  foreign  hotly  may  be  supposed  to  be  in  the  air-passages 
it  may  be  in  the  oesophagus,  and  vice  versa.  A  body  which  the  patient 
describes  as  having  been  swallowed  may  have  really  been  drawn  down 
into  the  trachea,  and  one  thought  to  have  been  inhaled  may  have  been 
swallowed.  In  either  case  there  may  for  a  consid(;rable  time  be  an 
absence  both  of  symptoms  and  physical  signs,  or  these  may  be  anomalous. 

Foreign  bodies  entering  the  lung  by  perforation  of  the  chest  wall  may 
become  surrounded  by  a  capsule  of  fibrous  tissue  and  give  rise  to  no 
further  serious  symptoms,  but  when  entering  by  the  air-passage  they 
almost  invariably  set  up  some  septic  trouble,  such  as  septic  broncho- 
pneumonia, purulent  bronchitis,  abscess,  gangrene,  bronchiectasis,  or 
empyema  :  actinomycosis  may  be  caused  by  the  inhalation  of  some 
foreign  body  such  as  an  ear  of  corn  or  a  carious  tooth.  Garre  and 
Quincke  ^  classify  the  treatment  of  foreign  bodies  in  the  lungs  and 
bronchi  as  follows  :  (1)  Alleviation  of  expectoration  by  position,  external 
majiipulation  and  emetics.  (2)  Extraction  of  the  foreign  body  by 
bronchoscopy.  (3)  Low  tracheotomy.  (4)  Interthoracic  tracheotomy 
immediately  above  the  bifurcation  of  the  trachea.  (5)  Bronchotomy 
from  the  posterior  mediastinum.     (6)  Pneumobronchotomy. 

It  will  be  best  first  to  describe  the  old  method  of  treatment,  as,  if  the 
special  instruments  described  below  are  not  available,  this  is  the  only 
way  of  deahng  with  these  cases.  In  any  case,  should  a  foreign  body 
such  as  a  piece  of  bone  or  a  bolus  of  food  become  impacted  in  the  larynx 
causing  urgent  dyspnoea,  an  immediate  laryngotomy  or  tracheotomy  must 
be  done  at  once,  and  the  foreign  body  be  extracted  later  by  one  of  the 
methods  described  below. 

If  the  foreign  body  is  in  the  trachea  or  a  bronchus  a  low  tracheotomy 
(see  p.  567)  should  be  performed,  with  as  free  an  opening  as  possible. 
The  edges  of  the  wound  in  the  trachea  should  be  held  open  and  the  patient 
be  allowed  to  come  round  from  the  anesthetic,  when  attempts  can  be  made 
to  excite  attacks  of  coughing  by  inserting  a  probe,  with  the  hope  that  the 
body  may  be  expelled.  If  provided  with  suitable  instruments  the  surgeon 
may  at  once  proceed  to  attempts  at  extraction,  but  it  is  well  to  remember 
that  in  a  large  proportion  of  cases  that  have  done  well  after  this  operation 
that  expulsion  has  not  been  effected  until  some  time  afterwards.  When- 
ever a  fit  of  coughing  brings  the  body  into  view,  the  next  inspiration  will 
draw  it  back  again,  so  that  careful  watching  and  prompt  use  of  forceps,  &c. , 
will  be  required.  If  from  its  shape,  or  from  the  interval  which  has  elapsed, 
the  body  is  too  firmly  impacted  to  be  expelled  by  exciting  coughing, 
the  following  instruments  may  be  resorted  to,  viz.  Gross's  flexible 
German  silver  tracheal  forceps,  long  and  slender  and  easily  bent  into  any 
curve  ;  or  Durham's  forceps,  equally  flexible  and  giving  a  better  grip. 
Another  forceps  which  has  proved  itself  most  useful  in  these  cases  is 
Tait's  alligator  forceps. 

Mr.  R.  Anderson,  of  Nottingham,  has  recorded  a  case  in  which  a  nail  was  removed 
from  the  right  bronchus  in  a  child  aged  2i  years  by  means  of  these  forceps. 2  Mr. 
W.  M.  Willis  3  mentions  another  case  in  which  the  same  forceps,  after  a  low  trache- 
otomy in  a  child  aged  7  years,  quickly  removed  a  fruit  stone  from  the  right  bronchus. 

1  Loc.  inf.a  cit.  2  jjrif^  Med.  Journ.,  April  12,  1902. 

3  Lancet,  1904,  vol.  ii,  p.  1641. 


604 


OPERATIONS  ON  THE  HEAD  AND  NECK 


Failing  the  above,  stout  silver  vnre  should  be  bent  into  the  form  of 
a  blunt  hook,  or  a  long  probe  fashioned  into  the  same  shape.  The  above 
instruments  are  first  used  as  sounds  and  searchers,  aided  by  the  forefinger, 
which  can  be  passed  as  far  as  the  bifurcation  of  the  trachea  and  the  orifice 
of  each  primary  bronchus,  as  pointed  out  by  Dr.  Sands. 


Oil, 


■V! 


Fig.  258.  A,  Lens.  B,  Parallel  rays 
of  light  concentrated  by  the  lens  and 
thrown  by  the  mirror  along  the  inner 
tube.  C,  Screw  for  adjusting  lens.  D, 
Perforated  mirror.  E,  Screw  for  adjust- 
ing miri'or.  F,  Screw  which  forms  the 
axis  about  which  the  mirror  rotates. 
G,  Spring  for  securing  (I)  in  position. 
H.  Holder  for  mirror,  which  can  be 
rotated  around  the  axis  of  the  screw  F' 
to  allow  of  cleaning  the  mirror  and 
access  to  the  lamp.  I,  Rod  for  adjust- 
ment of  hand-light  to  handle.  J,  Screw 
for  securing  tube  spatula.  K,  Handle. 
L,  Watch  spring  of  inner  tube.  M, 
Lamp.  N,  Switch.  O,  Eye  piece. 
P,  Terminals. 


The  operation  should  not  be  too  prolonged  especially  if  the  parts  are 
inflamed.  When  this  condition  has  subsided,  spontaneous  expulsion 
will  often  take  place. 

Direct  vision  Laryngoscopy  and  Bronchoscopy.^  This  method  should 
always  be  adopted  for  the  localisation  and  extraction  of  foreign  bodies, 
except  in  those  cases  where  the  severity  of  the  dyspnoea  calls  for  immediate 

^  A  very  large  number  of  cases  treated  by  this  method  have  now  been  recorded. 
Reference  to  the  Proc.  Lar.  Sec.  Boy.  Soc.  Med.  during  the  past  five  or  six  years  will 
provide  numbers  of  illustrative  cases.  Gottstein  (Uber  die  Diag.  u.  Ther.  der  Fremd- 
korper  in  den  imteren  Lushvegen  Mitt.  a.  d.  Grenzgeb.  d.  Med.  w.  Chir.,  Jena,  1907)  gives 
an  account  of  1.35  cases  ;  while  Killian  {Direct  Tracheobronchoscopy,  Ann.  Otol.  Rhin.  and 
Lar.,  New  York.  June  1907)  has  collected  159  cases.  Killian  points  out  the  importance 
of  distinguishing  clinically  between  hard  foreign  bodies  and  soft.  The  latter  are  liable 
to  swell,  completely  block  the  air-passage  and  cause  pneumonia. 


FOREIGN  I^ODIES  IN  AIR-PASSAGES  605 

laryii<i;()t()my  or  trachootoniy.  This  means  of  (lia<2;nosis  and  treatment 
was  put  on  a  thoroughly  practical  footing  by  Killian,  but  his  original 
instruments  have  been  modified  and  improved  by  Ikuiiing,  and  the 
modern  apparatus  bears  the  name  of  the  latter. 

Brlining's  apparatus  consists  of  the  following  parts,  (a)  The  tubular 
spatula  (Fig.  259),  which  slides  over  the  dorsum  of  the  tongue  and  the 
epiglottis  aiul  then  can  be  made  to  enter  or  to  pass  through  the  larynx. 
Various  lengths  and  sizes  are  supplied,  each  of  which  can  be  firmly  screwed 
to  the  handle  by  means  of  which  the  instrument  is  manipulated. 

(6)  Tlie  /land  light,  which  is  attached  to  the  handle  by  which  the  whole 
instrument  is  controlled.  The  arrangement  of  this  will  be  understood 
on  reference  to  Fig.  258.  The  lamp  from  a  powerful,  electric  lamp 
is  concentrated  by  a  lens  and  thrown  on  to  a  perforated  mirror,  from 
which  it  is  reflected  along  the  centre  of  the  tubular  spatula,  when  the 
latter  is  screwed  in  position.  Both  lens  and  mirror  can  be  adjusted  by 
screws  so  as  to  ensure  the  light  being  thrown  in  the  right  direction.  The 
operator's  eye,  looking  through  the  perforation  in  the  mirror,  can  thus 
see,  with  a  good  light,  the  structures  at  the  end  of  the  tube  spatula. 

(c)  The  inner  tubes  (Fig.  260).  These  are  of  different  lengths  and 
of  various  diameters  corresponding  to  the  diameters  of  the  spatulse. 
Each  inner  tube  is  provided  with  a  piece  of  watch  spring,  which,  when 
the  inner  tube  is  introduced  through  the  spatula,  rests  in  a  groove  in 
the  wall  of  the  latter.  Both  the  watch  spring  and  the  spatula  are  graduated, 
so  that  the  distance  to  which  the  tubes  have  been  introduced  can  easily 
be  ascertained. 

Indications  for  direct  vision  Laryngoscopy  and  Bronchoscopy.  (1)  For 
the  diagnosis  of  diseases  of  the  larynx,  especially  growths.  Portions  of 
doubtful  material  may  be  removed  by  means  of  cutting-forceps  for 
histological  examination. 

(2)  For  the  treatment  of  growths  of  the  larynx,  e.g.  the  removal  of 
papillomata  or  of  polypi. 

(3)  For  the  diagnosis  and  treatment  of  foreign  bodies  in  the  larynx, 
trachea,  or  bronchi. 

(4)  For  the  diagnosis  of  certain  diseases  of  the  trachea  and  bronchi,  e.g. 
bronchial  and  tracheal  fistulae  and  ulcerations,  also  carcinoma  of  the  bronchi. 

(5)  For  the  intra-tracheal  insufflation  of  ether. 

Indications  for  direct  vision  (Esophagoscopy.  (1)  For  the  diagnosis 
and  treatment  of  foreign  bodies  in  the  pharynx  (including  the  sinus 
pyriformis)  and  the  oesophagus. 

(2)  For  diagnostic  purposes,  e.g.  strictures,  malignant  or  otherwise, 
pouches. 

(3)  For  purposes  of  treatment,  e.g.  the  dilatation  of  fi.brous  strictures. 

Anaesthetic.  It  is,  of  course,  essential  that  while  using  these  instru- 
ments there  shall  be  no  movements  of  the  patient.  In  some  adults  it  is 
possible  to  introduce  the  tubes  and  examine  larynx,  trachea,  and  bronchi 
after  effective  application  of  cocaine  ^  to  the  pharynx  and  larynx.  These 
parts,  however,  are  exceedingly  sensitive,  and  hence,  even  in  adults,  it  is 

1  Novocain  or  alypin  are  also  recommended  as  being  less  toxic.  If  the  patient  is  not 
under  the  influence  of  a  general  anaesthetic,  10  or  20  per  cent,  cocaine  to  which  a  httle 
adrenahn  hydrochloride  (1  in  1000)  has  been  added  should  be  deUberately  painted  over 
the  back  of  the  pharynx,  the  superior  aperture  of  the  larynx  and  the  vocal  cords,  by  means 
of  a  laryngeal  brush  and  a  laryngeal  mirror.  If  the  patient  is  anaesthetised  the  brush  is 
guided  by  a  finger  pushed  over  the  dorsum  of  the  tongue.  Owing  to  the  sensitiveness  of 
the  larynx  cocaine  is  always  necessary,  even  when  a  general  anaesthetic  is  given. 


606 


OPERATIONS  OX  THE  HEAD  AND  NECK 


generally  more  satisfactory  to  administer  cUoroform  in  addition  to  the 
local  application  of  cocaine.  In  children  chloroform  is  always  necessary 
and  here  it  must  be  remembered  that  a  comparatively  small  amomit  of 
cocaine  may  have  toxic  effects  in  children.  If  dyspnoea  is  present 
oxygen  may  be  given  with  the  chloroform.  Tracheotomy  instruments 
should  always  be  to  hand,  though,  owing  to  the  fact  that  the  tubes  hold 
the  air-passage  widely  open,  obstruction  to  breathing  is  seldom  met  ^^'ith. 
Position  of  the  patient.  The  dorsal  position,  with  the  head  slightly, 
but  not  too  much,  extended  is  best.     The  lateral  position  is  equally 

satisfactory.  In  either  case  the 
operator  should  be  provided  with 
a  low  stool  which  enables  him, 
without  undue  strain,  to  bring  his 
eye  to  the  level  of  the  tubular 
Fig.  2o9.  "Cj       spatula.     For  a    short    examina- 

tion under  local  anaesthesia  alone,  the  patient  should  sit  on  a  low  stool  while 
the  operator  introduces  the  tube,  standing  in  front  of  the  patient. 

Examination  oJ  the  Larynx  and  the  Bronchi.  A  tubular  spatula  of 
suitable  size  having  been  .selected  and  screwed  to  the  handle,  and  the 
apparatus  having  been  tested  to  ensure  that  all  parts  are  in  working 
order,  and  that  the  mirror  and  tube  are  accurately  adjusted,  the  mouth 
is  widely  opened  by  a  gag  and  the  spatula  passed  in  the  middle  hue  over 
the  dorsum  of  the  tongue.  During  this  and  the  whole  of  the  manipulation 
care  must  be  taken  to  avoid  injury  to  the  upper  lip  and  incisor  teeth. 
The  epiglottis  soon  comes  into  view  and  the  spatula  is  made  to  pass  over 
its  free  border.     By  pressing  the  spatula  forwards  the  aryteno-epiglotti- 


FiG.  260.     A,  B,  C,  Obturators  for  cesophageal  tubes.     0-H,  Extending  tubes 
for  cesophagoscopy  and  bronchoscopy. 

dean  folds  and  the  vocal  cords  come  into  view  and  the  instrument  is  then 
pushed  onwards  through  the  superior  aperture  of  the  larynx.  At  this 
stage  the  vocal  cords  and  the  larynx  may  be  examined  \\ith  dehberation, 
and  any  foreign  body,  growth,  or  other  disease  can  be  detected  and  its 
position  and  extent  ascertained.  It  will  also  be  possible  to  see  the  whole 
length  of  the  trachea  and  its  bifurcation.  The  narrow  extremity  of  the 
spatula  is  then  directed  backwards  and  is  pressed  onwards  between  the 
posterior  extremities  of  the  vocal  cords  into  the  trachea.^    Care  must  now 

1  If  there  is  any  difficulty  in  passing  the  spatula  through  the  glottis  it  may  be  rotated 
through  a  right  angle,  so  that  the  long  diameter  of  the  end  corresponds  with  the  antero- 
posterior diameter  of  the  glottis.     The  spatula  is  then  rotated  to  its  original  position. 


FOREIGN  JiUDIKS  IN  AI1M\\SSAGES 


007 


be  taken  tliat,  as  the  spatula  is  pushed  onwards,  it  passes  aloiij,'  the 
lumen  of  the  trachea  and  is  not  forced  against  its  walls.  The  bifurcation 
of  the  trachea  will  now  be  clearly  seen  and  also  the  right  main  bronchus. 
If  further  exploration  of  the  bronchi  is  required  a  suitable  inner  tube  must 
be  introduced  through  the  spatula  and  on  into  one  or  both  bronchi. 
To  explore  a  bronchus  this  nuist  be  brought  approximately  into  line 
with  the  spatula  and  the  trachea.  To  do  this  in  the  case  of  the  left  bron- 
chus the  upper  end  of  the  spatula  nmst  be  pressed  over  to  the  right  corner 
of  the  patient's  mouth,  and  in  the  case  of  the  right  bronchus  it  must  be 
pressed  over  to  the  left  side.  In  this  way  the  divisions  of  each  bronchi 
to  the  pulmonarv  lobes  may  be  brought  into  view  and  explored  and  also 


ALLEN  tc 


HANBUHYS 


Fig    261.     1.   Cutting  ends  for  removing  growths,   &c.     2,   Cross  action  for 

removing  hollow  bodies,  &c.     3,  For  removing  needles,  &c.     4,  Oval-shaped,  for 

''removing  bean-shaped  foreign  bodies,     o,  Claw-ended  forceps. 

their  larger  subdivisions.  Considerable  difficulty  may  be  met  with  in 
identifving  the  division  of  the  right  bronchus  which  passes  to  the  upper 
lobe  of  the  right  lung  :  this  leaves  the  main  bronchus  almost  at  a  right 
angle,  just  beyond  the  bifurcation  of  the  trachea. 

The  bronchi  can  also  be  explored  by  Briining's  tubes  introduced 
through  a  tracheotomy  wound,  either  specially  done  for  the  purpose,  or 
on  account  of  urgent  dvspnoea.  This  is  kno^ra  as  the  "  lower  "  method 
of  bronchoscopv.  The"  instrument  should,  generally  speaking,  be  intro- 
duced through  the  mouth  and  the  lower  method  reserved  for  cases  where  a 
tracheotomv  has  already  been  done. 

Extraction  of  a  ForeignBody.  The  foreign  body  having  been  brought  into 
view  it  should  be  extracted  by  means  of  Briining's  forceps.  These  are 
of  sufficient  length  to  pass  through  the  whole  length  of  the  spatula  and 
inner  tube  and  can  be  used  under  the  eye  of  the  operator  looking  through 
the  perforated  mirror.  The  instrument  consists  of  a  solid  rod  passing 
through  a  hollow  tube.  Forceps  of  various  shapes  appropriate  to  the 
nature  of  the  body  can  be  screwed  to  the  end  of  the  rod  (Fig.  261).  Thi^ 
there  is  a  ^^llsellum  forceps  for  grasping  small  sohd  bodies,  "  bean  " 
forceps  for  grasping  soft  bodies,  forceps  for  hollow  bodies,  a  hook  for 
encircling  projections  from  irregular  bodies,  scoop-forceps  for  removing 
portions^'of  growths,  &c.  for  examination.  Withdrawal  of  the  rod 
through  the  tube  closes  the  forceps,  while  pushing  the  rod  onwards  allows 
the  jaws  to  separate.  A  small  body  may  at  once  be  drawn  through  the 
tube  while  a  larger  body  may  be  displaced  and  drawn  against  the  inner 
tube  and  then  is  gradually  wlthdraw^l  as  this  is  removed.     If  the  field  of 


608 


OPERATIONS  OX  THE  HEAD  AND  NECK 


operation  is  obscured,  as  it  very  likely  will  be  by  pus,  mucus,  or  blood, 
small  pieces  of  sterilised  wool  may  be  fixed  to  the  forceps  and  used  as 
swabs. 

During  the  whole  manipulation  every  care  must  be  taken  to  avoid 
the  use  of  undue  force,  or  serious  laceration  of  the  bronchi  may  occur  and 
extraction  be  rendered  still  more  difficult  by  the  bleeding  thus  caused. 

Foreign  bodies  in  the  larynx  may  be  recognised  and  removed  through 
the  tubular  spatula  without  the  employment  of  an  inner  tube. 

If  attempts  at  extraction  fail  two  courses  are  open  :  (a)  To  do  a 
tracheotomy  in  the  hope  that  the  body  will  become  loosened  and 
that  it  will  subsequently  be  expelled  through  the  tracheotomy  wound 
during  a  fit  of  coughing  ;  (6)  To  remove  the  foreign  body  by  mediastinal 
bronchotomy,  or  to  open  the  pleural  cavity  and  reach  the  body  by  in- 
cising the  lung  {see  Operations  on  the  Lmig  and  Mediastinum,  p.  792). 
The  latter  very  serious  steps  viiW.  not  be  midertaken  ^^^thout  a  careful 
consideration  of  the  nature  of  the  foreign  body,  the  time  it  has  been 
in  the  bronchus,  the  evidence  of  abscess  or  gangi'ene,  and  the  general 
condition  of  the  patient. 

Removal  of  Innocent  Growths  from  the  Larynx.  These  may  be  removed 
by  means  of  special  cutting-forceps,  introduced  through  the  tube  spatula. 
The  larynx  should  be  thoroughly  treated  with  cocaine  and  adxenahn 
applied  by  a  brush  through  the  spatula,  in  order  to  render  the  larj^nx 
insensitive  and  to  make  the  operation  bloodless. 

Removal  of  Foreign  Bodies  from  the  CEsophagus.  A  great  variety  of 
foreign  bodies  may  become  impacted  in  the  oesophagus.     Among  those 

more  frequently  met  with  may  be 
mentioned  toothplates,  pieces  of 
bone,  fish  bones,  and  coins.  A  great 
variety  of  foreign  bodies  may  be 
swallowed  by  children  _and  there 
may  be  the  same  difficulties  about 
the  diagnosis  of  these  as  mentioned 
in  the  case  of  foreign  bodies  in  the 
air-passages. 

Site  of  Impaction.  This  will 
usually  be  at  one  of  the  three  follow- 
ing places  :  (a)  behind  the  cricoid 
cartilage,  (6)  where  the  left  bronchus 
crosses  the  oesophagus,  (c)  at  the 
lower  end  of  the  oesophagus,  just 
above  the  diaphragm. 

Diagnosis.     There  will  usually  be 
dysphagia  and  pain,  and  there  may 
be  some  dyspnoea  gi\4ng  rise  to  some 
uncertainty  as  to  whether  the  foreign 
body  is  in  the  oesophagus  or  the  air-passages.     Later  there  will  be  ulcera- 
tion, suppuration,  and  eventually  perforation  with  an  abscess  or  celluhtis, 
deep  in  the  neck  or  in  the  mediastinum. 

Treatment.  Formerly  impacted  foreign  bodies  were  treated  by  the 
probang,  or  the  coin  catcher.  Though  coins  or  small  foreign  bodies  may 
be  extracted  or  pushed  downwards  into  the  stomach  by  these  means,  there 
is  a  serious  danger  of  laceration  of  the  oesophageal  wall  if  they  are  em- 
ployed for  large  or  irregular  substances,     A  remarkable  reduction  in  the 


Fig.  262.     Seizure  of  a  foreign  body  with 

the  aid  of  the  bronchoscope  (extension  of 

the  left  bronchus).     (V.  Eicken.) 


FOREIGN  B01)IP:S  IN  THE  (ESOPHAGUS  609 

mortality  of  these  serious  cases  has  resulted  from  the  use  of  Briining's 
oesophageal  tubes,  and  extraction  with  the  help  of  this  apparatus  must  be 
regarded  as  the  most  desirable  means  of  treatment.  Special  tubes 
are  made  of  varying  diameter  suitable  for  the  oesophagus  of  children  and 
adults,  and  some  are  of  sufficient  length  to  reach  to  the  lower  end  near  the 
cardiac  orifice  of  the  stomach.  The  tubes  are  graduated  so  that  the 
distance  to  which  they  are  introduced  can  be  easily  seen.  Similar  forceps 
to  those  used  for  the  bronchi,  but  longer,  are  constructed,  and  with  their 
help  foreign  bodies  can  be  loosened  and  withdrawn. 

No  special  description  of  the  mode  of  use  of  these  tubes  need  be  given 
as  it  closely  resembles  that  given  for  the  bronchi.  When  introducing  the 
tube  it  must,  of  course,  be  made  to  pass  across  the  superior  aperture  of 
the  larynx  and  then  behind  the  cricoid  cartilage. 

It  must  be  remembered  that  it  is  possible  to  push  the  tube  past  the 
foreign  body,  and  hence,  if  it  is  at  first  missed,'the  wall  of  the  oesophagus 
must  be  carefully  inspected  during  its  slow  withdrawal  as  well  as  during 
its  introduction. 

If  firmly  impacted  attempts  at  extraction  may  fail.  In  this  case 
extraction  by  oesophagotomy,  either  at  the  root  of  the  neck  or  through 
the  posterior  mediastinum,  must  be  employed.  These  severe  operations, 
which  will  only  be  undertaken  after  the  failure  of  simpler  means,  are 
described  at  pp.  649  and  792. 

An  irregular  foreign  body  such  as  a  tooth-plate  firmly  impacted  at 
the  lower  end  of  the  oesophagus  may  present  very  great  difficulties. 
Should  other  methods  not  be  successful  such  an  object  may  be  extracted 
by  opening  the  stomach,  seizing  the  foreign  body  by  means  of  suitable 
curved  forceps  introduced  into  the  oesophagus  through  the  cardiac 
orifice  of  the  stomach,  and  withdrawing  it  through  the  incision  in  the 
gastric  wall. 


SURGERY  I  39 


CHAPTER  XXIX 
OPERATIONS  ON  THE  THYROID  GLAND 

EXTIRPATION  OF  PART  OF  THE  GLAND.  ENUCLEATION  OF 
ENCAPSULED  TUMOURS.  LIGATURE  OF  THE  THYROID 
ARTERIES 

A  goitre  or  bronchocoele  is  the  term  generally  applied  to  an  enlargement 
of  the  thyroid  gland.  The  enlargement  may  be  due  to  one  of  the  following 
causes  :  (1)  General,  or  parenchymatous  enlargement.  Here  there  is 
generally  a  uniform  enlargement  of  the  whole  gland.  (2)  Adenomata. 
The  enlargement  is  usually  asymetrical  and  may  be  confined  to  one  lobe 
of  the  gland.  (3)  Cysts.  These  are  often  associated  wdth,  and  are 
probably  derived  from,  adenomata.  (4)  Exophthalmic  goitre,  or  Graves' 
disease.  (5)  Mahgnant  goitre,  generally  a  carcinoma,  but  occasionally 
a  sarcoma. 

Frequently  the  enlargement  is  due  to  a  combination  of  two  of  the 
above.  Thus  a  combination  of  parenchymatous  enlargement  with 
adenomata  or  cysts,  is  common,  and  mahgnant  disease  may  occur  in  a 
gland  which  already  contains  an  innocent  growth.  It  is  always  of  great 
importance  to  ascertain  the  cause  of  the  enlargement,  as  the  treatment 
and  the  prognosis  will  to  a  great  extent  depend  upon  this. 

Indications  for  Operation.  These  will  have  to  be  considered  in  detail 
for  each  of  the  above-mentioned  varieties,  but  the  indications  may  be 
summed  up  as  follows  :  (1)  Dyspnoea-  This  is  a  very  common  indication 
for  operative  treatment.  Several  varieties  may  be  distinguished  :  (a)  Short- 
ness of  breath  on  exertion,  (b)  Attacks  of  sudden,  suffocating  dyspnoea. 
A  goitre,  whether  it  be  moderate  in  size  or  large,  may  from  some  sudden 
engorgement  or  rupture  of  its  vessels  cause  sudden  and  even  fatal  dyspnoea. 
The  first  attack  may  then  prove  fatal. ^  The  following  ingenious  ex- 
planation of  these  attacks  has  been  given  by  Dr.  Hurry  :  Owing  to  the 
slowly  progressive  enlargement  of  the  thyroid,  the  dyspnoea  may  at  first 
be  very  shght ;  one  day  some  extra  exertion  calls  into  play  the  additional 
muscles  of  respiration,  e.g.  sterno-mastoid  and  infra-hyoid  muscles,  which 
pressing  on  the  trachea,  still  further  close  its  lumen,  already  narrowed  by 
the  progressive  increase  in  size.  This  brings  about  additional  dyspnoea, 
and  so  induces  more  vigorous  contraction  of  the  inspiratory  muscles,  and 
so  further  closure  of  the  trachea,  and  finally  fatal  dyspnoea.  Occasionally 
it  may  be  an  accessory  thyroid,  not  the  main  gland  itself,  which  is  the 
cause  of  the  dyspnoea,  and  perhaps  of  death.  Such  a  case  is  recorded 
by  Sir  J.  Bland  Sutton. ^ 

^  Thus  in  one  case,  a  woman  with  a  goitre  which,  so  far  as  was  known,  had  not  given 
previous  trouble,  waking  out  of  sleep  suddenly,  was  terrified  by  seeing  her  Uttle  child 
playing  with  a  lighted  piece  of  wood  taken  from  the  fire.  Most  urgent  dyspnoea  set  in. 
ancl,  before  surgical  relief  could  be  given,  death  took  place  from  suffocation. 

2  Lancet,  1895,  vol.  i.  p.  462. 

610 


PARENCHYMATOUS  GLAND  Oil 

A  man.  .not.  ,30.  was  found  lying  on  liis  back  in  a  street  adjoining  llie  Middlesex 
Hospital,  apparently  in  a  fit.  When  brought  in  by  the  jjolice  he  was  tlead.  At  the 
autopsy  an  accessory  thyroid  end)edded  in  a  thick  fibrous  capsule  was  fountl  firiidy 
fixed  to  the  trachea  from  the  fourth  to  the  ninth  cart ilages.  "j'hough  only  about 
tho  size  of  a  dove's  egg,  it  had  severely  compressed  the  trachea  and  caused  the 
fatal  dysi)na>a. 

In  otlior  cases  tlio  dyspnoea  may  render  it  impossible  for  the  patient 
to  sleep  lying  down. 

(2)  Dys'phagia,  especially  if  associated  with  other  indications. 

(3)  Steady  or  rapid  enlargement,  with  or  without  dyspnea,  if  the 
enlargement  be  in  a  downward  direction  so  as  to  become  substernal. 

(4)  Operation  may  be  called  for  on  account  of  deformity  apart  from 
other  symptoms. 

(5)  With  very  large  and  weighty  tumours  there  may  be  constant 
dragging  fain  in  the  neck. 

(6)  In  selected  cases  of  exophthalmic  goitre. 

(7)  Some  cases  of  parenchymatous  goitre  or  adenomata  where 
symptoms  of  hyperthyroidism,  such  as  palpitation,  cardiac  dilatation, 
or  muscular  weakness  and  tremor  are  present. 

(8)  Suitable  cases  of  malignant  goitre. 

Mr.  James  Berry  in  the  Lettsomian  Lectures  on  the  Surgery  of  the 
Thyroid  Gland  for  1913^  gives  the  following  Table  of  the  chief  reasons 
for  operation  in  a  series  of  351  cases  : 

Dyspnoea   .........     209  operations 

Deformity  .         .  .  .  .....       17  „ 

Discomfort  or  deformity  (with  minor  degrees  of  dyspntt^a)       57  ,, 

Malignant  or  papilliferous  tumours  .  .  .  .         9  ,, 

Suspected  malignancy  .  .  .  .  .  .3  ,, 

Dysphagia  ........  2  ,, 

Increasing  size     ........         3  ,, 

Typical  exophthalmic  goitre  .  .  .  .  .17  ,, 

Palpitation,  nervousness,  &c.,  mostly  with  dyspnoea  .       34  „ 

Parenchymatous  Goitre.  The  whole  gland  here  is  usually  uniformly 
enlarged.  As  is  well  known  medical  treatment  such  as  the  administration 
of  iodine,  potassium  iodide,  and  thyroid  extract  is  often  successful  in  these 
cases.     Only  a  small  proportion  will  therefore  require. surgical  treatment. 

The  special  indications  for  operation  in  these  goitres  will  be  : 
(a)  Failure  of  medical  treatment.  In  spite  of  careful  and  prolonged  treat- 
ment by  drugs  a  large  goitre  may  remain  stationary,  or  even  show  a  steady 
increase  in  size.  (6)  Dyspnoea.  A  large  parenchymatous  goitre  may 
cause  lateral  compression  of  the  trachea,  and,  as  Mr.  Berry  points  out, 
such  pressure  may  easily  lead  to  rapid  and  even  fatal  suffocation,  especially 
in  young  patients  about  the  age  of  puberty,  where  the  soft  and  yielding 
nature  of  the  tracheal  wall  readily  permits  of  collapse.  It  may  here  be 
pointed  out  that  the  amount  of  dyspnoea  does  not  necessarily  depend  upon 
the  size  of  the  goitre.  A  comparatively  slight  enlargement,  if  deep-seated 
and  especially  if  it  extends  behind  the  manubrium,  may  cause  the  most 
serious  dyspnoea.  Increase  of  size  in  a  downward  direction,  especially  if 
passing  behind  the  manubrium,  is  therefore  an  indication  for  operation, 
(c)  A  parenchymatous  goitre  may  require  operative  treatment  if  associated 
with  symptoms  of  hyperthyroidism  :  such  cases  have  to  be  carefully  dis- 
tinguished from  true  exophthalmic  goitre,     (d)  Operation  is  generally 

1  See  Lancet,  1913,  vol.  i.  pp.  583,  668,  737,  and  738.  These  lectures  should  certainly 
be  carefuUy  read  by  those  interested  in  this  subject. 


612 


OPERATIONS  ON  THE  HEAD  AND  NECK 


indicated  in  cases  of  adeno-parenchymatous  enlargement.  In  some  of  these 
cases  medical  treatment  may  cause  the  parenchymatous  enlargement  to 
diminish  and  so  render  ob\'ious  the  presence  of  a  previously  unsuspected 
cyst  or  adenoma. 

Cystic  and  adenomatous  goitres  may  be  considered  together.  Here 
medical  treatment  will  be  of  no  effect,  beyond,  perhaps,  diminishing 
any  parenchymatous  enlargement  which  may  also  be  present.     These 

tumours,  though  usually  growing  slowly 
and  often  remaining  stationary  for  many 
years,  may  reach  an  enormous  size. 
They  then  may  cause  excessive  displace- 
ment and  deformity  of  the  trachea  and 
the  larynx.  The  present  writer  recently 
rf--   ~^  ""^'^^ais,  ^^^  ^  ^^^®  ®^  ^^  enormous  adenomatous 

\V  -^^^^    ^^'^^■iiv  goitre  growing  from  the  right  lobe,  which 

y  ^^^^  lllll         ^^^  been  present  for  fifty  years,  and  had 

displaced  the  larynx  so  that  the  thyroid 
cartilage  was  rotated  through  a  right  angle 
and  could  be  felt  between  the  angle  of  the 
jaw  and  the  sternomastoid.  Generally 
speaking,  then,  the  treatment  of  this 
variety  of  goitre  is  essentially  operative, 
especially  if  any  symptoms  such  as 
dyspnoea  or  those  of  hyperthyroidism 
are  present.  Mr.  Berry  ^  advises  that  in 
young  children  operations  for  goitre 
should  not  be  performed,  unless  serious 
symptoms  are  present,  on  account  of  the 
serious  risk  of  interference  with  nutrition 
and  growth,  and  also  an  appreciable 
immediate  risk  to  life.  An  adenomatous 
goitre  in  an  elderly  patient,  unless  serious 
symptoms  are  present,  should  also,  as  a 
rule,  be  left  alone. 
Intrathoracic  goitres  may  also  be  mentioned  here  as  they  are  generally 
adeno-parenchymatous,  or  may  consist  entirely  of  adenomata  or  cysts. 

IVIr.  Berry,  in  his  series  of  351  cases  treated  by  operation,  had  no  fewer  than 
18  intrathoracic  goitres.  He  quotes  the  following  interesting  case.  "  A  gentleman, 
aged  62,  had  been  the  subject  of  slowly  increasing  stridor  and  dyspnoea  for  more 
tlaan  fifteen  years.  He  had  a  small  lump  low  down  on  the  left  side  of  the  neck, 
scarcely  visible  or  paljmble  except  diu'ing  deglutition.  A  skiagram,  however, 
revealed  the  fact  that  on  the  right  side  there  was  a  large  intrathoracic  mass.  It 
extended  as  low  as  the  level  of  the  sixth  rib  behind.  This  tumour  was  removed 
in  October  last  chiefly  by  means  of  a  large  scoop  and  an  ordinary  silver  tablespoon 
On  the  left  side  was  a  smaller  mass,  the  size  of  a  tangerine  orange,  which  was  also 
removed  from  the  thorax.  The  total  weight  of  the  two  masses  was  ten  ounces. 
I  saw  him  a  few  days  ago  and  found  him  in  robust  health,  without  a  trace  of  dyspnoea, 
and  he  is  now  enjoying  himself  on  a  tour  in  France." 

Exophthalmic    Goitre.     (Graves's  Disease,  Basedow's  Disease.)     The 

question  of  operative  treatment  of  exophthalmic  goitre  cannot  yet  be 
regarded  as  definitely  settled.  It  has  been  much  discussed  in  recent 
3^ears,  and  widely  divergent  views  have  been  expressed  by  different 
authorities  on  this  disease.     Probably  one  reason  for  this  is  that  cases 

1  Loc.  svpra  cit. 


Fig.  263.  This  figure  shows  one 
way  in  which  the  trachea  may  be 
narrowed  by  a  bronchocele,  and 
how  great  the  stenosis  may  be. 
If  in  addition  there  were  pressure 
on  the  opiJosite  recurrent  laryngeal 
nerve,  or  if  an  ant-estlietic  had  to 
be  given,  it  is  obvious  how  easily 
a  fatal  result  might  follow.  (Es- 
march  and  Kowalzis.) 


EXOPHTHALMIC  GOlTllE  013 

of  parenchymatous,  or  adcno-parenchymatoiKs,  goitre,  with  symptoms 
of  hyperthyroidism,  have  been  confused  with  true  exophthahiiic  goitre. 
As  has  ah-eady  been  pointed  out  such  cases  may  have  tacliycardia, 
palpitation,  tremor,  nervous  symptoms,  and  even  some  exophthahnos. 
It  is  admitted  that  these  symptoms  in  such  cases  clear  up  after  removal 
of  a  portion  of  the  gland.  The  thyroid  gland  in  exophthalmic  goitre 
has  certain  definite  and  microscopical  characteristics  ;  the  most  marked 
microscopical  change  is  the  diminution  or  even  complete  absence  of 
the  normal  colloid  secretion.  Histologically  there  is  a  considerable 
increase  in  the  amount  of  epithelium  so  that  the  walls  of  the  vesicles 
are  often  infolded,  there  is  an  increase  in  the  blood  vessels  and  a  diminu- 
tion in  the  colloid  secretion.  Only  cases  in  which  the  gland  has  these 
typical  characters  should  be  regarded  as  true  exophthalmic  goitre.  At 
the  present  day  it  is  generally  agreed  that  the  disease  is  due  to  the 
absorption  of  some  secretion  from  the  diseased  gland,  the  older  view  that 
it  is  due  primarily  to  a  disease  of  the  nervous  system  having  been  prac- 
tically abandoned.  The  object  of  operative  treatment  is,  by  removing 
a  portion  of  the  gland,  or  by  ligaturing  two  or  three  of  the  arteries  supply- 
ing it,  to  diminish  the  amount  of  secretion  which  by  its  absorption  causes 
the  disease.  There  is,  however,  without  doubt,  a  very  considerable  risk 
attached  to  these  operations. 

In  severe  cases  there  is  a  very  considerable  danger  of  the  patients 
dying  shortly  after,  or  even  during  the  course  of,  the  operation,  and  even 
in  mild  cases  the  risk  is  very  distinct.  The  reason  for  this  danger  is  easy 
to  understand.  In  most  fatal  cases  there  is  a  remarkably  large  persistent 
thymus,  and  in  some  there  is  evidence  of  increase  of  lymphoid  tissue 
elsewhere — often,  for  instance,  in  the  cervical  lymphatic  glands  (Kocher), 
In  other  words  the  dangers  resemble  those  associated  with  the  status 
lymphaticus  {q.v.).  Hyperthyroidism,  too,  is  apt  to  lead  to  secondary 
degeneration  of  the  viscera  :  thus  the  heart  becomes  dilated,  and  albu- 
minuria and  glycosuria  are  often  present.  Owing  to  these  secondary 
visceral  troubles  patients  with  exophthalmic  goitre  are  liable  to  die 
suddenly,  quite  apart  from  any  operative  interference.  Though  for  these 
reasons  there  is  a  very  considerable  danger  attached  to  the  operation, 
there  is  no  doubt  that  in  a  large  number  of  cases  operation  is  followed 
by  rapid  improvement  and  even  cure.  With  improvement  in  the 
technique  of  the  operation  the  mortahty  has,  in  the  hands  of  those 
specially  skilled  in  these  operations,  diminished  to  4  per  cent,  or  even  less. 

The  question  of  ancesthetic  is  a  most  important  one.  While  some 
surgeons  favour  a  general  anaesthetic  others  prefer  local  anaesthesia. 
Death  may  occur  even  with  the  latter,  as  in  a  case  of  Mr.  Berry's.^  Intra- 
tracheal anaesthesia  {q.v.)  is  so  satisfactory  for  the  other  varieties  of 
goitre  that  it  is  worthy  of  an  extended  trial  in  these  cases  also. 

The  question  to  be  decided  is  whether  the  benefit  to  be  obtained  from 
operative  treatment  justifies  the  risk  which  is  necessarily  run.  To  settle 
this  important  point  it  is  necessary,  first  of  all,  to  know  the  results  that 
are  to  be  expected  from  medical  treatment.  Most  interesting  informa- 
tion on  this  subject  is  contained  in  a  paper  by  Dr.  Hale  White,  on 
"  The   Outlook  of  Sufferers  from  Exophthalmic  Goitre."      Dr.   Hale 

1  Loc.  supra  cit.  See  also  a  discussion  on  "Partial  Thyroidectomy  under  Local 
Anaesthesia  with  Special  Reference  to  Exophthalmic  Goitre  "(Pror.  Roy.  t^'oc.  Med.,  Surg. 
Sec,  March  1912). 

-  Quart.  Journ.  of  Med.,  October  1910,  and  Gui/s  Hospital  Reports,  vol.  Ixv,  p.  1. 


614    OPERATIONS  ON  THE  HEAD  AND  NECK 

White  investigated  the  after-history  of  all  the  patients,  161  in  number, 
who  were  admitted  to  Guy's  Hospital  between  1888  and  1907  inclusive. 
Of  these  18  died  in  hospital,  94  could  not  be  traced,  and  49  were  traced,  of 
whom  8  were  dead  in  1910.  Dr.  Hale  White  also  collected  55  private 
cases  between  1894  and  1909,  of  whom  7  were  dead  in  1910.  A  comparison 
was  made  between  the  actual  deaths  and  the  Table  of  expected  deaths 
according  to  the  "  Healthy  Females  Experience  of  20  British  Offices 
amongst  assured  lives."  The  comparison  showed  that  the  total  number 
of  deaths  in  hospital  cases  that  could  be  traced  was  8,  whereas  it  should 
have  been  5  according  to  the  Table  of  expected  mortality.  In  view  of 
the  fact,  however,  that  there  were  no  known  deaths  at  all  over  age  45, 
and  only  one  death  under  age  30,  it  is  quite  impossible  to  draw  any 
conclusions  as  to  the  comparative  rates  of  mortahty  at  the  older  and 
younger  ages.  If  we  compare  the  mortahty  between  the  ages  30  and  45, 
excluding  two  cases  in  which  the  age  at  death  is  unknown,  we  find  that 
the  number  of  deaths  was  5,  and  should  have  been  3  according  to  the 
Table.  If  a  similar  comparison  is  made  with  the  group  of  grivate  cases 
the  mortality  closely  resembles  that  of  the  first  group.  There  were  7 
actual  deaths  whereas  there  should  have  been  but  3  according  to  the 
normal  table.  In  these  cases  there  was  only  1  death  over  45  and  2 
under  30.  Comparing,  as  before,  the  mortahty  between  ages  30  and  45 
and  excluding  1  death  where  the  age  at  death  is  unknown,  there  were  3 
actual  deaths  while  there  should  have  been  only  2. 

"  The  data  are  so  few  that  it  would  be  dangerous  to  draw  any  con- 
clusions from  the  facts  here  set  out,  except,  perhaps,  the  general  conclusion 
that  the  mortality  experience  seems  to  be  heavier  than  would  be  expected 
according  to  a  well-known  standard  Table." 

Dr.  Hale  White  divides  the  cases  that  can  be  traced  into  three  groups. 
Thus  in  the  series  of  hospital  cases,  deducting  the  8  patients  who  died  and 
1  who  was  known  to  be  alive  though  the  condition  was  unknown,  there 
are  40  cases  which  Dr.  Hale  White  arranges  in  the  following  groups  : 
(1)  Those  that  have  done  well,  26.  (2)  Those  that  are  moderately  well  or 
better,  12.     (3)  Those  that  are  not  well,  2. 

In  the  same  way,  of  the  55  private  cases  there  were  7  deaths,  andhttle 
is  known  of  1  case,  so  that  47  cases  are  traced  as  before  :  (1)  Those  that 
have  done  well,  35.  (2)  Those  that  are  moderately  well  or  better,  9. 
(3)  Those  that  are  not  well,  3.  Adding  the  two  series  together  there 
are  87  cases,  of  which  61  have  done  well,  21  are  better  and  5  are  not 
better. 

These  results  indicate  that  the  prognosis  is  rather  better  than  is 
generally  supposed,  especially  in  private  cases  who  are  able  better  to  rest 
and  undergo  prolonged  treatment. 

Dr.  Hale  White's  figures  are  confirmed  by  those  of  other  physicians. 
Thus  Dr.  Hector  Mackenzie  ^  says  :  "  The  disease  is,  as  a  rule,  so  long 
drawn  out  that  many  cases  are  lost  sight  of,  especially  in  hospital  practice  ; 
and  a  good  deal  of  uncertainty  thus  prevails  as  to  the  issue  of  them.  I 
have  tabulated  the  result  in  33  patients  under  my  own  care  in  whom  the 
disease  either  lasted  over  five  years  or  ended  fatally,  and  Dr.  R.  T. 
Williamson  has  done  the  same  in  24  cases  observed  at  the  Manchester 
Infirmary." 

1  Allbutt  and  Rolleston's  System  of  3Iedicine,  vol.  iv,  pt.  I,  p.  377. 


EXOPHTHALMIC  GOITRE 


G15 


Result  in  Fifty-seven  Cases 


Fatal  termination  . 

Recovery  complete 

Recovery  almost  complete 

Improvement  considerable 

Inii)roveinent  slight 

In  statu  quo  . 

Alive  but  exact  condition  unknown 


Dr.  Mackenzie's 
series 

8 
5 
9 
9 
1 
1 
0 


L)r.  NVilliamson'i) 
series 

6 
5 
2 
4 
3 
3 
I 


ToUl 

14 
10 
11 
13 

4 

4 

1 


"  Out  of  900  cases  collected  by  Buschau  a  fatal  result  was  recorded  in 
105.  Ill  about  25  per  cent,  of  the  cases  death  results  from  the  disease. 
In  about  50  per  cent.,  more  or  less  complete  recovery  will  eventually 
take  place.  In  the  remainder  the  disease  continues  in  a  chronic  form 
during  hfe.  There  does  not  seem  to  be  any  rule  as  to  the  duration  of  the 
malady,  the  symptoms  of  which  may  last  from  a  few  months  to  many 
years." 

It  is  now  necessary  to  consider  the  results  of  the  treatment  of 
exophthalmic  goitre  by  operation.  There  is  no  doubt  that  the  great 
majority  of  cases  do  show  a  great  and  often  rapid  improvement  after 
removal  of  one  lobe  of  the  gland,  and  indeed  are  often  benefited  by  ligature 
of  one  or  more  of  the  thyroid  arteries.  Mr.  Berry  ^  says  :  "  Patients 
undoubtedly  do  improve  in  a  manner  that  is  not  seen,  as  far  as  I  know, 
after  any  other  method  of  treatment.  ...  Of  my  own  operation  cases, 
with  the  exception  of  the  two  that  died,  there  is  not  one  that  has  not 
benefited  by  the  operation,  although  in  one  or  two  the  benefit  has  not  been 
great,  and  in  one  case  at  least  there  has  been  a  shght  relapse."  Dr.  Hector 
Mackenzie,^  says  :  "  Were  it  not  for  the  considerable  risk  to  hfe  from  the 
operation  I  should  not  hesitate  to  recommend  it  as  the  most  rational  and 
most  practical  method  of  treatment  of  the  disease.  In  the  milder  forms 
there  is,  however,  a  good  prospect  of  recovery  imder  medical  treatment, 
and  there  does  not  seem  so  much  more  to  be  gained  by  operation  to 
warrant  the  incm'ring  of  the  risk  of  a  fatal  result.  The  risk  of  death  from 
operation  is  so  liigh  in  severe  and  acute  cases  as  to  render  it  doubtfully 
justifiable,  and  few  surgeons  would  be  fomid  wilhng  to  perform  it." 

What  then  is  the  mortahty  of  the  operation  ?  This  is  not  an  easy 
question  to  answer  owing  largely  to  the  fact  that  in  many  pubhshed 
statistics  there  is  some  doubt  as  to  whether  cases  of  parenchymatous 
goitre  with  symptoms  of  hyperthyroidism  are  not  also  included. 

Mr.  Jacobson  operated  on  four  cases  of  exophthalmic  goitre  before 
19(X). 

The  first  of  these  was  a  female  patient,  aged  22,  of  Dr.  Garrard  of  Rickmansworth 
The  right  lobe  and  the  isthmus  were  removed.  Two  years  after  she  reported  that 
the  swelling  in  the  neck  was  scarcely  to  be  seen.  The  palpitation  was  better  and  the 
eyes  not  so  prominent.  She  took  her  food  well  and  could  walk  over  ten  miles  without 
feeling  tired.  She  was  able  to  work  at  a  machine  dressmaking  from  8  a.m.  till 
8  P.M.  Subsequently  there  was  some  slight  relapse.  In  the  second  case  removal 
of  one  lobe  was  followed  by  immediate  relief  of  symptoms,  but  the  late  result  could 
not  be  ascertained. 

The  third  case  was  a  typical  exophthalmic  goitre  with  a  pulse  rate  of  140  and 
much  restlessness  and  irritability.  Palliative  treatment  gave  no  good  result.  At 
the  operation  the  right  lobe  and  part  of  the  isthmus  were  removed.  The  operation 
was  followed  by  marked  relief  of  the  symptoms,  which  did  not,  however,  disapi^ear. 
In  1900,  six  years  after  the  operation,  the  breathlessness  had  much  improved,  but  the 

1  Loc.  supra  cit. 


616    OPERATIONS  ON  THE  HEAD  AND  NECK 

proptosis  and  paljiitation  on  exertion  were  still  present.  The  restlessness  and 
excitability  remained  as  before.  Her  general  health  was  then  good  and  she  was 
able  to  walk  eight  or  ten  miles  at  a  stretch ;  the  slightest  hill,  however,  produced 
breathlessness  and  palpitation. 

The  fourth  case  was  suffering  from  severe  symptoms  of  thyroidism  at  the  time  of 
operation  as  shown  by  great  agitation  and  restlessness  and  a  pulse-rate  of  130. 
The  right  lobe  and  the  isthmus  were  removed.  After  the  operation  the  restlessness 
was  very  marked,  the  pulse-rate  rose  to  180,  and  the  patient  died  suddenly  from 
cardiac  failure  about  twenty-four  hours  later. 

Mr.  Berry  ^  says  :  "  We  should  be  very  careful  in  drawing  conclusions 
from  mortality  statistics,  as  given  in  published  records,  unless  we  know 
to  what  class  of  cases  the  statistics  refer.  Probably  the  only  safe  test  is 
the  pathological  one.  .  .  .  Mortahty  statistics  based  upon  such  patho- 
logical findings  are  rare  in  medical  literature  at  the  present  day.  The 
number  of  patients  upon  whom  I  have  myself  operated  for  exophthalmic 
goitre  is  comparatively  small,  amounting  up  to  the  end  of  1912  only  to  26. 
These  were  all  cases  of  undoubted  Graves's  disease,  in  which  all  the 
classical  symptoms,  including  exophthalmos,  were  present,  mostly  in  a 
very  marked  form.  Of  these  26  patients,  2  have  died  as  the  result  of 
operation,  1  in  1901  after  simultaneous  hgature  of  three  arteries,  and  1  in 
1911  after  a  bilateral  excision.  One  patient  with  severe  Graves's  disease, 
who  died  before  I  commenced  the  intended  operation  of  ligature  of  a 
superior  thyroid  artery,  is  not  included  in  these  statistics." 

Kocher  ^  says  :  "  To  the  present  time  we  have  operated  on  200  cases 
of  Basedow's  disease  (including  10  cases  of  struma  vasculosa  and  60  of  a 
mild  type)  with  a  mortahty  of  4-5  per  cent.,  this  mortahty  being  higher 
than  in  other  forms  of  goitre.  We  have,  however,  learned  how  to  over- 
come the  operative  risks,  which  are  almost  entirely  dependent  on  the 
condition  of  the  heart,  i.e.  toxic  myocarditis.  Excision  should  not  be 
undertaken  when  the  disease  is  advanced,  i.e.  when  the  pulse,  besides 
being  rapid,  is  also  small  and  irregular,  or  when  the  heart  is  dilated  and 
oedema  is  present.  If  there  is  severe  thyro-intoxication,  the  slightest 
excitement  causing  acceleration  of  the  heart's  action  (180  beats  or  more 
per  minute)  with  an  increase  in  the  dilatation,  it  is  advisable  to  begin  by 
hgaturing  one  or  possibly  two  arteries,  and  to  postpone  the  excision  till 
the  patient's  condition  shows  distinct  improvement.  Even  then  the 
operation  is  attended  with  considerable  responsibihty  and  requires 
the  utmost  caution.  The  large  vessels  are  very  readily  torn,  and  the 
goitre  is  exceedingly  vascular,  even  the  external  capsule  bleeding  freely, 
while  it  is  often  firmly  adherent.  Operation  is  thus  a  matter  of  greater 
difficulty,  and  attended  with  greater  haemorrhage  than  is  the  case  even  in 
malignant  goitres.  The  success  of  operative  treatment  in  Basedow's 
disease  depends  on  the  patients  being  seen  by  the  surgeon  at  an  early 
stage,  as  with  early  operation  brilhant  results  can  be  obtained."  Mr, 
Berry  also  advises  that  operation  should  not  be  undertaken  in  acute  cases 
where  there  is  much  thyroid  intoxication  as  shown  by  great  excitabihty, 
mania,  or  muscular  weakness,  or  in  those  who  are  suffering  from  any  acute 
inflammatory  infection  such  as  bronchitis.  Albuminuria,  glycosmia,  diar- 
rhcea,  a  constantly  irregular  pulse,  and  low  blood  pressm'e  are  all  contra- 
indications, and  should  lead  the  surgeon  to  at  least  postpone  operation  ; 
if  these  conditions  cannot  be  remedied  by  medical  treatment,  operation 

1  Loc.  supra  cit.  A  paper  by  Mr.  Berry  on  the  "Surgery  of  Exophthalmic  Goitre" 
{Brit.  Joum.  Surg.,  vol.  i,  p.  699),  in  which  the  indications  for,  and  the  results  of 
operative  treatment  are  discussed,  should  also  be  consulted. 

2  Oj)er.  Surg.,  3rd  English  edition,  trans.  Stiles  and  Paul,  p.  467. 


EXOTIIYROPEXY  G17 

should  not  be  performed  at  all.  Of  all  chronic  complications,  marked 
dilatation  of  the  heart  is  perhaps  the  most  common  and  the  most 
serious. 

Dr.  Charles  H.  Mayo,  of  Rochester,  gave,  in  1904,  his  experience  of 
partial  thyroidectomy  for  exoplithalmic  goitre  based  upon  40  cases.^  Of 
the  40  cases  6  died,  1  death  occuning  on  the  table,  2  in  15  to  18  hours,  and 
3  from  24  to  72  hours,  after  the  operation.  More  recently  the  same 
writer  has  pubhshed  a  most  interesting  paper  on  "  The  Factors  of  Safety  in 
Operating  for  Exophthalmic  Goitre."  ^    In  this  paper  he  says  : 

"  The  early  oix?ration  mortality  was  20-30  per  cent.  Our  own  mortality  in  our 
first  sixteen  cases  was  25  per  cent.  Within  the  past  year  we  have  operated  on 
a  consecutive  series  of  278  cases  of  exophthalmic  goitre  ^  without  a  death.  This 
is  a  marked  gain  on  our  early  work,  and  1  believe  it  has  been  caused  by  taking 
advantage  of  the  so-called  factors  of  safety  in  the  treatment,  preparation  and  opera- 
tion of  these  patients.  That  factors  of  safety  are  becoming  recognised  is  proved  by 
the  present  mortality  which  is  a  varying  one  from  1  to  4  per  cent.  The  estimated 
proportion  of  cures  based  on  the  examination  of  patients  operated  on  and  from 
letters  and  reports  is  about  75  per  cent."  He  then  proceeds  to  quote  the  following 
remarks  by  Dr.  Plummer  on  the  coui'se  of  the  disease.  "  If  the  average  course 
of  the  disease  be  represented  by  a  curve,  the  greatest  height  of  th3  intoxication  is 
found  to  be  reached  during  the  latter  half  of  the  first  year,  and  then  drops  rapidly 
to  the  twelfth  month.  In  many  instances  it  reaches  the  normal  base  line  during 
the  next  six  months,  more  often  it  fluctuates  with  periods  of  exacerbation  for  the 
next  two  to  four  years.  Secondary  symptoms  and  exophthalmos  may  remain,  but 
the  active  coiu-se  rarely  continues  over  four  years  without  distinct  intermissions. 
The  ascent  may  be  gradual,  sudden,  or  irregularly  marked  by  many  secondary  curves." 
The  "  factors  of  safety  "  are  as  follows  :  (a)  As  regards  ojierating  during  periods 
of  exacerbation  :  the  mortality  in  these  cases  is  frequently  high,  and  it  is  such  we 
would  choose  for  medical  treatment  with  attention  to  heart,  stomach,  or  intestines, 
accorchng  to  the  special  indications  in  each  case,  (b)  Gastric  crises  and  delirium  are 
serious  manifestations,  and  operation  should  not  be  done  until  these  have  subsided 
under  medical  treatment,  (c)  Dilatation  of  the  heart  wliich  exceeds  one  inch  is  a 
serious  condition,  while  that  of  an  inch  and  a  half  will  give  a  percentage  of  un- 
avoidable mortality  for  thyroidectomy,  {d)  Ligature  has  an  accredited  position  in 
the  treatment  of  exophthalmic  goitre,  (e)  Serious  risks  are  best  treated  by  a 
single  ligature  of  the  vessels  at  the  ujjper  left  pole.  The  reaction  is  about  three 
quarters  as  severe  as  from  a  double  ligature,  but  the  missing  quarter  is  an  element  of 
safety.  If  the  reaction  be  very  severe,  a  second  ligature  of  the  right  superior 
thyroid  vessels  is  made  a  week  later.  As  compared  with  the  first  ligature  the  reac- 
tion following  this  one  is  slight.  If  the  reaction  be  not  severe  at  the  second  opera- 
tion the  right  lobe,  isthmus,  and  possibly  a  jiortion  of  the  left  lobe  are  removed." 

The  follo^^ang  operations  have  been  performed  for  exophthalmic 
goitre  : 

(a)  Operations  on  the  Cervical  Sympathetic.  These  operations,  which 
are  now  but  seldom  performed,  are  alluded  to  on  p.  677.  Excision  of  the 
superior  cer\4cal  ganghon  and  division  of  the  sympathetic  trunk  have 
both  been  tried. 

(b)  Exothyropexy.  This  consists  in  exposing  one  of  the  lobes  of  the 
gland  and  fixing  it  in  the  wound  in  the  hope  that  the  exposed  portion  will 
atrophy  and  the  symptoms  diminish.  Though  several  successful  cases 
have  been  reported  the  operation  is  but  seldom  performed.^ 

^  Med.  Record,  November  o,  1904.  p.  734. 

-  Journ.  Amer.  Med.  Assoc,  vol.  lix,  p.  26. 

■^  The  278  operations  are  made  up  as  follows  :  Single  ligature.  105  ca.ses  ;  double 
ligature,  13  cases  ;  single  ligature  followed  by  thjToidectomy,  30  cases  ;  two  single 
ligatures  followed  by  thyroidectomy,  21  cases  ;  double  ligature  followed  by  thjToidec- 
tomy,  26  cases  ;  thyroidectomy,  78  ca.ses  ;  thyroidectomy  followed  by  Ugature,  4  cases  ; 
thyroidectomy  followed  by  Ugature  and  by  a  second  thyroidectomy,  1  case. 

*  The  objections  to  this  operation  are  :  («)  Its  uncertainty  as  to  the  production  of 
atrophy  of  the  gland.     (6)  The  certain  risk  of  infection,  in  spite  of  the  most  careful 


618  OPERATIONS  ON  THE  HEAD  AND  NECK 

(c)  Excision  of  a  Portion  of  the  Gland.  This  is  the  operation  usually 
performed  and  which  gives  the  most  satisfactory  results.  It  is  usual 
to  remove  one  lobe,  though  a  portion  of  the  opposite  lobe  may  be  removed, 
if  necessary,  on  a  subsequent  occasion. 

{d)  Ligature  of  one  or  more  of  the  Thyroid  Arteries.^  Ligature  of 
one  or  both  superior  thyroid  arteries  is  usually  performed  ;  one  of  the 
inferior  thyroid  arteries  may  also  be  tied.  The  latter  may  be  a  very  diffi- 
cult operation  (q.v.).  Though  often  followed  by  considerable  improve- 
ment these  operations  are  rather  to  be  regarded  as  preliminaries  to  ex- 
cision of  a  portion  of  the  gland.  They  are  especially  indicated  in  severe 
cases. 

The  present  position  as  regards  the  operative  treatment  of  Graves's 
disease  may  be  summed  up  as  follows  :  (a)  Operation,  especially  excision 
of  a  portion  of  the  gland,  is  generally  followed  by  a  marked  improvement 
and  in  many  cases  by  a  cure  of  the  disease.  (6)  The  operation  is,  however, 
attended  with  a  very  considerable  risk,  especially  when  visceral  compli- 
cations such  as  dilatation  of  the  heart  are  present,  (c)  On  this  account 
indiscriminate  operative  treatment  is  strongly  to  be  deprecated,  (d)  In 
severe  cases  where  there  is  much  tachycardia  and  where  there  is  excessive 
cardiac  dilatation  operation  is  contra-indicated,  (e)  In  all  cases  medical 
treatment  should  have  a  thorough  trial  :  even  in  cases  where  it  has  been 
decided  that  operation  is  desirable,  there  should  be  a  more  or  less  pro- 
longed period  of  rest  and  medical  treatment.  (/)  The  operation  should 
not  be  performed  while  the  thyroid  intoxication  is  at  its  height. 

Malignant  Goitre.  Both  carcinoma  and  sarcoma  may  occur  in  the 
thyroid  gland,  the  former  probably  being  the  commoner.^  In  either  case 
it  is  unusual  for  the  local  condition  to  admit  of  successful  extirpation 
of  the  growth. 3  There  may  be  considerable  difficulty  in  the  diagnosis 
of  a  malignant  tumour  of  the  thyroid.*  Rapid  gro^vth,  fixity,  hardness, 
are  all  suggestive  of  malignancy,  especially  if  occurring  in  an  elderly 
or  middle-aged  patient.  In  some  doubtful  cases  an  exploratory  incision 
with  histological  examination  of  a  portion  of  the  growth  will  be  desirable. 

The  two  indications  for  operation  are  :  (1)  The  growth  must  still  be 
contained  within  the  limits  of  the  capsule  of  the  gland.  (2)  The  growth 
must  not  be  adherent  to  the  trachea.  Hence  it  should  move  freely 
both  with  and  on  this  structure.  Unfortunately,  as  Mr.  Berry  points  out, 
"  penetration  of  the  capsule  usually  occurs  very  early,  especially  in  the 
inner  and  posterior  part.  Hence  the  early  involvement  of  the  recurrent 
nerve  and  fixation  to  the  trachea  and  the  oesophagus.     Many  a  tumour 

precautions.  Patients  with  exophthalmic  goitre  are  subjects  very  liable  to  infection, 
(c)  Grave  sequelae,  such  as  tetany,  and  those  referable  to  disturbance  of  the  recurrent 
laryngeal  nerve,  e.g.  dyspncca  and  pneumonia,  have  followed  this  operation,  (d)  What 
is  known  at  the  present  day  as  the  "  cosmetic  "  result  is  likely  to  be  bad. 

^  Removal  of  the  isthmus,  combined,  if  the  condition  of  the  patient  admitted  it, 
with  ligature  of  the  two  superior  thyroid  vessels,  may  also  be  carried  out  in  more  serious 
cases. 

2  Limacher,  of  Berne,  found  the  proportion  to  be  forty-four  sarcomata  and  thirty- 
eight  carcinomata. 

'  A  remarkable  instance  of  a  successful  operation  for  carcinoma  of  the  thyroid  with 
extensive  infection  of  the  glands  is  afforded  by  a  case  recorded  by  Mr.  Wilfrid  Trotter 
(Proc.  Roy.Soc.  il/ec/..  Clin.  Sec,  vol.iv,  1911,  p.  118).  The  patient  was  free  from  recurrence 
three  and  a  half  years  after  the  operation. 

*  A  third  variety  of  malignant  disease  is  the  mysterious  malignant  adenoma,  only 
distinguished  by  the  peculiarity  of  its  metastases,  which  especially  affect  bones,  e.g.  the 
skull,  sternum,  &c.  Further,  it  may  be  impossible  to  detect  either  in  the  apparently 
normal  thyroid  or  the  metastases  in  the  bones  or  lungs  any  histological  difference  from 
the  normal  thyroid  tissue. 


OPERATIONS  ON  THE  THYROID  GLAND  619 

which  moves  freely  on  deglutition  and  is  apparently  easily  removable 
will  be  found  at  operation  to  be  hopelessly  incorporated  with  the  wall  of 
the  trachea,  the  oesophagus,  or  the  carotid  sheath." 

Alteration  of  voice,  dysphagia,  dyspnoea,  pain,  signs  of  involvement 
of  the  recurrent  laryngeal  and  sympathetic  nerves,  are,  on  this  account, 
early  signs  and  symptoms. 

In  advanced  cases  a  palhative  tracheotomy  will  very  probably  be 
required. 

Even  in  cases  of  malignant  disease  removal  of  the  whole  gland  will 
not  be  called  for.  If  the  growth  is  so  extensive  as  to  involve  both  lobes 
it  \vill  certainly  be  inoperable.  If  the  growth  involves  one  lobe  and  is 
operable,  recurrence  does  not  take  place  on  the  opposite  side  of  the  gland, 
but  in  the  tissues  adjacent  to  the  gland  on  the  side  originally  afiected. 
For  this  reason  Mr.  Berry  advises  that  in  all  cases  the  upper  pole  of 
the  opposite  lobe  should  be  left. 

OPERATIONS  ON  THE  THYROID  GLAND 

The  following  will  be  described:  (1)  Excision  of  one  lobe  with  or 
without  the  isthnms.  (2)  Enucleation  of  growths  or  cysts.  (3)  Enu- 
cleation resection.  (4)  Ligature  of  the  thyroid  arteries.  (5)  Operations 
on  the  cervical  sympathetic  will  also  be  briefly  alluded  to. 

(1)  Excision  o£  one  Lobe  of  the  Gland.  As  has  already  been  indicated 
this  is  the  operation  most  frequently  called  for.  It  is  indicated  in  most 
cases  of  parenchymatous  enlargement  requiring  operative  treatment,  in 
some  cases  of  adenoma  or  cystic  disease,  and  in  many  cases  of  exophthal- 
mic goitre  calhng  for  operative  treatment. 

The  ancesthetic.  The  question  of  the  anaesthetic  is  always  an  anxious 
one  in  all  thyroid  operations.  The  difficulties  and  dangers  in  Graves's 
disease  have  already  been  touched  upon,  but  in  all  operations  for  goitre 
serious  difficulties  may  arise  in  the  course  of  the  administration,  especially 
when  dyspnoea  has  been  a  troublesome  symptom.  Serious  symptoms  are 
particularly  liable  to  arise  during  the  stage  described  below  as  dislocation 
of  the  gland.  During  this  stage  the  condition  of  the  patient  should 
receive  the  close  attention  both  of  the  anaesthetist  and  the  operator. 
The  most  suitable  anaesthetic  is  still  a  matter  of  opinion,  but  in  any  case 
the  administrator  should  be  a  skilled  and  experienced  anaesthetist.  The 
ideal  method,  if  the  necessary  apparatus  is  available,  and  the  services  of  an 
anaesthetist  sldlled  in  its  use  can  be  secured,  is  the  intratracheal  adminis- 
tration of  ether,  preceded  by  an  injection  of  morphia  and  atropine.  The 
advantages  of  this  method  are  great.  Even  with  very  large  goitres  there 
is  no  obstruction  to  breathing  in  the  course  of  the  operation,  and,  what  is 
of  almost  equal  importance,  the  anaesthetist  and  his  apparatus  are  not  in 
the  way  of  the  operator.  Faihng  this  method,  open  ether  preceded  by  an 
injection  of  morphia  and  atropine  may  be  recommended.  A  few  operators 
still  prefer  chloroform.  In  cases  of  exophthalmic  goitre  where  there 
is  much  nervousness  an  injection  of  scopolamine  may  be  given  before  the 
commencement  of  the  administration,  while  in  very  bad  cases  local  anaes- 
thesia may  be  employed. 

Sterihsation  of  the  skin  must  be  far-reaching  and  thorough,  including  a 
wide  area  over  the  sternum,  and  the  cleansing  of  the  axillae,  under  which 
the  bandages  will  pass  for  security. 

To  minimise  the  possibihty  of  infection  of  the  wound  from  the  patients 


620 


OPERATIONS  OX  THE  HEAD  AND  NECK 


mouth  and  from  the  anaesthetic  apparatus  the  sterilised  towels  may  be 
arranged  as  follows  :  A  medium-sized  towel  is  placed  behind  the  head 
extending  well  down  behind  the  shoulders  ;  a  second  towel  is  then 
wrapped  securely  round  the  patient's  head  so  as  to  enclose  the  whole 
of  the  hair,  and  "is  kept  in  position  by  towel-cHps  ;   a  third  towel,  or,  if 


Fig.  264.     The  "  bib  "  which  has  been  tied  round  the  upper  part  of  the  patient's 

neck  is  seen  resting  on  the  sterilised  towel  covering  the  chest.     The  tube  for 

the  intratracheal  anaesthesia  is  also  shown. 

necessary,  towels,  are  then  arranged  so  as  to  cover  the  whole  of  the  patient's 
bodv  from  the  top  of  the  sternum  to  the  feet  ;  another  small  towel,  with  a 
notch  for  the  neck  and  tapes  to  tie  behind,  after  the  fashion  of  a  child's 
bib,  is  then  laid  on  the  last-mentioned  towel  and  over  the  patient's 
neck  ;  an  assistant  then  draws  this  upwards,  so  that  the  notch  fits  the 
junction  of  the  neck  and  the  floor  of  the  mouth,  and  ties  the  tapes  firmly 
behind  in  the  suboccipital  region  (Fig.  264)  :    the  bib  is  then  turned 


Fig.  265.     The  "  bib  "  has  been  turned  upwards  over  the  patients  face  and 
exjKJsing  the  goitre.     The  tube  for  the  anfesthetic  is  seen  passing  beneath  the 

"  bib." 

upwards  so  as  to  cover  the  whole  of  the  head  and  to  leave  the  front 
of  the  neck  and  the  tumour  freely  exposed  (Fig.  265).  In  this  way 
the  mouth  and  the  anaesthetic  apparatus  are  securely  shut  ofE  from  the 
field  of  operation.  If  intratracheal  anaesthesia  is  employed  the  anaes- 
thetist and  his  apparatus  will  be  at  some  little  distance,  the  tube  through 
which  the  anaesthetic  is  administered  passing  beneath  the  bib  well  out 
of  the  way  to  the  side.     The  anaesthetist  will  have  only  occasionally 


OPKRATIOXS  ON  THE  THYROID  GLAND  621 

to  raise  the  bib  to  observe  the  condition  of  the  patient,  and  there  will 
thus  be  no  obstruction  of  the  field  of  operation,  and  no  fear  of  infection 
of  the  wound  from  the  mouth.  If  open  ether  or  any  other  anaesthetic 
be  preferred,  it  will  be  still  possible  for  the  anaesthetist  to  work  beneath 
the  bib,  though  in  this  case  he  may  find  it  impossible  to  avoid, 
by  his  apparatus,  or  by  his  hand  holding  forwards  the  patient's  jaw, 
hampering  the  operator's  free  view  and  access  to  the  wound. 


Fig.  266.     "  Collar  "  incision  for  goitre.     The  incision  is  carried  to  a 
higher  level  on  the  affected  side. 

The  incision  chosen  must  be  sufficiently  free  to  enable  haemorrhage  to 
be  efficiently  met,  and  every  part  of  the  lobe  operated  on  to  be  seen. 
While  an  ample  obUque  incision  along  the  anterior  border  of  the  sterno- 
mastoid  curved  over  to  the  opposite  side  below  will  nearly  always  give 
all  the  room  required  and  a  scar  that  will  be  but  slightly  conspicuous, 
Kocher's  "  collar  "  incision  (Figs.  266, 267)  is  now  very  generally  employed. 
This  is  convex  below  and  extends  from  the  outer  border  of  one  sterno- 
mastoid  to  the  outer  border  of  the  other.  It  is  made  at  a  higher  or  lower 
level  according  to  the  position  of  the  swelling,  in  most  cases  just  below 
the  cricoid  ;  in  those  which  dip  into  the  thorax  it  is  placed  just  above  the 
episternal  notch.  One  end  may  be  curved  well  upwards  to  facilitate 
the  exposure  of  the  superior  thyroid  vessels.  In  difficult  cases  such  as 
inflamed  goitres,  mahgnant  goitres,  or  Graves's  disease,  where  the 
thyroid  is  likely  to  be  adherent,  Kocher  recommends  an  angular  incision 
(Fig.  267)  beginning  at  the  level  of  the  thyroid  cartilage  over  the  promi- 
nent part  of  the  sterno-mastoid,  then  carried  forward  to  the  middle  hne, 
and  then  vertically  downwards  to  the  suprasternal  notch. 

Exposure  of  the  Goitre  (Figs.  268,  269).  The  incision  is  carried 
through  the  platysma  and  the  superficial  fascia  down  to  the  deep  fascia  : 
several  superficial  veins  will  be  met  wdth,  including  the  anterior  jugular, 
often  double,  and  oblique  veins  along  the  anterior  borders  of  the  sterno- 
mastoids.     These  must  be  tied  and  divided  between  hgatures.     The  infra^ 


622 


OPERATIONS  ON  THE  HEAD  AND  NECK 


hyoid  muscles  are  now  seen  and  must  be  widely  exposed  by  dissecting  up 
the  skin  and  superficial  fascia  as  high  and  as  low  as  possible.  The  deep 
fascia  is  now  divided  in  the  mid-hne  and  the  infrahyoid  muscles  of  the 
two  sides  separated.  The  layers  of  deep  fascia  met  with  vary  much  in 
strength,  and,  to  a  less  degree,  in  number  also.  Every  one  of  them  must 
be  divided  in  the  full  extent  of  the  wound  before  any  attempt  is  made  to 
deal  with  the  bronchocele  itself.  Inattention  to  this  point  will  largely 
increase  the  difficulties  met  with.  The  goitre  in  its  capsule  will  be 
recognised  by  its  bluish-red  colour  and  the  large  veins  which  stand  out 
as  they  ramify  on  the  surface  of  the  gland. 

Dislocation  of  the  Goitre.    We  now  come  to  this  important  stage  of 
the  operation,  during  which  respiration  may  become  obstructed  :    the 


/^^ 


Fig.  267.     Kocher's  collar  incision,  and  angular  incision  for  adherent 
or  malignant  goitres. 

operator  should  therefore  always  call  the  attention  of  the  anaesthetist 
that  this  stage  has  been  reached,  and  should  himself  also  closely  watch 
the  condition  of  the  patient.  The  finger  should  be  inserted  in  the  interval 
between  the  sterno-hyoid  muscles  and  the  fibrous  capsule  of  the  gland  on 
the  outside,  and  the  gland  and  its  capsule  proper  on  the  inside.  The 
finger  is  then  gently  worked  upwards  and  downwards  and  then  backwards, 
so  as  gradually  to  free  the  gland  and  draw  it  forwards  through  the  opening 
in  the  deep  cervical  fascia.  The  greatest  care  and  gentleness  must  be 
exercised  while  doing  this.  If  the  capsule  of  the  gland  is  torn  and  the 
gland  substance  lacerated  there  will  probably  be  very  severe  haemorrhage 
which  it  may  be  difficult  to  control.  In  the  course  of  the  separation,  es- 
pecially if  the  goitre  is  large,  the  finger  will  feel  one  or  more  fibrous  bands 
passing  from  the  goitre  to  the  fascial  sheath :  these  contain  veins,  often 
of  considerable  size,  and  must  be  divided  between  two  pairs  of  Spencer- 
Wells  forceps  and  subsequently  secured  by  catgut  hgatures.  While 
shelhng  the  enlarged  gland  from  its  bed,  the  greatest  care  must  be  taken  to 
work  gently  and  to  keep  close  to  the  tumour,^  the  veins  being  often  much 
enlarged  and  thin  walled.  If  torn  the  proximal  extremity  is  apt  to 
retract  outwards,  close  to  the  internal  jugiilar  vein  ;  the  bleeding  will  be 
profuse  and  the  cut  end  will  only  be  secured  with  difficulty.  The  shelhng- 
out  process  will  be  aided  by  retracting  the  sterno-hyoid  muscles ;   only 

1  The  capsule  proper  of  the  tumour  must  be  nowhere  opened.  Such  a  step  not  only 
leads  to  flooding  of  the  wound  with  blood,  but  thus  also  obscures  and  may  lead  to  damage 
of  important  parts,  e.r/.  the  recurrent  laryngeal  and  the  trachea.  By  the  capsule  proper 
is  meant  the  thin  sheath  of  the  gland  which  gives  off  numerous  septal  processes  into  it. 
Every  layer  of  fascia  above  this,  including  the  sheath  from  the  pretracheal  layer  of  the 
(leep  cervical  fascja,  must  be  divided. 


OPERATIONS  ON  THE  THYROID  GLAND  623 

excoptionaliy  will  it  be  necessary  to  partially  divide  these  transversely. 
As  a  rule,  when  the  dislocation  has  been  effected  any  dyspnoea  which  may 
have  been  present  ceases. 

Securing  the  vessels.  The  tumour  is  now  only  held  in  position  by  the 
superior  and  inferior  vessels  and  the  isthmus.  The  next  step  is  to  secure 
the  superior  thyroid  vessels.  These  enter  at  the  superior  cornu  of  the 
gland  :  they  are  freed  by  separating  the  fascial  capsule  in  this  situation, 


Fig.  268. 


partly  by  the  finger  and  partly  by  the  blunt  dissector,  until  the  artery  can 
be  hooked  forwards  as  a  distinct  pedicle.  It  is  then  divided  between  two 
pairs  of  Spencer-Wells  forceps,  and  each  divided  end  is  at  once  secured 
by  a  catgut  hgatuxe.     (Fig.  270.) 

The  inferior  thyroid  vessels  which  now  have  to  be  hgatured  are  brought 
into  view  by  drawing  the  tumour  well  over  to  the  opposite  side.  (Fig.  271 .) 
The  greatest  care  must  be  taken  to  avoid  injury  to  the  recurrent  laryngeal 
nerve  which  runs  upwards  behind  the  artery.  Owing  to  the  fact  that  the 
trunk  of  the  inferior  thyroid  artery  does  not  come  into  relation  with  the 
recurrent  laryngeal  till  both  are  close  to  the  trachea,  either  the  trunk 
of  the  vessel  should  be  hgatured  and  cut  at  some  distance  from  this  tube, 
or  its  branches  tied  close  to  the  gland.  The  latter  procedure  is  recom- 
mended. The  fibrous  bands  in  which  the  branches  of  the  artery  run  are 
freed  by  careful  use  of  the  blunt  dissector,  and  are  divided  between  two 
pairs  of  Spencer- Wells  forceps  close  to  the  gland,  and  at  once  secured  by 
hf^atures.  If  the  vessel  be  tied  near  the  junction  of  the  cricoid  and  the 
trachea,  the  nerve  may  very  hkely  be  included ;   and  the  same  risk  will 


624 


OPERATIONS  OX  THE  HEAD  AND  NECK 


be  run  if,  at  this  stage  especially,  the  wound  be  not  kept  dry  and  bloodless. 
The  inferior  thyroid  arteries  ha\'ing  been  secured,  the  lower  pole  of  the 
gland  is  then  examined  and  the  thyroidea  ima  artery  and  veins,  if  present, 
are  separated  and  ligatured  in  the  same  way. 

Separation  and  division  of  the  Isthmus  (Fig.  272).  The  enlarged  lobe  is 
now  only  held  in  position  by  the  isthmus.  This  is  separated  from  the 
trachea  by  careful  use  of  a  director  or  blunt  dissector.    Care  must  be  taken 


*-4k^ 


Fig.  269. 


not  to  injure  the  trachea ,  which  is  often  closely  a  dherent ,  as  in  the  following 
case  described  by  Mr.  Spencer  ;  ^  here  the  isthmus  and  the  trachea  were 
most  intimately  miited,  although  the  thyroid  gland  seemed  the  seat  of 
fibroid  and  not  mahgnant  change. 

The  patient  was  a  young  woman  with  a  thjToid  normal  in  size  and  shape,  but 
of  marked  hardness.  The  pulse-rate  was  130-140.  There  was  no  exophthalmus. 
Stridor  was  present,  loudest  at  the  level  of  the  isthmus.  At  the  operation,  no  line 
of  demarcation  could  be  made  out  between  the  isthmus  and  the  trachea,  so  the 
isthmus  and  the  adjacent  part  of  each  lateral  lobe  were  shaved  away  from  the  trachea, 
leaving  a  portion  about  as  large  as  the  end  of  the  thumb.  The  trachea  thus  exposed 
felt  like  a  soft  tube,  and  was  sucked  in  and  blo^^Ti  out  hy  inspiration  and  expiration. 
The  cartilaginous  rings  had  softened  or  disappeared.  As  the  breathing  was  none  the 
better  for  the  removal  of  the  isthmus,  the  trachea  was  opened  immediately  below 
the  cricoid.  The  lumen  below  this  point  being  seen  to  be  narrowed  to  a  chink, 
the  incision  was  carried  downwards  through  that  part  of  the  trachea  which  had  been 
in  contact  with  the  thjToid,  until  cartilaginous  rings  were  again  met  with.  In  a 
fortnight  the  patient  was  able  to  discard  thetracheotomy  tube,  and  she  made  a  good 
recovery,  though  the  pulse-rate  was  still  120  per  minute. 

^  Ann.  oj  Surg.,  May  1895. 


OPERATIONS  ON  THE  THYROID  GLAND 


G25 


When  the  isthmus  has  been  sufficiently  separated  it  may  be  transfixed 
and  ligatured  by  stout  catgut,  or  it  may  be  carefully  torn  through  with 
the  ])()int  of  a  director  and  each  bleeding-point  secured.  The  latter  step 
will  usually  suHice.^ 

The  amount  of  luumorrhage  met  with  in  detaching  and  dividing 
the  isthnms  varies.  If  the  separation  is  effected  piecemeal,  the  bleeding 
is  often  very  slight.     This  is  probably  accounted  for  by  the  fact  that  the 


Fig.  270.     Securing  the  superior  thyroid  artery. 


intimacy  of  connection  and  continuity  of  structure  between  the  halves  of 
the  thyroid  and  the  isthmus  varies  much ;  also  in  many  cases  the  con- 
nection is  mainly  by  connective  and  a  little  glandular  tissue  with  a  very 
few  vessels. 

The  tumour  is  now  removed  and  the  wound  should  be  carefully 
examined  for  any  bleeding-points,  which  should  be  secm-ed  and  tied.  Any 
general  oozing  may  be  checked  by  irrigation  wath  hot  sterile  saline  solution. 
All  blood  clot  should  be  thoroughly  sponged  away  and  the  wound  care- 
fully dried. 

The  question  of  drainage  now  arises.  The  w^ound  left  after  the 
removal  of  one  lobe  only,  if  much  enlarged,  is  often  extensive  and  deep, 

1  If  the  pedicle  seem  too  thick  and  vascular  to  treat  in  this  way  it  may  be  crushed 
in  powerful  clamp  forceps  as  advibcd  by  Prof.  Kocher.  When  these  are  taken  off  only 
the  connective  tissue  and  vessels  are  left.  The  latter  can  now  be  Ugatured  en  masse  m 
the  much-diminished  pedicle. 

SURGERY  I  4*^ 


62G 


OPERATIONS  ON  THE  HEAD  AND  NECK 


the  larynx,  trachea,  large  vessels,  and  oesophagus  being  all  exposed.  In 
some  cases  the  dome  of  the  pleura  will  be  seen  rising  and  falling  in  the 
root  of  the  neck.  In  such  a  wound,  in  spite  of  the  most  careful  attention 
to  hsemostasis,  some  oozing  is  likely  to  occur.  Out  his  account,  except  in 
some  cases  of  ordinary  parenchymatous  goitre,  where  the  operation  has 
been  easy  and  the  parts  but  little  disturbed,  drainage  is  desirable.  Not 
infrequently  after  operations  on  any  form  of  goitre,  but  especially  after 


Fig.  271.     The  goitre  is  drawn  well  over  to  the  opposite  side  so  as  to  bring  the 
inferior  thyroid  vessels  into  view. 


operations  for  exophthalmic  goitre,  symptoms  of  thyroidism  such  as  rapid 
action  of  the  heart,  restlessness,  &c.,  may  appear.  These  are  often 
attributed,  but  probably  erroneously,  to  thyroid  secretion  being  forced 
into  the  circulation  as  the  result  of  rough  handhng  of  the  gland  ;  if  this 
were  the  case,,  the  symptoms  would  be  present  immediately  after  the 
operation,  whereas  there  is  usually  an  interval  of  some  hours  before  their 
development.  This  points  to  the  symptoms  of  thyroidism  being  due  to 
the  absorption  of  serum  and  thyroid  secretion  from  the  wound,  and  is  an 
additional  argument  for  drainage.  A  small  rubber  tube,  about  a  quarter 
of  an  inch  in  diameter,  is  passed  into  the  deeper  part  of  the  wound  and 
made  to  emerge  at  the  lower  part  of  the  incision  just  above  the  episternal 
notch.  The  divided  deep  cervical  fascia  is  then  brought  together  by  a 
few  interrupted  catgut  stitches  over  the  drainage-tube,  and  if  the  muscles 
have  been  cut  across  they  also  should  be  brought  together  in  the  same 
manner.  The  edges  of  the  wound  should  then  be  brought  into  the  most 
exact  apposition  in  order  to  promote  early  and  sound  healing  vnih.  the 
least  possible  scarring.  Fine  salmon-gut  and  horse-hair  are  the  most 
satisfactory  materials.     Over  the  sterilised  gauze  in  immediate  contact 


OPERATIONS  ON  THE  THYROID  GLAND 


G27 


with  the  wound,  firm  even  pressui'e  shoukl  be  made  with  steriUsed  pads 
and  absorbent  wool,  with  the  twofold  object  of  distributing  the  discharges, 
and  obliterating  the  cavity  of  the  wound.  And  for  the  first  week  after  the 
o])eration  the  same  care  should  be  taken  to  keep  the  dressings  securely  in 
position.  This  is  especially  difficult  in  a  mobile  part  like  the  neck,  and  one 
which  does  not  admit  of  nuich  compression.  The  best  plan  is  to  pass  the 
bandages  under  the  axillae  (protected  from  chafing  by  wool)  below,  and 


Fig.  272.     Cmshing  the  isthmus  of  the  thyroid. 


to  "wind  them  over  the  chin  and  forehead  above,  all  being  made  secure  by 
safety-pins  or  by  stitching.  This  alone  will  prevent  the  dressings  shpping 
down  and  exposing  the  upper  end  of  the  wound,  which  is  thus  readily 
infected.  A  piece  of  jaconet  should  be  so  arranged  as  to  prevent  soihng 
of  the  upper  dressings  by  any  vomited  material  or  sahva  as  the  patient  is 
coming  round  from  the  anaesthetic. 

After-treatment.  The  patient  must  be  kept  quiet  and  the  head 
still  to  avoid  any  danger  of  displacement  of  hgatures.  The  dressing 
should  be  changed  at  the  end  of  forty-eight  hours,  when  the  drainage-tube 
may  be  removed.  The  stitches  should  be  removed  on  the  eighth  day. 
Comphcations  and  their  treatment  are  described  on  p.  634. 

After  operations  for  exophthalmic  goitre  it  is  advisable  to  give  plenty 
of  water  by  the  mouth,  rectum,  or  even  as  a  subcutaneous  infusion.  In 
ordinary  cases  of  goitre  where  symptoms  of  thyroidism,  such  as  pjTexia, 
tachycardia,  restlessness,  &c.,  appear,  similar  treatment  should  be  em- 
ployed.    When  these  symptoms  are  very  severe  it  may  be  necessary  to 


G28 


OPERATIONS  ON  THE  HEAD  AND  NECK 


open  up  the  wound,  wash  it  out  with  sterilised  sahne  solution  and  pack 
with  gauze. 

(2)  Enucleation  of  Thyroid  Adenomata.  This  method  has  been  largely 
used  by  Porta,  Billroth,  Socin,  Reverdin,  Wolfier,  and  other  Continental 
surgeons.  Mr.  Symonds  ^  considered  that  it  is  sufficient  and  a  much  less 
severe  operation  to  enucleate  these  instead  of  removing  one  half  of  the 
gland.     In  practising  enucleation  it  is  necessary,  when  the  enlarged  lobe 


Fig.  273. 


Kocher's   thyroid   enucleator,    goitre-holding   forceps,    and   goitre- 
crushing  forceps. 


has  been  exposed  and  brought  well  up  into  the  wound,  to  search  for  and 
define  most  accurately  the  capsule  of  the  adenoma.  The  surface  of  the 
gland  is  exposed  in  the  manner  described  above.  The  most  prominent 
part  of  the  gland  is  then  incised  until  the  capsule  of  the  adenoma  or  cyst 
is  reached. 

In  most  cases  it  will  be  seen  at  once,  but  in  a  few  the  edge  of  the 
gland  may  have  to  be  raised  first.  It  is  most  essential  to  be  sure  that  the 
smooth,  white  covering  is  exposed,  for  if  not,  and  the  dissection  be 
carried  outside  it,  troublesome  haemorrhage  is  sure  to  follow  ;  in  fact, 
the  entire  success  turns  upon  this  point.  Any  surgeon  adopting  this 
method  will  remember  (1)  the  above  danger — a  very  present  one — of 
haemorrhage  ^ ;    the  deeper  the  dissection  has  to  be  carried  the  more 

1  Clin.  Soc.  Trans.,  vol.  xxiii,  p.  51. 

^  Wolfier,  in  his  exhaustive  monograph  (Berlin:  A.  Hirschwald,  1891),  shows  that 
this  method,  while  successful  in  a  great  majority  of  cases,  has  proved  fatal  from  hsemor- 
rhage.  Mr.  Berry  {Lancet,  May  3,  1902)  has  seen  cases  of  death  from  this  cause,  and 
has  heard  of  others. 


OPERATIONS  ON  THE  THYROID  GLAND  629 

severe  this  will  be.  (2)  The  fact  that  these  adenomata  may  be  multiple,^ 
and  that  if  one  be  left  behind  it  may  later  bring  about  eiilargement  ot  the 
lobe  ;  (3)  that  shrinking  of  the  opposite  lobe,  winch  it  is  the  aim  ot  the 
surgeon  to  bring  about  by  removing  one  lobe,  is  not  so  hkely  to  follow  on 
removal  of  an  adenoma  as  it  is  when  one  lobe  and  half  the  isthmus  have 
been  removed  ;  (4)  that  enucleation  is  not  applicable  to  all  cases,  e.g.  the 
gelatinous  form  of  adenoma,  the  multiple  cases  or  where  a  single  one  lies 

deeply.  .  i     x     ^.i 

To  quote  Mr.  Berry,^  the  method  is  obviously  suited  only  to  those 
cases  in  which  the  adenoma  forms  a  well-defined  tumour  embedded  in 
the  thyroid.  Again,  as  pointed  out  by  the  same  authority,  it  is  only 
in  the  unilateral  goitres  that  the  enlargement  is  brought  about  either 
by  adenomata  or  cysts.  A  careful  examination  of  specimens  shows 
that  single  adenomata  are  rare.  They  are  generally  multiple,  and 
often  too  soft  for  enucleation.  For  the  above  reasons  enucleation  is 
not  recommended.  But  the  words  of  Prof.  Kocher  will  be  conclusive, 
"  It  is  the  simplicity  of  the  procedure  that  frequently  misleads  the 
inexperienced  into  giving  it  the  preference  over  excision.  It  is  attended 
with  more  serious  haemorrhage  than  excision,  because  bleeding  and 
general  oozing  occur  from  numerous  small  vessels  in  the  capsule  which 
is  left  behind.  On  this  account,  as  well  as  from  the  fact  that  ^it  does 
not  ensure  a  radical  cure,  it  is  not  a  good  method  to  employ.  The 
same  authority  would  only  perform  enucleation  "  (1)  when  the  other 
half  of  the  thyroid  is  atrophied,  or  has  already  been  removed  ;  (2)  when 
only  one  or  two  isolated  nodules  are  to  be  felt  in  otherwise  healthy  gland 
tissue  ;  (3)  when  a  single  nodule  exists  which  has  caused  extensive 
pressure  atrophy  of  the  surrounding  gland  structure,  so  that  vascular  tissue 
is  only  present  to  a  limited  extent,  generally  posteriorly  ;  (4)  when  the 
goitre  is  very  adherent  to  the  external  capsule  as  a  result  of  inflammation. 

Resection  of  the  thyroid  gland  may  here  be  briefly  alluded  to.  In  this  operation 
the  diseased  portion  of  the  gland  is  alone  removed.  It  should  only  be  carried  out 
when  there  is  a  definite  pedicle  to  the  diseased  portion.  The  gland  is  exposed  in 
the  way  described  above  and  the  pedicle,  after  being  crushed,  is  ligatured  and  then  cut 
through.  If  Ihe  pedicle  is  broad  several  ligatures  may  be  required.  Ihe  chiel 
objection  to  tliis  operation  is  the  danger  of  severe  haemorrhage  ;  this  may  take  place 
as  the  result  of  laceration  of  the  gland  by  the  forceps,  or  from  cutting  through,  or 
separation  of  the  ligatures. 

(3)  Resection-Enucleation.  This  operation  has  considerable  advantages 
over  pure  enucleation  or  resection. 

The  operation  is  thus  described  by  Mr.  Berry  ^  in  the  lectures  before 
quoted.  "  Of  late  years  I  have  been  practising  simple  enucleation  less 
and  less,  substituting  for  it  the  much  more  satisfactory  operation  known 
as  resection-enucleation.  This  consists,  as  is  well  known,  in  proceeding 
as  for  extirpation  in  all  the  earlier  stages  of  the  operation,  as  far  as  the 
isolation  and  dislocation  of  the  lobe.  Pressure  forceps  having  then 
been  applied  to  the  larger  vessels  visible  on  either  side  of  the  line  along 
which  it  is  proposed  to  cut,  the  gland  is  incised  over  a  hmited  area,  gener- 
ally on  the  front  and  inner  aspect  of  the  tumour,  until  its  surface  has  been 
reached.     The  shelhng  out  is  then  performed  at  the  inner  and  back  part 

1  Wolfler  {loc.  supra  cil.)  mentions  a  case  in  which  as  many  as  thirty  or  forty  adenomata 
were  present.  He  states  that  recurrence  took  place  in  one  case  after  this  method  had 
been  employed,  but  that,  as  most  of  the  cases  are  too  recent,  nothing  definite  can  be 
stated  on  this  point. 

2  Birmingham  Med.  Rev.,  1890,  p.  332.  ^  LanceU  1913,  vol.  i,  p.  7.J9. 


630  OPERATIONS  ON  THE  HEAD  AND  NECK 

of  the  tumour  only,  until  the  operator  has  got  well  beyond  the  region  of 
the  recurrent  nerve.  The  glandular  capsule  is  then  again  cut  through  and 
the  whole  tumour  removed,  together  with  most  of  the  thin  and  functionally 
useless  gland  tissue  covering  it.  By  this  means  the  size  of  the  enucleation 
wound  from  which  haemorrhage  occurs,  is  greatly  diminished.  If  the 
tumour  is  a  large  one,  or  if  for  any  reason  the  operation  is  likely  to  be 
accompanied  by  serious  haemorrhage,  it  is  prudent  to  tie  the  superior 
thyroid  vessels  or  even  the  inferior  as  well,  before  incising  the  gland. 
Personally,  it  is  only  in  exceptional  cases  that  I  now  do  either,  as  I 
find  it  is  usually  quite  easy  to  prevent  haemorrhage  by  placing  forceps  on 
the  vessels  on  the  surface  of  the  gland  before  the  latter  is  incised.  It  need 
scarcely  be  said  that  after  placing  forceps  upon  vessels  in  their  continuity, 
care  must  be  taken  to  cut  round  them  lest  the  ligature  should  slip." 

(4)  Ligature  of  the  Thyroid  Arteries.  Wolfler,  who  revived  this  method 
of  treatment,  showed  (1)  that  considerable  shrinking,  with  marked  relief 
to  the  dyspnoea,  should  follow  it,  if  successful,  in  a  few  days,  and  that  there 
should  be  no  reappearance.  Splendid  results  are  here  opposed  by  utter 
failures.  If  in  the  latter  cases  all  the  four  arteries  have  been  tied,  ab- 
normal vessels  have,  perhaps,  existed.  On  this  point  he  quotes  Billroth 
as  to  whether  the  atrophy  will  be  permanent :  "If  all  four  arteries  have 
been  tied,  yes ;  if  the  circulation  is  re-established  either  through  one  of 
the  principal  arteries  or  through  the  vasa  vasorum,  no."  (3)  Experience 
has  shown  that  ligature  of  all  the  four  arteries  is  not  followed  by  gangrene 
of  the  thyroid.  According  to  v.  Eiselsberg,  this  method  (in  parenchy- 
matous goitres)  is  frequently  associated  with  recurrences  :  both  tetany 
and  myxoedema  have  been  recorded  as  consequences. 

According  to  Prof.  Kocher,  ligature  of  the  thyroid  arteries  finds  its 
chief  application  in  the  following  :  (1)  In  Graves's  disease.  In  this 
affection  a  combined  excision  and  ligature  give  still  better  results  than 
hgatm*e  alone  ;  but  excision  is  often  too  dangerous,  and  one  is  very  glad 
to  leave  matters  alone  after  ligaturing  the  three  arteries  which  are  chiefly 
dilated.  It  has  already  been  pointed  out  that  ligature  is  especially 
indicated  in  the  more  severe  cases  of  exophthalmic  goitre.  (2)  In  large 
vascular  colloid  tumours,  especially  of  the  diffuse  Idnd,  where  excision 
is  too  serious  an  undertaking,  first  on  account  of  the  haemorrhage,  and 
secondly  on  account  of  the  sudden  loss  of  a  mass  of  thyroid  tissue  which, 
though  diseased,  was  still  assisting  to  maintain  an  otherwise  imperfect 
function.  These  vessels  vary  so  much  in  situation  and  course,  according 
to  the  size  and  growth  of  the  goitres  in  different  directions,  that  any 
directions  for  finding  them  must  be  uncertain.  The  chief  points  to  bear 
in  mind  are  the  upper  and  lower  parts  of  the  enlarged  lobe  ;  the  superior 
thyroid  artery  is  often  rendered  superficial  by  the  upper  limit  of  the 
tumour  raising  it  up.  Both  vessels  may  be  enlarged  and  somewhat 
softened,  and  thus  secondary  haemorrhage  may  readily  occur  unless 
the  wound  is  kept  sterile.  The  same  free  incisions  as  for  a  partial  thyroid- 
ectomy may  be  required. 

Ligature  oJ  the  Superior  Thyroid  Artery.  Relations.  This  vessel, 
the  first  branch  of  the  external  carotid,  arises  just  above  the  bifurcation 
of  the  common  carotid,  about  a  quarter  of  an  inch  below  the  great  cornu 
of  the  hyoid.  At  first,  covered  only  by  thin  fasciae  and  the  platysma,  it 
ascends  slightly,  and  then  curves  downwards  with  a  tortuous  course, 
covered  by  the  depressors  of  the  hyoid  bone,  and  the  sterno -thyroid. 

Operation.    The  patient's  head  being  suitably  raised,  and  turned  to  the 


OPKRATIONS  OX  THE  THYROID  GLAND  G31 

opposite  side,  an  incision,  about  two  inches  long,  is  made  along  the 
anterior  border  of  the  sterno-mastoid,  with  its  centre  corresponding  to 
the  upper  border  of  the  thyroid  cartilage.  The  superficial  parts  being 
divided,  the  sterno-mastoid  and  the  large  vessels  are  drawn  outwards,  and 
the  omo-hyoid  downwards  and  inwards,  or  this  muscle  may  be  divided. 
The  artery  is  then  searched  for  in  the  hollow  between  the  larynx  and  the 
carotid.  The  ligature  should  be  placed  beyond  the  origin  of  the  superior 
laryngeal  branch.  The  chief  difficulty  will  probably  be  the  number  and 
size  of  the  veins  which  are  met  with.  Some  of  these  will  have  to  be 
divided  between  two  ligatures.  The  superior  laryngeal  nerve  may  be 
seen  and  should  be  carefully  preserved.  The  artery  itself  should  be 
divided  after  the  application  of  double  ligatures.  Kocher  advises  that 
the  lower  ligature  should  be  inspected  to  make  sure  that  the  posterior 
branch  of  the  artery  is  not  given  off  above  the  ligature. 

The  operation  can  be  quite  satisfactorily  carried  out  under  local 
anaesthesia. 

Ligature  of  the  Inferior  Thyroid  Artery.  This  operation  may  be  a  very 
difficult  one,  owing  to  the  depth  of  the  vessel  and  its  intimate  relations  to 
important  structui-es. 

Relations.  The  artery,  the  largest  branch  of  the  thyroid  axis,  ascends 
along  the  inner  border  of  the  scalenus  anticus.  It  then  makes  a  curve  with 
the  convexity  upwards,  passing  inwards  behind  the  carotid  sheath, 
entering  the  gland  near  the  middle  of  the  posterior  border  of  the  lateral 
lobe.  Near  its  commencement  it  is  in  front  of  the  vertebral  artery,  while 
the  middle  cervical  ganglion  of  the  sympathetic  is  in  front  of  it  as  it  curves 
inwards.  At  the  lower  extremity  of  the  thyroid  gland  it  is  in  close 
relation  with  the  recurrent  laryngeal  nerve  ;  the  latter  may  be  either 
in  front  of  or  behind  the  artery.  On  the  left  side  the  thoracic  duct  passes 
in  front  of  the  artery. 

Guide.  The  carotid  tubercle  of  Chassaignac,  or  the  transverse  process 
of  the  sixth  cer\'ical  vertebra.     The  common  carotid  is  also  a  guide. 

Operation.  The  vessel  may  be  secured  either  in  front  of  or  behind 
the  sterno-mastoid.  In  the  former  case  an  incision  three  inches  long  is 
made  along  the  anterior  border  of  the  sterno-mastoid  extending  down 
to  the  cla^acle,  as  if  for  ligature  of  the  common  carotid  low  do'v^Ti  :  the 
deep  fascia  is  opened  and  the  sterno-mastoid  and  the  structures  in  the 
carotid  sheath  drawn  outwards.  The  head  being  now  flexed  to  relax  the 
parts,  the  goitre  is  raised  and  displaced  inwards,  the  carotid  tubercle  is 
felt  for,  and  the  artery  sought  for  below  it,  by  carefully  working  here  with 
a  blunt  dissector.  All  bleeding  must  be  checked  and  the  wound  be 
quite  dry  before  the  artery  is  secured,  or  there  is  great  danger  of  including 
the  recurrent  nerve  in  the  ligature. 

The  artery  may  also  be  secured  through  a  long  incision  along  the 
posterior  border  of  the  sterno-mastoid.  This  method  is  recommended  by 
Mr.  Berry,  who  points  out  that  it  involves  less  disturbance  of  the  gland 
and  less  trouble  with  the  veins.  The  sterno-mastoid,  the  large  vessels 
and  nerves,  are  dra%TO  inwards,  and  the  scalenus  anticus  sought  for,  which 
may  be  recognised  by  the  phrenic  nerve  crossing  it.  The  artery  will  be 
found  running  diagonally  upwards  and  inwards  at  the  inner  margin  of 
this  muscle  after  raising  the  goitre.  The  vessel  should  be  exposed  and 
the  hgature  appHed  as  far  from  the  th}Toid  gland  as  possible,  so  as  to 
avoid  injury  to  the  recurrent  laryngeal,  which,  as  above  stated,  crosses 
over  the  trunk  or  ascends  among  its  branches.     The  neighbourhood  of 


632  OPERATIONS  ON  THE  HEAD  AND  NECK 

other  important  structures,  e.g.  the  phrenic  nerve  and,  on  the  left  side, 
the  oesophagus  and  thoracic  duct,  must  be  remembered. 

Treatment  of  Intrathoracic  Goitres.  As  has  already  been  pointed 
out  these  goitres  are  especially  likely  to  produce  severe  dyspnoea  by 
pressure  on  the  trachea.^  An  intrathoracic  tumour  of  considerable  size 
may  be  present  with  little  or  no  swelling  in  the  neck  :  the  diagnosis  may 
on  this  account,  be  difficult,  in  which  case  the  tumour  will  probably 
originate  from  the  lower  pole  of  one  of  the  lateral  lobes. 

The  earlier  steps  of  the  operation  are  the  same  as  those  given  already. 
Kocher's  "  collar  "  incision  should  be  employed,  as,  until  the  tumour  is 
actually  exposed,  it  may  be  impossible  to  say  to  which  side  of  the  thyroid 
it  is  attached.  The  superior  thyroid  vessels  should  first  be  identified  and 
hgatured.  The  isthmus  is  next  separated,  divided  after  being  crushed,  and 
tied.  The  depressors  of  the  hyoid  will  have  to  be  divided,  and  it  may 
even  be  necessary  to  cut  through  the  sternal  head  of  the  sterno-mastoid. 
All  veins  and  fascial  bands  must  be  divided  between  ligatures.  Attempts 
may  now  be  made,  by  drawing  on  the  gland,  to  pull  the  tumour  up  from  the 
thorax.  If  these  are  not  successful  a  finger  should  be  introduced  behind 
the  manubrium,  or  Kocher's  elevator,  shaped  like  a  blunt  spoon,  will  be 
useful  in  freeing  the  intrathoracic  portion.  If  this  is  not  available  an 
ordinary  tablespoon  with  the  handle  bent  to  a  suitable  curve,  as  recom- 
mended by  Mr.  Berry,  may  be  employed.  Kocher's  goitre  forceps,  with 
ring-shaped  blades  and  hooks  to  prevent  slipping,  and  giving  a  firm  grip 
without  causing  haemorrhage,  are  most  useful  for  pulhng  on  the  tumour. 
If  in  spite  of  these  procedures  the  tumour  is  too  large  to  pass  through  the 
superior  aperture  of  the  thorax  some  steps  must  be  taken  to  reduce  its 
size.  Thus,  if  a  cyst  is  present  this  may  be  incised  and  the  contents 
allowed  to  escape  :  if  the  tumour  is  solid  it  may  have  to  be  broken  up 
(exenteration).  The  latter  procedure  is  likely  to  be  followed  by  severe 
haemorrhage,  and,  if  it  has  to  be  tried,  the  remains  of  the  tumour 
should  be  drawn  out  as  quickly  as  possible  and  any  vessels  at  once 
secured. 

The  great  danger  of  the  operation  is  haemorrhage.  As  many  vessels 
as  possible,  including  the  inferior  thyroid  artery  if  it  can  be  identified, 
should  be  tied,  before  attempts  are  made  to  withdraw  the  tumour  from  the 
thorax.  If,  in  spite  of  all  care,  the  inferior  thyroid  artery  should  be  torn, 
Prof.  Kocher  points  out  that  the  bleeding  may  be  stopped  by  firm  pressure 
with  the  finger  downwards  and  outwards,  after  which  the  vessel  can  be 
caught  and  secured. 

Operation  for  a  Goitre  growing  from  the  Isthmus.  A  cyst  in  this 
region  may  be  enucleated.  An  adenoma  will  frequently  be  found  to 
extend  laterally  into  one  lobe.  As  a  division  of  the  gland  on  each  side 
of  the  tumour  mil  be  necessary  the  collar  incision  should  always  be 
employed.  A  pedicle  will  certainly  be  present  on  one  side.  This  should 
be  separated,  crushed  and  ligatured.  The  isthmus  is  then  cleared  away 
ficm  the  trachea,  any  veins  and  branches  of  the  superior  thyroid  artery 
being  secured  and  ligatured.  The  pedicle  on  the  opposite  side  is  then 
crushed  and,  after  one  or  more  ligatures  have  been  applied,  is  divided. 

In  some  cases  of  severe  dyspnoea,  where  for  some  reason  any  more 
radical  treatment  is  deemed  inexpedient,  the  isthmus  may  be  excised  or 
divided. 

^  See  a  paper  by  Dr.  Walton  Martin  on  "  Large  Intra-thoracic  Cysts  of  the  Thyroid 
causing  DyspncEa  "  {Ann.  oj  Surg.,  1911,  vol.  liii,  p.  737). 


OPKHATIONS  ON  THE  THYROID  (iLAND  633 

Cases  of  Goitre  which  persist  or  recur  after  operation.  These  are 
rare  after  removal  of  half  the  thyroid.  After  enucleation  it  is  much 
more  common.  Brunner  has  shown  that  of  18  per  cent,  of  recurrences 
after  thyroid  operations  the  majority  were  after  enucleation.  These 
recurrent  cases  are  rendered  difficult  (a)  by  the  presence  of  the  scar  of  the 
previous  operation,  (b)  by  the  fact  that  myxcedema  and  tetany  are  liable 
to  follow  complete  removal. 

Prof.  Kocher's  advice  is  as  follows  :  The  remaining  lobe  is  isolated 
in  the  usual  way,  access  being  gained  laterally  ;  and  where  the  cicatricial 
adhesions  cause  much  difficulty,  the  scar  should  be  removed  with  that 
part,  of  the  goitre  which  is  resected.  If  the  upper  part  of  this  appear 
healthy,  the  superior  thyroid  vessels  are  not  tied  ;  sufficient  of  the  gland 
is  left  connected  with  them,  its  junction  with  the  rest  being  crushed 
through  ;  the  crushed  lower  part  is  then  ligatured  and  removed  according 
to  the  directions  already  given.  If  the  upper  part  is  diseased,  the 
superior  thyroid  vessels  are  first  tied,  the  goitre  is  then  displaced,  the 
thyroidea  ima  veins  ligatured  and  the  goitre  separated  from  the  trachea. 
Partly  by  crushing,  partly  by  careful  enucleation  of  colloid  material 
from  within  the  capsule,  a  pedicle  may  be  formed  which  can  be  ligatured. 
Thus  sufficient  thyroid  tissue  is  left  below,  nourished  by  the  inferior 
thyroid  artery.  The  upper  portion  is  removed.  Some  form  of  efficient 
crushing  forceps  is  essential. 

Treatment  of  Thyroid  Cysts.  These  are  sometimes  of  much  importance 
owing  to  their  size,  their  important  relations  and  occasional  vascularity. 

As  has  already  been  pointed  out,  these  are  best  treated  by  enucleation 
or  by  enucleation-resection.  Where  there  are  many  cysts,  or  where  a 
cyst  is  combined  with  much  disease,  the  whole  portion  of  the  thyroid 
affected — usually  half  the  gland — had  better  be  removed.  Where 
excision  is  impossible^ — a  rare  condition — the  method  of  incision  may  be 
employed.  The  soft  parts  having  been  duly  sterilised,  an  incision  is 
made  through  them  down  to  the  cyst,  and  any  bleeding-points  secured. 
The  cyst  is  then  slit  open  and  its  interior  examined.  A  cyst  may  vary 
considerably  both  as  to  its  thickness  and  contents,  and  the  vascularity 
of  its  lining  membrane.  Thus  the  contents  may  be  a  serous,  mucoid, 
gelatinous  or  grumous  material,  or  coagulated  blood  clot.  The  amount 
of  vascularity  is  of  twofold  importance  :  if  of  very  long  standing  the 
cyst- wall  may  be  so  fibrous  and  evascular  that  sloughing  of  it  may  readily 
take  place,  especially  if  the  wound  becomes  infected.  On  the  other 
hand,  it  may  be  extremely  vascular,  in  which  case  such  abundant  hsemor- 
rhage  will  take  place  as  will  leave  no  time  for  suturing,  and  require 
immediate  plugging  with  gauze. 

In  the  few  cases  at  the  present  day  where  incision  is  called  for  it  will 
generally  be  done  as  a  preliminary  to  excision,  as  in  the  cases  alluded  to 
at  p.  632.  If  for  any  reason  further  treatment  is  considered  undesirable, 
the  interior  may  be  gently  curetted,  the  cavity  plugged  with  sterile  gauze, 
and  the  cut  margin  of  the  cyst  sutured  to  the  edge  of  the  skin.  The 
obliteration  of  the  cyst  will  certainly  be  very  tedious,  and  a  sinus  will 
persist  for  a  long  time. 

Formerly  thyroid  cysts  were  sometimes  treated  by  blistering,  or  by  the 
injection  of  substances  such  as  perchloride  of  iron,  or  tincture  of  iodine. 
These  methods  must  be  regarded  as  obsolete. 

Question  of  Operation  in  Malignant  Disease  of  the  Thyroid.  Both  sarcoma 
and  carcinoma  may  be    met  with,  and  a  third  variety  of  maUgnant  disease   is 


634  OPERATIONS  ON  THE  HEAD  AND  NECK 

the  mysterious  "  malignant  adenoma,"  characterised  by  the  peculiarity  of  its 
metastases  which  especially  affect  the  bones,  e.q.  skull,  sternum,  &c.  These  meta- 
stases may  appear  while  the  thyroid  itself  appears  normal,  and  in  some  cases  it  may 
be  impossible  to  detect  either  in  the  apparently  normal  thyroid  or  the  metastases 
any  histological  difference  from  normal  typhoid  tissue.  The  operative  steps  to 
consider  are  attempted  removal  and  palliative  tracheotomy.  With  regard  to  the 
former  the  remarks  on  p.  618  should  be  referred  to,  and  it  may  again  be  insisted 
upon  here  that  such  an  operation  is  only  likely  to  be  successful  if  the  disease  has 
not  extended  beyond  the  capsule  of  the  gland.  Unfortunately  this  usually  happens 
at  a  very  early  stage  and  generally  posteriorly  so  that  the  trachea,  carotid  sheath, 
oesophagus,  and  the  nerves  are  invaded  by  the  growth.  A  palliative  tracheotomy 
will  be  called  for  to  relieve  dyspnoea,  but  it  will  be  a  difficult  and  dangerous  operation. 
The  tracheotomy  will  be  a  low  one,  and  a  long  cannula,  such  as  Konig's  flexible 
tracheoomy  tube,  will  probably  be  required. 

Dangers  of  the  Operation,  Immediate  and  Later.  (1)  Hcemorrhage. 
This  can  usually  be  met  by  paying  careful  attention  to  the  details  given 
above  in  the  account  of  the  operation.  One  of  the  most  important 
points  is  to  expose  the  growth  thoroughly,  (a)  by  a  sufficient  incision, 
{b)  by  adequate  retraction  or  division  of  the  overlying  muscles,  and  (c)  by 
identif}'ing  the  capsule  itself.  A  mistake  is  often  made  here,  and  the 
difficulties  of  the  operation  are  largely  and  needlessly  increased.  The 
layers  of  deep  cervical  fascia  over  the  thyroid  vary  in  individual  cases. 
Every  one  must  be  divided,  in  the  whole  extent  of  the  wound,  before  the 
goitre  itself  is  dealt  with.  This  will  be  recognised  by  its  peculiar  colour 
(reddish-purple),  its  consistence,  and  the  way  in  which  the  vessels  ramify 
and  stand  out  on  its  surface.  The  arteries  are  usually  easily  commanded  ; 
it  is  the  veins  which  give  trouble,  being  numerous  and  thin- walled,  and, 
in  the  severer  cases,  met  with  at  every  step  of  the  operation.  In  these 
cases,  also,  when  the  growth  is  soft  as  well  as  vascular,  any  opening  of  the 
capsule  is  liable  to  give  rise  to  flooding  of  the  wound  with  blood,  which 
makes  it  difficult  to  find  the  bleeding-point,  thus  incurring  risks  of  in- 
cluding in  a  ligature  or  otherwise  injuring  important  structures  such  as 
the  recurrent  laryngeal.  Even  in  the  removal  of  a  small  tumour,  if  soft 
and  rapidly  growing,  most  severe  hsemorrhage  may  be  met  with,  especially 
if  the  capsule  be  opened. 

Thus,  Mr.  Foy,^  after  shelling  out  a  tumour  the  size  of  a  hen's  egg,  met 
with  such  copious  bleeding  that  the  application  of  seven  clip-forceps  gave 
no  appreciable  check  to  the  flow.  The  wound  was  plugged  with  sponges, 
kept  in  place  by  uniting  the  wound  with  figure  of  eight  sutures.  The 
patient  recovered. 

Occasionally,  even  though  there  be  no  bleeding  when  the  wound  is 
closed,  severe  hsemorrhage  may  occur  some  hours  after  the  patient  has 
been  returned  to  bed.  This  is  probably  due  to  some  ligature  having  been 
displaced  by  the  movements  brought  about  by  swallowing  or  vomiting, 
though  sometimes  a  clot  may  be  displaced  by  an  increase  in  the  blood 
pressure.  Blood  will  probably  escape  through  the  drainage-tube  and 
soak  the  dressings,  while  a  hsematoma,  possibly  as  large  as  or  even  larger 
than  the  original  tu.rnour,  may  form  in  the  loose  tissues  of  the  neck.  The 
only  treatment  under  these  circumstances  is  to  open  up  the  wound,  to 
sponge  away  the  blood  clot,  and  to  look  for,  secure,  and  ligature  any 
bleeding-point.  General  oozing  may  be  stopped  by  irrigation  with  hot 
saline  solution.  When  the  bleeding  has  been  satisfactorily  stopped 
infusion  will  most  likely  be  necessary.     As  a  prophylactic  measure  against 

1  Dub.  Med.  Journ.,  1888,  vol.  i,  p.  242. 


OPERATIONS  ON  THE  THYROID  GLAND  G35 

this  recurrent  haemorrhage  the  patient's  head  sliould  be  kept  as  still  as 
possible  for  the  first  twenty-four  hours. 

(2)  Injury  to  the  recurrent  laryngeal  nerve,  asphyxia,  aphonia.  This 
most  grave  accident  has  happened  with  sufficient  frequency  to  put  any 
surgeon  on  his  guard.  The  injury  may  be  due  to  including  the  nerve 
in  a  ligature,  cutting  the  nerve,  or  seriously  bruising  it.  Aphonia  after 
the  operation  may  be  due  to  one  of  the  following  causes  :  (a)  Wound  of 
the  recurrent  laryngeal  nerve  ;  (h)  dragging  on  this  nerve  ;  (c)  perhaps 
section  of  the  crico-thyroid  branch  of  the  superior  laryngeal  ;  (d)  months 
after  the  operation  it  may  come  on  from  inclusion  of  the  recurrent 
laryngeal  nerve  in  the  cicatrix ;  (e)  when  the  laryngeal  symptoms  are 
progressive,  from  ascending  neuritis.  This  may  be  i)resent  before  the 
operation,  and  so,  too,  may  be  (/)  compression  of  the  recurrent  laryngeal 
by  the  goitre.  Whatever  be  the  exact  cause,  it  is  certain  that  the 
dyspnoea  and  aphonia  are  not  always  permanent.  Thus,  this  complication 
occurred,  but  subsequently  cleared  up,  in  a  patient  on  whom  Mr.  Jacobson 
operated  in  June  1894. 

The  patient  was  aged  35,  the  subject  of  an  ordinary  solid  bronchocele,  of  large 
dimensions,  the  right  lobe  being  seven  inches  long.  The  voice  was  decidedly  weak 
before  the  operation,  but  while  this  presented  no  difficulties  and  was  not  accom- 
panied by  any  cyanosis,  dysjDncea,  &c.,  it  was  followed  by  marked  aphonia,  the 
voice  being  reduced  to  a  loud  whisper.  The  right  vocal  cord  was  now  found  to  be 
motionless.  Complete  recovery  had  taken  place  in  April  1895.  In  February  1899 
the  patient  was  seen  again  for  a  Colles's  fracture.  Her  voice  was  then  good  though 
a  little  weak. 

Injury  to  the  nerve  is  especially  hkely  to  occur  under  the  following 
conditions  :  (a)  Where  the  growth  is  huge  ;  (b)  when  it  is  very  fixed 
or  where  it  has  a  broad  base  ;  (c)  when  it  is  ill-defined  ;  (d)  when  it 
encircles  the  oesophagus  and  the  trachea  closely  ;  (e)  when  it  is  mahgnant. 
Ad\'ice  as  to  the  avoiding  of  this  complication  is  given  in  the  description 
of  the  operations. 

(3)  Cellulitis,  leading  to  purulent  and  diffuse  mediastinitis.  This 
is  very  liable  to  occur  if  the  wound  becomes  infected.  In  such  cases 
the  latter  complication  is  almost  certain,  even  in  small  goitres,  if  they 
dip  down  behind  the  sternum,  owing  to  the  difficulty  of  providing  adequate 
drainage.  The  accompanying  symptoms  are  pain  in  the  region,  coming 
on  soon  after  the  operation  and  increasing,  followed  by  feebleness  of  the 
pulse,  distress,  dyspnoea,  and  speedy  death. 

(4)  Myxcedema,  both  acute  and  more  deferred.  This  condition,  which 
unexpectedly  overclouded  othermse  successful  operations  for  complete 
removal  of  an  enlarged  thyroid  gland,  was  first  noticed  and  published  by 
Kocher  and  Reverdin.^  The  probable  explanation  is  the  one  which  Sir 
V.  Horsley  brought  before  the  profession  in  his  lucid  and  convincing 
Brown  Lectures  of  1 885.^  The  following  extract  is  of  interest  to  the  oper- 
ating surgeon  : 

Effects  of  Excision  :  Phenomena  following  complete  thyroidectomy  in  monkeys  : 
"  At  a  variable  period  after  the  operation,  but  averaging  five  days,  the  animal 

1  Ajxh.f.  Klin.  Chir.,  Bd.  xxix,  S.  254,  1883. 

2  Brit.  Med.  Jomn.,  January  17  and  31,  1885.  "  The  Thyroid  Gland  :  Its  relation 
to  the  pathology  of  Myxcedema  and  Cretinism,  to  the  question  of  the  surgical  treatment 
of  Goitre,  and  to  the  General  Nutrition  of  the  Body."  Further  detailed  and  most  inter- 
esting information  is  given  by  Sir  V.  Horsley :  "  The  functions  of  the  Thyroid  Gland  " 
[Brit.  Med.  Journ.,  1892,  vol.  i,  pp.  215,  265),  and  in  his  report  as  a  member  of  the 
Clinical  Society's  Committee  on  Myxcedema,  1888. 


636  OPERATIONS  ON  THE  HEAD  AND  NECK 

is  found  to  have  lost  its  apjietite  for  a  day  or  two,  and,  on  closer  examination,  to 
exhibit  slight  constant  fibrillar  tremors  in  the  muscles  of  the  face  and  hands  and  feet. 
These  tremors  disajji^car  at  once  on  voluntary  effort.  At  the  same  time  the  animal 
is  noticed  to  be  growing  pale  and  thin,  in  spite  of  the  appetite  returning  quickly  ; 
rapidly  the  tremors  increase,  affect  all  the  muscles  of  the  body  without  exception, 
the  animal  becomes  languid,  paretic  in  its  movements,  and  imbecile.  Then  puffiness 
of  the  eyelids  and  swt^lling  of  the  abdomen  follow,  with  increasing  hebitude.  During 
the.se  last  stages  the  temperature  becomes  subnormal  and  then  the  tremors  disappear 
as  they  came.  Meanwhile  the  pallor  of  the  skin  often  becomes  intense,  and,  leuco- 
cytosis  having  been  well-marked,  oligaemia  follows,  and  the  animal  dies  perfectly 
comatose  in  a  variable  period,  but  usually  about  five  or  seven  weeks  after  operation." 

Mr.  Berry,  in  his  Lettsomian  lectures,  quoted  above,  says  that  provided 
that  one  leaves  the  patient  a  sufficiency  of  healthy  thyroid  tissue,  a 
quantity  which  may  be  estimated  at  from  a  sixth  to  a  quarter  of  the  gland, 
there  will  be  no  danger  of  myxoedema,  or  of  the  next  possible  sequela  to  be 
described,  tetany. 

At  the  present  day  it  is  thoroughly  recognised  that  complete  removal 
of  the  gland  is  an  unjustifiable  proceeding,  and  hence  this  complication, 
except  occasionally  in  a  slight  and  transient  degree,  is  practically 
unknown. 

In  the  laborious  report  of  the  Clinical  Society  on  myxoedema  it  is 
stated  that  myxoedema  followed  in  about  33  per  cent,  of  all  cases  of  com- 
plete thyroidectomy.  Doubtless  in  some  cases  regarded  as  complete 
removal  of  the  gland  sufficient  thyroid  tissue  has  really  been  left  behind. 
The  existence  of  residual  and  also  of  accessory  thyroid  tissue  probably 
account  for  many  of  the  cases  where  complete  removal  has  been  stated 
to  have  been  followed  by  no  ill  effects. 

(5)  Tetany.  It  has  been  stated  that  tetany  is  likely  to  occur  especially 
if  the  parathyroids  ^  have  been  removed  in  addition  to  the  diseased  portion 
of  the  thyroid.  Though  tetany  may  follow  complete,  or  nearly  complete, 
removal  of  the  thyroid,  there  is  no  clinical  evidence  to  show  that  this 
depends  upon  removal  of  the  parathyroids.  Mr.  Berry  says,  "  For  many 
years  I  have  been  in  the  habit  of  removing  such  portions  of  the  thyroid 
gland  as  seemed  advisable  without  paying  any  attention  whatever  to  the 
parathyroids.  I  never  remove  the  whole  thyroid,  but  I  have  often 
removed  both  inferior  horns,  or  both  superior  horns,  or  the  whole  or 
nearly  the  whole  of  one  lobe  together  with  a  half  or  even  more  of  the 
opposite  lobe,  either  the  upper  or  the  lower  half.  In  no  single  case  have 
I  seen  tetany,  although  I  have  been  fully  aware  of  the  possibility  of  its 
occurrence  after  too  free  a  removal  of  the  gland,  and  have  been  constantly 
on  the  watch  for  it." 

The  following  is  a  most  instructive  case  of  fatal  tetany  after  w^hat 
amounted  to  a  complete  removal  of  the  gland,  published  by  a  surgeon 
of  large  experience.  Prof.  Madden,  Cairo  School  of  Medicine. ^  A  girl, 
aged  12  years,  had  a  large  trilobed  goitre,  so  easily  shelled  out  that  the 
operator  was  tempted  to  remove  it  entirely,  leaving  a  piece  of  the  isthmus 
the  size  of  a  walnut.  On  the  third  day  there  were  signs  of  tetany,  which 
disappeared  when  thyroid  tabloids  were  given.  As  marked  emaciation 
followed,  maltine  was  substituted.  On  the  twelfth  day  the  tetany  re- 
appeared.    Thyroid  tabloids    were    again    given,  but    with    no    effect. 

^  The  parathyroid  question  is  discussed  by  Dr.  C'has.  H.  Mayo  in  a  paper  in  the  Ami. 
of  Surg.,  1909,  vol.  1,  p.  78.  In  1200  operations  for  goitre  the  writer  has  seen  no  case 
of  tetany.  Should  tetany  follow  the  operation,  he  recommends  the  administration  of 
calc.  lactate  in  4  or  5  per  cent,  solution,  either  by  mouth,  rectum,  or  intravenously. 

2  Lancet,  June  20,  1903,  p.  1729. 


OPERATIONS  ON  THE  THYROID  GLAND  G37 

Twenty-four  days  after  the  operation  death  took  place  in  an  attack  of 
tetany,  general,  but  especially  affecting  the  respiratory  muscles.  The 
necropsy  showed  no  trace  of  thyroid  tissue.  The  small  portion  left  had 
completely  atrophied. 

Operation  for  Lingual  Goitre,  or  Accessory  Thyroid  ^  at  the  base  of  the 
tongue.  These  tiiiuouis  arise  in  eoiiiiectioii  with  the  thyro-glossal  duct, 
which,  in  fa'tal  Hfe,  extends  from  the  foramen  caecum  of  the  tongue 
to  the  isthmus  of  the  thyroid.  The  operation  here  must  be  either 
through  the  mouth,  or  by  the  transhyoid  or  suprahyoid  routes.  In 
making  his  choice  the  surgeon  must  not  attach  too  much  importance 
to  the  fact  that  accessory  thyroids  of  the  tongue  usually  occur  in  female 
patients,  and  that  the  intra-oral  operation  leaves  no  external  scar.  He 
must  remember  the  position  of  the  growth  far  back  close  to  the  aperture 
of  the  larynx,  the  vascularity  of  the  region,  and  the  need  of  total  enuclea- 
tion, otherwise  recurrence  of  the  trouble  is  certain.  Such  tumours  may 
be  removed  through  a  median  incision  extending  from  the  symphysis 
of  the  lower  jaw  downwards  to  below  the  hyoid  bone.  Dermoids  and 
small  encapsuled  growths  may  be  removed  in  this  way,  but  if  they 
are  of  large  size,  or  if  malignancy  is  suspected,  it  will  be  necessary  to 
divide  the  symphysis  of  the  inferior  maxilla  and  to  retract  the  two 
halves.  The  muscles  are  divided  and  separated  in  the  mid-Une  and  the 
tumour  enucleated  by  a  blunt  dissector.  This  route  gives  good  access, 
is  well  removed  from  the  aperture  of  the  larynx,  gives  good  drainage, 
and  the  median  scar  left  is  not  disfiguring.  If  the  growth  is  certainly 
mahgnantthe  advice  given  on  p.  5.54  for  removal  of  growths  at  the  base 
of  the  tongue  should  be  consulted. 

The  intra-oral  route  may  be  preferred  by  some  when  the  mouth  is 
large,  the  tongue  slim  and  not  bulky,  and  where  the  growth  projects  well 
on  its  dorsum. 2 

All  haemorrhage  must  be  arrested  absolutely  owing  to  the  position  of 
the  wound,  and  this  should  be  partially  closed  with  a  few  catgut  sutures. 

1  Cases  of  lingual  thyroid  tumours  have  been  published  by  Mr.  W.  E.  Spencer  (Proc. 
Roy.  Soc.  Med.,  Lar.  Sec.  December  1910),  ]Mr.  Stuart  Low  {Proc.  Roy.  Sac.  Med.,  Lar. 
Sec,  May  1909),  and  Dr.  R.  A.  Stirling  {Ann.  Surg..  1907,  vol.  xlvi.  p.  826). 

2  Storrs,  Ann.  of  Surg.,  1904,  p.  323. 


CHAPTER  XXX 

OPERATIONS  FOR  THE  REMOVAL  OF  LARGE  DEEP- 
SEATED  GROWTHS  IN  THE  NECK,  TUBERCULOUS  GLANDS, 
LYMPHANGEIOMATA,  THYROGLOSSAL  AND  BRANCHIAL 
CYSTS.    REMOVAL  OF  CERVICAL  RIBS 

Before  deciding  to  undertake  the  removal  of  one  of  these,  the  surgeon 
should  consider  carefully  the  following  points  : 

A.  The  nature  and  surroundings  of  the  growth. 

B.  His  operative  skill  in  these  cases,  and  his  knowledge  of  anatomy. 

C.  His  experience  in  aseptic  surgery,  and  in  keeping  a  large  wound 
sterile. 

The  chief  growths  which  call  for  a  decision  are  the  following  :  The 
(rarely  met  with)  more  innocent  ones,  e.g.  fibromata,  glandular  tumours 
including  the  tuberculous  ;  sarcomata,  very  likely  cystic,  originating  in 
the  neck  apart  from  the  cervical  glands,  sarcomata  of  the  tongue,  lip 
(p.  548),  &c.  Of  the  three  points  above  mentioned,  it  will  only  be  needful 
to  consider  separately  the  first ;  the  importance  of  the  two  others  will  be 
sufficiently  shown  in  the  remarks  on  the  operation  and  after-treatment. 

A.  The  Nature  and  Surroundings  o£  the  Growth.  In  examining  into 
these,  careful  attention  should  be  paid  to  the  following  :  Duration,  rate 
of  increase,  amount  of  fixity.  How  far  this  last  was  early  established,  and 
how  far  it  is  absolute,  are  of  the  utmost  importance.  The  gravest  cause 
of  fixity  is,  of  course,  a  growth  with  a  wide  base,  or  numerous  root-like 
processes  extending  into  important  parts.  The  fixity  should  be  tested  by 
seeing  how  far  the  finger-tips  can  be  insinuated  beneath  the  growth,  how 
far  it  can  be  lifted  up,  and  the  amount  of  its  connection  to  parts  such  as 
the  jaw  and  larynx,  the  head  being  steadied  by  an  assistant  while  the 
growth  is  lifted  up  and  its  deep  processes  put  on  the  stretch  as  much  as 
possible.  The  outline  :  is  this  well  marked  or  indistinct,  and,  if  the  latter, 
is  it  in  dangerous  regions,  such  as  the  parotid,  the  zygomatic,  and  other 
fossae,  that  the  growth  is  lost  ?  Its  relation  to  important  structures, 
and  the  degree  to  which  it  blends  with  them  :  thus,  any  evidence  of 
pressure  on  vessels  and  nerves,  trachea  and  pharynx,  &c.,  should  be 
carefully  looked  for,  e.g.  weakness  of  the  temporal  pulse,  engorgement  of 
veins  above,  alteration  of  pupil,  numbness  of  upper  limb,^  dyspncEa,  or 
dysphagia.  Does  the  growth  dip  near  or  into  the  thorax  ?  How  far 
under  the  sterno-mastoid  does  it  go  ?  Are  the  glands  enlarged  as  well  ? 
Is  the  skin  involved  ?  This  last  point,  together  with  fixity,  indistinctness 
of  outline,  rapid  growth,  softness,  and  fusion  with  surrounding  parts,  is 
of  chief  importance,  and,  if  co-existing  to  any  extent,  will  usually  put 
any  operation  out  of  the  question. 

^  Growths  springing  from  the  lower  vertebraj  or  the  first  rib  may  interfere  with  the 
nerves  and  vessels  of  the  arm.  Such  a  case  was  brought  before  the  Medico-Chirurgical 
Society,  January  12,  1886,  by  Dr.  Bruce  and  Mr.  Bellamy. 

638 


REMOVAL  OF  GROWTHS  IN  THE  NECK     G39 


MAIN  POINTS  IN  THE  OPERATION  ITSELF 

(i)  Free  Exposure  oJ  the  Growth.  The  incisions  should  be  sufficient, 
the  fiaps  turned  back,  V,  T,  or  X  in  shape.  Thus,  if  the  growth  be  in 
the  anterior  triangle,  not  encroaching  on  the  posterior,  a  V-shaped  flap 
with  the  base  upwards,  one  hnib  along  the  sterno-mastoid  and  the  apex 
above  the  sternum,  may  be  employed,  or  one  with  the  long  limb  inside  the 
entire  length  of  the  above-mentioned  muscle,  and  another  at  right  angles 
to  it  at  the  level  of  the  thyroid  cartilage,  curving  upwards  towards  the 
chin.  If  the  growth  invade  both  triangles,  and  it  be  necessary  to  divide 
the  sterno-mastoid,  an  incision  obliquely  across  both  triangles,  and  over 
the  muscle,  from  mastoid  process  to  sternum,  and  then  a  second  to  make 
it  crucial,  will  be  the  best.  Where  it  is  not  needful  to  divide  the  muscle 
the  incision  going  by  the  name  of  Dr.  Beatson,  of  Glasgow,  will  be  sufficient 
and  leave  a  less  noticeable  scar.  It  begins  in  the  submaxillary  region 
near  the  angle  of  the  jaw,  is  carried  outwards  across  the  sterno-mastoid 
and  the  posterior  triangle  as  far  as  the  anterior  border  of  the  trapezius. 
It  is  then  carried  down  the  anterior  border  of  this  muscle  as  far  as  the 
clavicle  and  then  forwards  over  the  sterno-mastoid,  again  to  end  at  the 
sterno-clavicular  joint.  The  large  flap  is  turned  forwards,  and  access  thus 
gained  to  both  triangles.  It  is  always  to  be  remembered  that  inadequate 
exposure  of  the  tumour  will  lead  to  groping  in  the  dark,  bruising  of  the 
soft  parts,  and  injury  to  important  structures. 

(ii)  Deeper  Dissection.  In  this  attention  must  be  paid  to  :  (a)  Work- 
ing as  much  as  possible  with  a  dissector,  Kocher's  elevator  (p.  628), 
or  using  blunt-pointed  scissors  partly  to  cut  with  and  partly  closed  as  a 
blunt  dissector,  and  keeping  the  instrument  used  close  to  the  growth.  The 
dissection  should  be  begun  either  where  the  growth  is  most  free,  and 
where  its  relations  are  not  important,  or  by  at  once  identifying  the 
most  important  structures,  e.g.  the  carotid  sheath  and  internal  jugular 
vein. 

(6)  Clamping  or  tying  with  sterilised  ligatm'es  every  vessel  before 
it  is  divided,  not  only  to  minimise  the  loss  of  blood,  but  also  to  avoid 
the  risk  of  air  entering  the  veins,  especially  low  down  in  the  neck. 

(c)  Of  the  important  structures  to  be  remembered  several  are  alluded 
to  in  the  next  section.     Others  must  be  remembered. 

Injury  to  the  Vagus  on  one  side.  Accidental  ligature  or  clamping  of 
this  nerve  has  been  followed  by  perilous  interference  with  respiration  and 
the  heart's  action.  Division  or  resection  of  the  trunk  below  the  origin  of 
the  superior  laryngeal  nerve  will  lead  to  hoarse,  diminished  voice  from 
paralysis  of  the  recurrent  laryngeal  branch,  while  after  injury  higher  up, 
m  addition  to  these  laryngeal  symptoms,  there  will  be  diminished  sensa- 
tion of  the  mucous  membrane  of  the  larynx.  While  not  of  itself  imme- 
diately fatal,  injury  to  the  vagus  is  a  serious  addition  to  the  dangers 
which  a  patient,  usually  of  diminished  vitality,  and  often  advanced  in 
years,  has  to  pass  through  after  a  prolonged  operation  for  the  removal 
of  a  large  growth  of  the  neck. 

Sir  R.  Godlee  ^  showed  a  child  in  whom,  during  the  removal  of  a  deep-seated 
growth,  the  nature  of  which  was  doubtful  and  which  was  pressing  upon  the  pharynx, 
the  cervical  sympathetic  had  been  wounded.  The  only  results  were,  that  the  pupil 
on  that  side  was  smaller  but  not  stationary,  and  that  the  ocular  slit  was  also  smaller. 

^  Clin.  Soc.  Trans.,  vol.  xix,  p.  321. 


640  OPERATIONS  ON  THE  HEAD  AND  NECK 

Wounds  o£  the  Thoracic  Duct.^  In  the  extirpation  of  deep  tuberculous 
or  malignant  glands,  especially  if  adherent  and  breaking  down,  extirpation 
of  malignant  growths,  in  ligature  of  the  first  part  of  the  left  subclavian 
artery,  this  complication  has  been  several  times  recorded.  Its  occurrence 
may  be  discovered  at  once,  the  surgeons  seeing  fluid  like  watered  milk 
issuing  from  the  depths  of  the  wound  ;  the  first  intimation  may  be  given 
a  few  hours  after  the  operation  by  the  dressings  being  found  soaked  ; 
or  several  days  later,  the  wound  having  healed  superficially,  a  large  fluc- 
tuating swelling  may  appear,  on  opening  which  a  similar  fluid  escapes. 
If  the  wound  is  a  partial  one  lateral  ligature  or  suture  with  very  fine  silk 
or  catgut  is  the  ideal  treatment.  Deanesley  ^  transplanted  the  severed 
duct  into  the  wall  of  the  vein.  If  the  injury  be  complete,  the  distal  end 
of  the  duct  should  be  ligatured,  but  these  steps  are  difficult  and  liable 
to  failure.  The  treatment  best  adapted  to  the  largest  number  of  cases  is 
pressure  by  a  graduated  tampon  at  the  root  of  the  neck,  the  wound  having 
been  first  carefully  sutured  without  drainage,  if  possible.  The  prognosis 
in  these  days  is  good.  Even  in  those  cases  where  the  discharge  has  been 
profuse  and  loss  of  flesh  has  been  rapid,  recovery  has  usually  followed. 
In  some  cases  this  favourable  result  has  been  due  to  the  main  duct  sub- 
dividing before  its  termination. 

{d)  If  possible,  the  growth-capsule,  which  is  often  soft  and  dehcate, 
must  not  be  ruptured.  On  examining  the  growth  after  removal,  the 
capsule  should  not  only  be  entire,  but  any  process  should  be  blunt  and 
rounded,  not  soft  and  ragged  as  if  torn  away  from  parts  left  behind. 

If  the  surgeon  feel  doubtful  as  to  any  portion  being  left,  as  in  the 
fossae,  about  the  base  of  the  skull,  he  should  use  a  sharp  spoon  and 
Paquelin's  cautery,  or  diathermy  {see  p.  396)  may  be  tried. 

(e)  Throughout  these  operations,  which  may  necessarily  be  prolonged 
and  attended  with  loss  of  blood,  and  in  which  important  parts  may  be 
disturbed  and  pulled  upon,  the  surgeon  should  keep  himself  informed  as 
to  the  effects  of  the  ansesthetic. 

(iii)  Closure  o£  the  Wound  and  Application  of  Dressings.  After  com- 
pletely removing  the  growth  and  any  outlying  glands,  the  resulting 
cavities  are  thoroughly  dried  out,  and  drainage  provided  in  accordance 
with  the  position  which  the  patient  will  occupy.  Tubes  of  sufficient 
size  being  in  position,  the  wound  is  brought  together  and  the  dressings 
applied  with  the  precautions  already  given  at  p.  627. 

OPERATIVE  TREATMENT  OF  TUBERCULOUS  GLANDS 

This  may  be  given  here  owing  to  the  greater  frequency  and  importance 
of  this  disease  in  the  neck. 

Question  of  Operative  Interference.  The  following  abundantly  justify 
something  more  vigorous  than  mere  palliative  treatment  :  (1)  The  fact 
that  one  gland  has  power  to  infect  others,  even  when  the  local  starting- 
point  may  have  been  cured,  though  too  late  to  prevent  extension. 
(2)  The  disease,  if  merely  palliated,  is  often  extremely  tedious,  keeping 
the  patient  from  the  enjoyment  and  activity  of  some  of  the  best  years  of 

1  See  a  paper  by  Dr.  H.  P.  de  Forest  (Ann.  of  Surg.,  1907,  vol.  xlvi,  p.  705).  Dr. 
de  Forest  concludes  that  the  thoracic  duct  has  collateral  branches  which  are  probably- 
able  to  perform  the  functions  of  the  main  duct,  should  this  be  injured.  He  recommends 
that  a  wound  of  the  duct  should  be  treated  in  the  same  way  as  a  wound  of  a  blood-vessel, 
i.e.  that  it  should  be  sutured,  if  possible,  or  ligatured. 

2  Lancet,  1903,  vol.  ii. 


REMOVAL  OF  GROWTHS  IN  THE  NECK  G41 

life.  (3)  The  scars  which  follow  on  a  natural  cure  are  far  more  dis- 
figuring and  extensive  than  those  after  a  well-planned  operation,  especially 
one  ill  which  primary  union  has  been  secured  by  strict  aseptic  precautions, 
and  by  operating  before  casetltion  and  suppuration  have  altered  the 
normal  condition  of  the  parts.  (-1)  The  long  years  a  natural  cure  re- 
quires ;  the  repeated  suppurations  and  the  blighted  days  cause  grave 
deterioration  of  the  general  health,  which  may  persist  for  life,  long  after 
local  cure  has  taken  place.  (5)  The  poor  vitality  thus  induced,  and  the 
actual  presence  of  the  tubercle  bacillus,  render  the  patient  very  liable 
to  such  diseases  as  phthisis.  (6)  The  chief  indication  for  operation  is 
persistence  of  the  disease,  in  spite  of  careful  general  treatment,  and  the 
slightest  evidence  of  commencing  caseation.  (7)  There  are  a  few  and 
very  occasional  cases  in  which  operation  is  to  be  deferred  or  avoided. 
For  instance,  where  (a)  there  is  advanced  disease  elsewhere,  and 
(6)  there  is  threatening  of  a  general  outbreak.  Here  the  temperature 
will  be  a  valuable  guide.  (8)  In  advising  operative  steps  in  tuberculous 
glands  of  the  neck,  any  thoroughly  qualified  surgeon  is  justified  in 
impressing  on  the  friends  (a)  that  the  treatment  of  the  case  will  be 
shortened ;  (6)  that  convalescence  will  be  hastened ;  (c)  the  result 
will  be  more  permanent ;  {d)  if  it  be  performed  early,  less  of  an  operation 
will  be  required. 

The  Chief  Groups  of  Glands  must  be  remembered.  (!)  The  parotid 
or  pre-amicular.  Some  of  these  are  embedded  in  the  sahvary  gland. 
While  the  greater  part  of  the  pes  anserinus  will  be  protected  by  a  sufficient 
layer  of  sahvary  gland  tissue,  its  proximity  is  not  to  be  forgotten,  and 
most  operators  vnW  keep  exceedingly  close  to  tJie  capsule  of  the  diseased 
gland,  and,  if  it  be  adherent,  scrape  rather  than  dissect.  (2)  Posterior 
amicular.  (3)  Suboccipital,  (-i)  Submaxillary.  Some  of  the  deepest 
of  these  he  in  the  folds  of  the  submaxillary  sahvary  gland.  This  structure 
should  be  extirpated  in  all  doubtful  cases.  (5)  Submental,  a  small  group 
often  overlooked.  (6)  Superficial  cervical.  A  group  running  ^^ith  the 
external  jugular  superficial  to  the  sterno-mastoid,  and  along  its  posterior 
border.  When  these  are  adherent  the  presence  of  the  spinal  accessory 
coming  out  into  the  posterior  triangle  must  be  remembered.  (7)  Deep 
cervical,  lying  along  the  carotid  sheath.  Their  relation  to  the  large 
veins  is  alluded  to  below.  (8)  Glands  in  the  posterior  triangle,  continuous 
with  the  superficial  cervical  above  and  (9)  the  supraclavicular  below. 
If  these  last  have  become  affected,  extension  to  the  glands  in  the  axilla 
is  extremely  probable.  (10)  The  suprasternal  gland  in  Burns's  space. 
(11)  The  retro-pharyngeal  group. 

By  far  the  best  is  (A)  Excision.  (B)  Curetting  or  scooping  out  the 
glands  is  very  inferior,  and  only  to  be  made  use  of  in  those  advanced 
cases  where  excision  is  impossible. 

A.  Excision.  General  Principles  to  be  remembered.  These  refer 
chiefly  to  advanced  cases,  (i)  Antedate,  if  possible,  caseation  and  sup- 
pm-ation.  If  these  have  been  allowed  to  run  on  before  an  operation  is 
permitted,  the  parts  will  be  matted,  adherent,  altered  ;  relations  will  be 
difficult,  perhaps  impossible,  to  make  out ;  important  structures,  such 
as  the  internal  jugular  vein,  will  easily  be  damaged  ;  primary  union  will 
be  rarely  secured,  and  the  scar  will,  therefore,  be  needlessly  prominent. 
Where  one  or  more  glands  are  softening,  opening  the  abscess  and  thorough 
curetting  may  suffice  ;  but  as  a  rule  a  sinus  is  left,  and  further  glands  may 
enlarge.     If  the  surroundings  are  favourable  the  suppurating  area  may  be 

SURGERY  I  41 


642  OPERATIONS  ON  THE  HEAD  AND  NECK 

removed  through  a  free  incision.  As  a  rule,  it  is  best  to  open  the  abscess, 
and,  two  or  three  weeks  later,  to  deal  with  its  remains  together  with  the 
rest  of  the  disease.^  Where  a  sinus  is  present  this  should  be  first  curetted 
and  sterilised,  as  far  as  possible,  with  pure  carbolic  acid.  At  the  time  of 
the  operation  sterilisation  should  be  thorough,  the  hair  shaved,  and  kept 
out  of  the  way  with  prepared  towels,  (ii)  Wherever  possible,  the  incision 
should  be  placed  along  some  natural  crease  or  in  some  sulcus,  so  that  the 
scar  should  be  less  noticeable.  But  (iii)  the  incision  must  always  be  suffi- 
ciently free.  The  scar  will  be  little  larger,  and  much  handling  through  a 
small  incision  impedes  primary  union.  Moreover,  a  free  incision  enables 
the  operator,  in  cases  where  caseation  has  already  taken  place,  to  find 
one  or  more  spots  where  the  anatomy  is  normal,  and  where  he  can  start 
with  important  relations,  e.g.  the  internal  jugular  vein,  easily  recognised. 

Transverse  incisions  following  like  folds  leave  less  disfiguring  scars, 
and  should  be  employed  in  slighter  cases.  But  this  fear  of  scars  can  be 
overdone.  The  too  wide  adoption  of  transverse  scars  will  certainly 
defeat  its  object  by  leading  to  repeated  operations.  While  longitudinal 
wounds  may  leave  thicker  scars,  and  ones  more  liable  to  be  keloid,  there 
are  other  conditions  in  their  productions  which  must  be  remembered. 
It  is  the  more  advanced  cases  which  call  for  free  incisions  ;  patients  or 
their  relations,  by  postponing  the  operation  on  account  of  the  fear  of  scars, 
are  often  largely  responsible  for  the  conditions  which  these  incisions  have 
to  meet ;  finally,  in  some  cases  deficiency  in  the  technique  of  the  operation 
must  bear  some  of  the  responsibility.  Several  incisions  have  already 
been  mentioned  (p.  639)  ;  the  two  chiefly  useful  are  one  along  the  cervico- 
submaxillary  crease  and  another  along  the  anterior  border  of  the  sterno- 
mastoid.  In  extensive  cases  it  is  always  well  to  begin  with  deeper  work 
below  where  the  anatomy  is  usually  normal ;  to  define  the  internal  jugular 
vein  here  and  work  upwards  at  first.  The  flaps  must  be  raised  carefully, 
owing  to  superficial  glands  being  often  affected,  which  must  not  be  cut 
into.  Any  infected  skin  or  disfiguring  scars  should  be  left  to  be  re- 
moved with  the  subjacent  glandular  areas.  The  flaps  when  raised  are 
to  be  wrapped  in  sterile  gauze.  Especial  care  must  be  taken  with  the 
upper  one  that  it  is  not  infected  by  the  manipulations  of  the  anaesthetist, 
or  by  saliva  from  the  mouth,  (iv)  The  chief  structures  to  be  remembered 
are  (a)  the  iaternal  jugular  vein.  As  in  all  operations  on  the  neck  where 
this  is  likely  to  be  involved,  the  first  point  is  to  define  it.  This,  for  the 
reason  already  given,  is  best  done  below.  The  edge  of  the  sterno-mastoid 
having  been  defined,  the  deeper  layer  of  deep  fascia  is  incised  here,  the 
sheath  opened,  and  the  vein  well  exposed.  By  working  upwards  towards 
the  more  affected  area  the  glands  can  usually  be  peeled  off  from  the  vessel 
by  insinuating  a  Watson-Cheyne  dissector,  the  closed  ends  of  blunt- 
pointed  curved  scissors,  or  an  elevator  such  as  Kocher's  (p.  628). 

Frequently,  when  the  glands  seem  quite  adherent,  careful,  patient 
working  is  successful  in  leaving  the  vessel  unopened.  Where  the  glands 
are  too  adherent  to  admit  of  this  and  the  vein  is  torn,  the  opening, 
caught  with  Spencer-Wells  forceps,  may  be  tied  up,  or  sutured  laterally 
with  fine  catgut.  To  admit  of  this  being  done  a  sufficient  area  of  the  vessel 
must  be  exposed  to  allow  of  pressure  being  made  on  it  above.     Where  these 

^  When  caseation  occurs  the  gland  becomes  adherent  to  the  deep  fascia,  perforates 
this,  often  by  a  minute  opening,  and  thus  leads  to  the  formation  of  a  subcutaneous  abscess. 
If  this  alone  is  incised  and  scraped  a  sinus  is  certain  to  persist.  Generally  speaking,  it 
i  s  best  to  deal  with  the  caseating  gland  in  these  cases  at  a  second  operation. 


REMOVAL  OF  GROWTHS  IN  THE  NECK  043 

stops  arc  not  available,  where  the  anaesthetic  is  causing  anxiety,  or  where 
a  gland  has  ruptured  and  part  remains  adherent,  the  vein  should  be 
resected  between  douJ)le  ligatures  securely  applied.  But  this  step  is  not 
to  be  as  lightly  inideitaken  here  as  in  the  removal  of  epitheliomatous 
glands.  While  resection  of  the  intei'ual  jugular  greatly  facilitates 
extirpation  of  the  glands,  it  is  doubtful  whether  the  loss  of  the  vein  makes 
no  difference  to  the  patient.  This  step  should  certainly  not  be  adopted 
as  a  matter  of  routine,  as  one  of  the  improvements  of  modern  surgery. 
'I'hose  who  have  seen  much  of  these  cases  kn(nv  that,  in  children  especially, 
it  is  not  veiy  umisual  for  tuberculous  cervical  glaiuls  to  be  bilateral.  Let 
us  suppose  that  the  internal  jugular  has  been  resected  on  one  side.  A 
little  later  like  mischief  appears  on  the  opposite  side  ;  and  a  surgeon 
holding  advanced  views  adopts  the  same  step  on  this  side  also.  The  effect 
of  this  on  the  intracranial  circulation  of  the  child  might  be  instructive  ; 
it  would  scarcely  be  harmless. 

(6)  The  spinal  accessory  is  often  embedded  in  a  mass  of  glands,^  and 
this  oppoi'tunity  may  be  taken  of  saying  that  where  the  posterior  and 
the  anterior  triangles  of  both  contain  tuberculous  glands  they  should  be 
operated  upon  on  different  occasions.  The  nerve  should  be  defined 
where  it  enters  the  sterno-mastoid  at  a  point  which  is  about  opposite  to 
the  angle  of  the  jaw,  the  upper  part  of  the  sterno-mastoid  freed  by  dis- 
section and  drawn  inwards,  the  point  of  exit  of  the  nerve  into  the  posterior 
triangle  found,  and  a  probe  passed  downwards  and  outwards  along  its 
course  as  a  landmark.  Li  the  posterior  triangle  it  is  easy  to  mistake 
one  of  the  descending  branches  of  the  cervical  plexus  for  the  spinal 
accessory.  Division  of  the  sterno-mastoid,  always  permissible  in  the 
removal  of  epitheliomatous  glands,  is  rarely  needed  now,  if  the  muscle 
is  well  retracted  first  to  one  side  and  then  to  the  other.  If  division  of 
the  muscle  is  really  needful,  the  point  chosen  should  be  below  that  of 
entrance  and  exit  of  the  spinal  accessory.  If  the  case  heals  primarily  a 
good  muscle  results,  but  usually  it  is  for  the  removal  of  entensive  ad- 
herent broken-down  masses  that  its  section  is  necessary,  and  these  are  just 
the  cases  which  heal  slowly  and  leave  a  depression  at  the  point  of  healing. 
Disability  or  torticollis  does  not  follow  its  division. 

(c)  The  position  of  the  phrenic  nerve  on  the  scalenus  anticus  is  always 
quite  easy  to  identify. 

(d)  The  inframandibular  branch  of  the  facial  is  frequently  divided  in 
clearing  out  the  submaxillary  group.  Some  weakness  of  the  lower  lip 
follows,  but  disappears  in  about  six  weeks.  The  patient  or  friends  should 
be  prepared  for  this.^  The  possibility  of  injury  to  (e)  the  thoracic  duct  has 
been  referred  to  at  p.  640.  In  operations  low  down  in  the  neck  the  risk 
of  entrance  of  air  into  the  veins  is  always  present ;  if  this  accident  should 
occur  the  wound  should  always  be  flooded  with  sterile  saline  solution 
before  artificial  respiration  is  resorted  to,  and  in  this  region,  to  avoid 
dangerous  haemorrhage,  every  vessel  should  be  secured  before  it  is  divided, 
otherwise  it  may  retract  out  of  reach. 

(v)  Each  group  of  glands  should  be  removed,  as  far  as  possible, 

^  This,  therefore,  is  one  of  the  few  occasions  on  which  the  operator  must  depart  from 
the  rule  of  removing  infected  glandular  areas  as  far  as  possible  en  masse. 

^  Dr.  Dowd,  of  New  York  (Ann.  of  Surg.,  July  1905),  gives  rules  for  avoiding  this 
nerve.  The  chief  are  that,  as  the  nerve  runs  just  below  the  mandible  and  lies  between 
the  platysma  and  deep  fascia,  the  skin  incision  should  be  made  an  inch  below  the  bone, 
and  the  muscle  and  deep  fascia  should  be  divided  a  little  below  the  level  of  the  skin 
incision ;   they  should  then  be  retracted  upwards  with  the  filament  between  them. 


644  OPERATIONS  ON  THE  HEAD  AND  NECK 

en  masse,  (vi)  Tuberculous  mischief  is  to  be  dealt  with,  here  as  elsewhere, 
as  if  it  were  mahgnant,  and  all  diseased  tissues  eradicated  as  if  this,  the 
first  opportunity,  were  going  to  be  the  last,  (vii)  Careful  asepsis  must 
be  maintained  throughout,  (viii)  In  all  doubtful  cases  drainage  is  to 
be  employed.  Thus  a  tube  should  always  be  employed  in  cases  where 
a  caseating  gland  has  ruptured  during  removal,  and  may  have  infected 
the  wound  in  spite  of  careful  washing  out.  Again,  where  the  cavity  is  a 
large  one,  of  uneven  base,  with  many  pockets  or  recesses,  where  much 
oozing  is  present,  a  drainage-tube  should  be  employed  for  two  or  three 
days.  All  surgeons  of  experience  must  be  familiar  with  cases  where, 
after  securing  primary  union,  the  swelling  has  soon  reappeared,  and,  on 
opening  up  the  diseased  area,  structures  which  at  the  fii'st  operation, 
e.g.  part  of  the  sterno-mastoid,  diagastric,  &c.,  were  absolutely  healthy, 
are  now  covered  with  greyish  granulation  tissue,  the  structures  being 
only  recognisable  by  their  position  and  outline.  Another  result  of  infec- 
tion of  the  wound  by  tuberculous  material  left  behind  is  rapid  breaking 
down  of  the  scar,  not  a  reappearing  deep  swelling.  The  risk  which 
the  drainage-tube  entails  of  infection  from  outside  can  be  met  by  careful 
dressing  and  regular  resterilisation  of  the  adjacent  skin  dm-ing  the 
time  that  it  is  needful  to  retain  the  tube,  (ix)  Pressure  is  always  to  be 
well  applied,  for  the  same  reasons  and  in  the  same  way  as  given  at  p.  626. 
But  where  there  is  any  doubt  about  the  wound  being  sterile,  boracic  acid 
fomentations  should  be  used  at  first,  (x)  Sufficient  rest  of  the  parts  is 
most  essential  here.  Sir  F.  Treves  has  insisted  on  this  point  in  the 
after-treatment.  It  is  one  of  very  great  importance,  if  a  small  and 
sound  scar,  and  obliteration  of  any  tuberculous  material  possibly  left 
behind,  are  to  be  secured.  The  patient  should  rest  absolutely  in  bed 
for  the  first  fortnight.  When  the  parts  are  thus  kept  at  rest,  the  child 
should  live  out  of  doors  in  the  best  air  available,  (xi)  The  patient  is  to 
be  kept  for  a  long  time  mider  observation,  owing  to  the  risk  of  persistence 
and  reappearance  of  the  disease.  Nowhere  do  the  wise  words  of  Verneuil 
find  better  application,  that  in  dealing  with  the  tuberculous  we  must  be 
prepared  for  "  half  successes,  incomplete  results,  and  unfinished  cm-es." 
A  wise  surgeon,  when  an  advanced  case  is  brought  to  him,  will  do  well 
to  midertake  only  his  fair  share  of  responsibihty  for  the  result.  The 
patient  or  the  friends  must  be  prepared  for  more  than  one  operation. 

(B)  Curetting  or  Scooping  out  the  Glands.  While  its  value  has  been  clearly 
proved  in  the  instructive  papers  on  "  Scrofulou.s  Neck  and  the  Surgery  of  Scrofulous 
Glands  "  put  forth  by  Sir  T.  C.  Allbutt  and  ]\Ir.  Tcale  as  clinical  lecturers  at  the  Leeds 
School,  from  which  so  much  good  surgery  has  already  come,  it  is  very  inferior  to 
aseptic  treatment  by  excision,  for  the  reasons  given  below.  The  following  are  Mr. 
Teale's  conclusions  as  to  the  surgical  treatment  of  these  cases  ;  (1)  That  surgery 
can  seciu'e  the  heaUng  in  a  very  few  weeks  ^  of  gland  cavities  and  sinuses,  even 
though  they  have  existed  for  years.  (2)  That,  in  dealing  with  sinuses,  gland 
abscesses,  and  decayed  or  semi-decayed  lymphatic  glands,  the  action  of  the  surgeon 
must  be  vigorous  and  thorough.  (3)  That  the  visible  abscess,  which  should  often 
be  called,  and  treated  as,  a  tuberculous  suppm-ating  gland,  is,  as  a  rule,  merely  a 
subcutaneous  reservoir  &f  pus,  its  source  a  degenerate  gland,  being  not  subcutaneous, 
but  sub-fascial,  i.e.  imder  the  deep  cervical  fascia,  and  sometimes  even  submuscular, 
the  communication  between  the  two  being  a  small  opening  just  large  enough  to 
admit  a  probe  or  director.  (4)  That  it  is  utterly  futile  merely  to  incise  or  puncture 
such  a  subcutaneous  abscess  dependent  upon  a  degenerate  gland  which  hes  beneath 
the  deep  fascia.  (5)  That  when  a  damaged  or  suppurating  gland  has  been  got  rid 
of  before  the  overl3dng  skin  is  thinned  by  advancing  suppuration  the  resulting  scar 

^  In  severe  cases  several  operations — three  or  more — wiU  be  needed.  After  the  first 
one  or  two  the  general  condition  is  said  to  improve  rapidly. 


REMOVAL  OF  GROWTHS  IN  THE  NECK  645 

is  insignilioant  and  not  an  eyesore.  (C^)  That,  in  dealing  with  a  sinus,  the  oliannel 
should  he  enhirged  by  the  knife  or  a  "  Bigelow's  dihitor,"  and  the  whok>  of  its 
granuhiting  surface  scraped  out.  Where  the  si<in  is  thin  and  bhie  this  siiould  be 
scraped  away,  and  any  cutaneous  overhanging  edges  trimmed  oiT  with  scissors. 
(7)  That,  in  deahng  with  a  sinus  or  an  abscess,  the  surgeon  should  not  rest  content 
until  he  has  discovered  and  eradicated  the  giaud,  always  remembering  that,  if  it  be 
not  obvious,  there  is  sure  to  be  a  small  track  leading  to  it  through  the  deep  fascia. 
This  should  be  enlarged  so  as  to  admit  a  sharp  spoon.  (8)  That,  when  a  gland 
has  suppurated  or  become  caseous,  the  capsule  should  be  freely  opened  and  the 
contents  scraped  out.  This  is  sometimes  easy,  the  enucleation  leaving  the  stiff 
capsular  case  virtually  cleaned  out.  Sometimes  it  is  very  difficult  to  get  rid,  even 
by  the  most  vigorous  scraping,  of  a  tough  living  stump  of  gland  firndy  adherent 
to  the  capsule.  It  is  well  to  dissect  this  renuiant  away  with  a  scalpel,  if  the  risk 
of  injuring  important  structures  be  not  too  great.  (9)  That  sometimes,  when  such 
an  empty  capsule  is  left,  the  finger  detects  in  its  wall  a  bulging  contiguous  gland. 
This  should  be  punctured  through  the  wall  of  the  cavity,  and  so  reached  and 
enucleated.  In  this  way,  in  more  than  one  instance,  Mr.  Teale  has  emptied  from 
one  external  opening  a  grou]i  of  three  or  four  glands,  suppurating  or  broken  down. 
In  the  event  of  sinuses  persisting  the  injection  of  an  emulsion  of  bismuth  carbonate 
may  be  tried.  Vaccine  treatment  and  the  injection  of  tuberculin  may  also  be 
employed  in  conjunction  with  surgical  treatment  on  the  above  lines. 

The  above  method  is  much  inferior  to  that  of  aseptic  excision,  for 
the  following  reasons  :  (a)  It  is  limited  to  cases  <xh.ere  one  or  two  glands 
are  involved.  Cases  such  as  these  form  a  small  minority  of  tuberculous 
cervical  glands.  (6)  It  deals  only  %\'ith  caseating  and  suppurating  glands.  ^ 
(c)  In  the  majority  of  cases  there  are  glands,  often  numerous,  which  are 
infected  and  which  will  certainly  give  trouble,  though  not  as  yet  softened. 
Such  can  only  be  removed  by  a  sufficient  incision  and  dissection,  (d)  It 
is  an  operation  in  the  dark.  This  is  an  objection  of  great  weight  when 
the  gland  lies  deeply  and  may  be  attached  to  important  structures,  e.g. 
the  internal  jugular,  (e)  This  operation  is  much  more  hkely  to  call  for 
repetition  than  a  well-planned  aseptic  excision  on  lines  mdely,  carefully, 
and  thoroughly  carried  out. 

CYSTIC  HYGROMA  ;    CONGENITAL  LYMPHANGIOMA 

Unless  these  growths  are  clearly  spreading  or  causing  dyspnoea,  they 
should  not  be  operated  upon  in  early  life.  The  poor  vitahty  and  the 
subsequent  restlessness  of  the  patient  and  small  size  of  the  parts,  contra- 
indicate  such  interference.  Where  this  step  is  rendered  necessary,  free 
incision  and  drainage  of  the  chief  cyst  or  partial  removal  of  the  larger  ones, 
in  a  multilocular  case,  and  drainage  are  the  wisest  steps.  But  the  risk 
of  infection  is  always  great.  Where  a  lymphangioma  involves  the  face, 
and  the  presence  of  the  facial  nerve  is  an  additional  contra-indication, 
the  surgeon's  choice,  if  he  be  compelled  to  interfere,  lies  between  multiple 
incisions,  electrolysis,  and  injections,  e.g.  of  iodine  diluted. 

THYROGLOSSAL  CYSTS 

These,  and  occasionally  soHd  growths,  are  derived  from  the  embryonic 
thyroglossal  duct,  which  passes  from  the  foramen  csecum  to  the  isthmus 
or  pyramidal  lobe  of  the  thyroid  gland.  Their  liability  to  form  discharging 
fistulse  in  the  middle  line  of  the  neck,  usually  situated  between  the 

^  In  some  extensive  cases  where  there  is  much  matting  and  infiltration  of  surrounding 
tissues  with  several  sinuses,  and  where  the  tuberculous  disease  has  extended  widely 
beyond  the  glands,  dia-thermy  {.::ee  p.  396)  may  be  tried  after  thorough  use  of  the  sharp 
spoon. 


64G  OPERATIONS  ON  THE  HEAD  AND  NECK 

cricoid  and  the  thyroid  cartilages,  is  well  known.  The  only  treatment 
is  complete  removal  of  the  cyst  or  fistula  with  that  portion  of  the  thyro- 
glossal  duct  which  remains  patent.  This  is  liable  to  be  a  matter  of  some 
difficulty.  A  median  incision  having  been  made  from  the  hyoid  bone 
down  to  the  upper  rings  of  the  trachea,  the  deep  fascia  is  opened,  and  the 
cyst  dissected  out.  If  a  sinus  is  present,  a  fine  probe  should  be  passed 
upwards  along  its  whole  length  as  a  guide.  It  is  usually  arrested  at  the 
body  of  the  hyoid.  The  puckered  skin  below  and  around  the  opening 
of  the  sinus  should  be  removed  as  well.  Sir  J.  Bland  Sutton  found  in 
one  case  that  the  duct  bifurcated  below,  one  portion  ending  at  an  opening 
in  the  middle  line  of  the  neck,  the  other  in  a  blind  pouch.  The  duct 
usually  becomes  obliterated  at  or  behind  the  body  of  the  hyoid,  it  being 
impossible  to  pass  a  piece  of  fine  silver  wire  beyond  this  point.  Probably 
a  fibrous  tract  replaces  the  rest  of  the  thyroglossal  duct  up  to  the  foramen 
caecum.  Rarely  it  extends  behind  the  hyoid  bone  upwards  into  the 
nmscles  of  the  tongue,  and  its  removal  is  then  a  matter  of  considerable 
difficulty.  The  incision  must  then  be  continued  towards  the  chin,  the 
hyoid  divided  with  a  fine  saw,  two  halves  and  the  genio-hyoids  separated, 
and  the  entire  tract  which  is  patent  removed.  Drainage  should  be  em- 
ployed in  these  cases.  Excellent  illustrations  of  median  cervical  fistulse 
dating  to  a  patent  thyroglossal  duct  are  given  by  Sir  J.  Bland  Sutton.^ 
He  refers  to  an  instructive  paper  by  Marshall  describing  the  anatomy 
of  the  parts  in  a  child  set.  5.^ 

Congenital  Branchial  Fistulse.  These  are  most  commonly  seen  at 
the  anterior  border  of  the  sterno-mastoid  a  short  distance  above  the 
suprasternal  notch.  They  are  generally  minute,  scarcely  noticeable 
openings  from  which  a  quantity  of  mucoid  fluid  exudes.  Occasionally 
they  become  infected  and  then  the  discharge  is  purulent.  If  a  fine  probe 
be  introduced  it  will  pass  upwards  for  a  considerable  distance  :  indeed, 
the  upper  end  of  the  fistula  may  be  intimately  connected  with  the  wall 
of  the  pharynx  above  the  level  of  the  hyoid  bone.  The  upper  part  of 
the  track  is  very  deeply  situated  ;  not  uncommonly  it  passes  between 
the  internal  and  the  external  carotid  arteries. 

The  treatment  wall  depend  upon  the  symptoms  which  are  present.  If 
there  is  only  a  slight  amount  of  inconvenience  the  fistula  is  best  left 
alone.  If  the  inconvenience  is  great,  or  if  the  fistula  is  infected,  it  should 
be  removed,  though,  on  account  of  its  intimate  relations  to  important 
structures  deep  in  the  neck,  this  should  not  be  lightly  attempted.  A 
fine  probe  is  introduced  into  the  fistula  and  an  incision  is  then  made 
along  the  anterior  border  of  the  sterno-mastoid,  encircling  the  opening 
below.  The  whole  track  is  then  carefully  dissected  out,  care  being 
taken  to  avoid  the  large  vessels  and  also,  above,  the  superior  laryngeal 
nerve.  When  connected  with  the  wall  of  the  pharynx,  the  upper  end, 
which  is  almost  certainly  fibrous,  should  be  ligatured  and  di\'ided.  The 
extensive  wound  should  be  drained  by  a  small  tube  for  forty-eight  hours. 
More  rarely  congenital  branchial  fistula?  are  foimd  in  front  of  the  ear. 
These  are  best  left  alone  unless  suppuration  should  occur,  when  incision 
and  drainage  will  be  required. 

Branchial  Cysts.  These  are  occasionally  found  along  the  anterior 
border  of  the  sterno-mastoid  or  in  the  submaxillary  region.  The  only 
treatment  is  removal,  but,  as  in  the  case  of  the  fistulee  described  above, 

^  Tumours,  Innocent  and  Malignant,  pp.  380  and  383. 
2  Journ.  of  Anat.  and  Phys.,  vol.  Ixxvii. 


REMOVAL  OF  GROWTHS  IN  THE  NECK  G47 

they  arc  likely  to  be  in  intimate  relation  with  the  large  vessels  and  nerves 
a  ml  also  to  extend  upwards  behind  the  ramus  of  the  jaw.  The  surgeon 
must  therefore  l)e  prepared  for  a  long  and  tedious  dissection. 

Dermoid  Cysts  and  Sebaceous  Cysts.  Both  these  forms  of  cyst  may 
occur  in  the  neck.  Dermoids  are  usually  in  the  mid-line  and  may  be 
found  either  above  or  below  the  hyoid  bone,  and  sometimes  at  the  root  of 
the  neck  just  above  the  suprasternal  notch.  In  removing  these  cysts 
the  incision  sliould  always  follow  one  of  the  natural  folds  or  creases  of  the 
skin.  In  the  case  of  a  large  dermoid  at  the  root  of  the  neck  an  incision 
similar  to  Kochcr's  collar  incision  for  thyroidectomy  should  be  employed. 

Lipomata.  These  tumours,  which  may  reach  a  large  size,  are  not 
unconnnon,  especially  at  the  root  of  the  neck.  Their  removal  by  an 
incision  in  the  long  axis  of  the  tumour  is  easy.  The  objection  to  this 
method  is  that  a  very  long  incision  is  required  if  the  tumour  is  large.  If 
this  is  regarded  as  of  importance  the  following  method  may  be  employed. 
An  incision  is  made  through  the  skin,  super- 
ficial fascia  and  capsule  into  the  tumour  itself. 
The  lipoma  is  then  fii-mly  grasped  and  squeezed 
as  firmly  as  possible.  The  fatty  masses  can 
in  this  way  be  forced  through  the  opening 
in  the  capsule,  and  a  large  lipoma  can  then 
be  removed  through  a  comparatively  small 
incision. 

With  either  method  it  will  be  necessary  to 
apply  pressure  by  a  fii'm  bandage  over  carefully 
arranged  dressings  in  order  to  obliterate  the 
cavity.  In  the  case  of  very  large  tumours 
drainage  for  the  first  forty-eight  hours  will  be 
desirable. 

Removal  of  Cervical  Ribs.^  Considerable  attention 
bas  been  directed  in  recent  years  to  this  subject,  Fig.  274.  A,  Vertical  in- 
and  it  is  now  recognised  that  the  presence  of  a  super-  cision  for  removal  of  cer- 
numerary  rib  is  not  infrequently  the  cause  of  more  or  yif^\  ^'i^-  ^'  Transverse 
less  severe  symptoms  owing  to  pressure  on  the  sub-  incision  for  removal  of  cer- 
clavian  vessels  or  the  brachial  plexus.  The  abnormal  ^'cal  nb.  C,  Incision  for 
rib   may    give   rise   to    a    swelling    which    can   easily  cesophagotomy. 

be  felt  in  the  posterior   triangle,   but,   on  the   other 

hand,  in  many  cases  nothing  abnormal  may  be  detected  on  palpation.  In  the 
latter  cases  a  diagnosis  can  only  be  made  after  a  radiographic  examination. 
Though  the  cervical  rib  may  be  felt,  it  is  very  rare  for  it  to  give  rise  to  any  notice- 
able deformity,  and  it  is  seldom,  if  ever,  that  operation  will  be  called  for  on  this 
account  alone.  The  more  serious  symptoms  may  be  divided  into  the  following 
groups  :  (a)  Nervous  symptoms.  Under  this  head  may  be  included  cutaneous 
hypersesthesia,  pains  often  severe,  of  neuralgic  character,  muscular  cramps,  paralysis 
and  atrophy  of  muscles,  especially  those  supplied  by  the  ulnar  nerve,  even  giving 
rise  to  the  "main  en  griffe."  Anaesthesia  is  also  occasionally  present.  (6) Vascular 
symptoms.  Coldness,  with  either  anajmia  of  the  iingers,  or  with  redness  and 
congestion.  In  some  cases  there  may  be  threatening  or  even  actual  gangrene  of 
the  fingers  simulating  Raynaud's  disease.  If  either  of  these  groups  of  symptoms 
are  present  to  any  extent  operation  is  always  indicated.  Not  infrequently  the 
onset  of  the  symptoms  is  sudden.  There  is  no  relation  between  the  size  of  the 
rib  and  the  severity  of  the  symptoms. 

The  following  anatomical  points  are  of  importance  :  (a)  Occasionally  the 
1  For  further  information  on  this  subject  the  reader  is  referred  to  an  interesting 
discussion  on  cervical  ribs  before  the  Clinical  Section  of  the  Royal  Society  of  Medicine 
in  February  1913  (see  Proc.  Roy.  Soc.  Med.,  Clin.  Sec,  March  1913.  p.  9(3).  Here  much 
vahiable  information  as  to  the  anatomy,  diagnosis,  symptoms,  treatment  and  results 
will  be  found.     Numerous  illustrative  cases  are  also  described. 


648  OPERATIONS  ON  THE  HEAD  AND  NECK 

abnormal  rib  may  be  a  rudimentary  first  dorsal  and  not  a  supernumerary  cervical 
rib.  (6)  The  anterior  extremity  of  the  rib  terminates  in  a  variable  manner.  It 
may  reach  the  sternum,  or  it  may  join  the  normal  first  rib  ;  a  fibrous  band  may 
connect  it  with  either  of  these  structures,  or  it  may  end  freely,  (c)  The  relation 
of  the  subclavian  artery  to  the  abnormal  rib  is  variable  ;  in  some  cases,  but  not  in 
all,  the  artery  passes  over  and  is  raised  up  by  the  rib  ;  in  some  cases  it  passes 
beneath  it  ;  not  uncommonly  the  artery  lies  in  a  groove  on  the  first  rib  just  anterior 
to  where  the  rudimentary  rib  fuses  with  it.  (d)  The  brachial  plexus  crosses  over 
the  rib,  the  lower  trunk  being  usually  in  immediate  contact  with  it  and  is  often 
tightly  stretched  over  it,  especially  when  the  shoulder  is  depressed.  The  supra- 
scapular nerve  crosses  the  rib  and  is  in  danger  of  being  damaged  during  the  opera- 
tion. 

Operation.  A  cervical  rib  may  be  removed  either  through  a  transverse  or  a 
vertical  incision.  Both  of  these  incisions  have  their  advocates,  but  a  long  vertical 
incision  extending  upwards  from  the  clavicle  along  the  anterior  border  of  the 
trajjczius  can  be  recommended  as  giving  a  good  exposure  of  the  rib,  though  the 
resulting  scar  will  probably  be  more  noticeable.  If  the  transverse  incision  be 
employed  it  should  extend  from  the  sterno-mastoid  to  the  trapezius  and  should  not 
be  too  low  down,  or  there  will  be  difficulty  in  exposing  the  vertebral  attachment. 
The  transverse  cervical  and  suprascapular  veins  Avill  probably  require  ligatures. 
Whichever  incision  is  employed  it  is  best  first  to  identity  the  rib  and  trace  it  to  its 
vertebral  attachment,  which  is  divided  or  freed.  The  brachial  plexus  is  gently 
drawn  downwards  by  a  broad  retractor,  special  care  being  taken  to  preserve  the 
suprascapular  nerve.  These  structures  must  be  handled  with  the  greatest  gentle- 
ness throughout  the  operation  in  order  to  avoid  bruising,  stretching  or  other  injury, 
which  may  leave  most  troublesome  after-effects.  To  expose  the  articulation  of  the 
rib  with  the  vertebrae  the  sterno-mastoid  and  scalenus  anticus  may  be  retracted 
inwards.  The  vertebral  extremity  having  been  freed,  the  adjacent  structures  are 
separated  from  the  rib  until  its  junction  with  the  first  rib  or  the  terminal  fibrous 
band  are  reached  :  this  is  then  divided  with  scissors  or  gouge,  and  the  rib  removed. 
There  is  some  difference  of  opinion  as  to  whether  the  rib  should  be  removed  sub- 
periosteally  ;  if  this  is  done  there  is  less  danger  of  wounding  the  pleura  and  other 
important  structures  which  are  in  contact  with  it,  and  Sir  Rickman  Godlee,  who 
recommends  this  procedure,  states  that  he  has  never  seen  any  trouble  from 
re-formation  of  the  rib. 

All  bleeding-points  should  now  be  secured,  and,  as  a  general  rule,  the  wound 
should  be  closed  without  drainage. 

After-treatment.  In  those  cases  where  muscular  weakness  and  atrophy  are 
present  electrical  treatment  and  massage  should  be  employed  as  soon  as  the  wound 
is  soundly  healed. 

Results.  Provided  that  the  symptoms  are  not  very  severe  and  that  they  are 
not  of  long  duration,  the  results  of  the  operation  are  usually  very  satisfactory.  In 
old-standing  cases  and  those  with  severe  symptoms,  especially  of  muscular  paralysis 
and  atrophy,  though  considerable  improvement  is  probable,  complete  cure  is 
unlikely.  In  the  discussion  mentioned  above,  Dr.  Hinds  Howell  sums  up  the 
results  of  operation  as  follows  :  "  In  a  large  proportion  of  cases  some  symptoms, 
such  as  pain  and  wealoiess  in  the  arm,  may  be  expected  to  follow  the  operation, 
but  not  to  last  more  than  three  months  or  so.  The  vaso-motor  symptoms,  which 
are  present  in  almost  all  the  cases,  will  be  certainly  improved,  and  in  the  majority 
of  cases  pain  will  be  relieved  or  cured.  With  regard  to  muscular  weakness  and 
atrophy,  the  expectation  is  that  tlie  operation,  if  it  is  not  too  long  delayed,  will 
greatly  improve  this  condition.  There  is  not,  as  a  rule,  complete  restoration  of  the 
wasted  muscles,  nor  complete  recovery  from  the  vaso-motor  disturbance. 
'  I  Some  surgeons  advise  that  only  that  part  of  the  rib  which  is  in  relation  with 
the  nerves  should  be  excised,  or  even  that  the  fibrous  band  only  should  be  removed. 
If  this  is  done  the  vertebral  attachment  of  the  rib  will  be  left. 


CHAPTER  XXXI 

OPERATIONS  ON  THE  (ESOPHAGUS 

(ESOPHAGOTOMY,  (ESOPHAGOSTOMY,  CESOPHAGECTOMY, 
(ESOPHAGEAL  POUCHES 

(ESOPHAGOTOMY 

Indications.  This  is  required  for  foreign  bodies,  e.g.  tooth-plates,  bones, 
coins,  &c.,  as  have  resisted  careful  attempts  at  extraction  by  other 
methods  :  bodies  which  are  certain,  if  left,  to  lead  to  grave  results, 
e.g.  sloughing,  deep  cervical  suppuration,  &c. 

As  in  the  case  of  foreign  bodies  in  the  respiratory  passages,  the 
diagnosis  and  treatment  of  foreign  bodies  in  the  oesophagus  has  been, 
within  recent  years,  completely  revolutionised  by  the  use  of  Killian's  and 
Briining's  direct-vision  tubes.  A  description  of  these  tubes  and  of  the 
indications  for  their  use,  and  the  method  of  using  them,  will  be  found 
at  p.  604. 

Foreign  bodies  are  likely  to  become  fixed  at  one  of  the  following  three 
places  :  (1)  behind  the  cricoid  cartilage,  (2)  where  the  left  bronchus 
crosses  the  oesophagus  ;  (3)  at  the  lower  end  of  the  oesophagus. 

The  diagnosis  of  a  foreign  body  in  the  oesophagus  may  present  con- 
siderable difficulties.  There  will  usually,  but  not  always,  be  pain  and 
dysphagia,  and  in  children  there  will  very  possibly  be  no  history  obtain- 
able of  such  a  body  having  been  swallowed.  A  metallic  substance,  such  as  a 
coin,  wall  be  revealed  by  an  X-ray  examination,  but  it  must  be  remembered 
that,  as  in  the  case  of  foreign  bodies  in  the  respiratory  passages,  many  of 
the  bodies  will  not  be  opaque  to  X-rays  and  thus  will  not  show  on  screen  or 
plate.  Even  opaque  materials  such  as  a  tooth,  or  a  small  piece  of  bone,  may 
not,  owing  to  their  deep  situation,  be  revealed  by  a  radiographic  examina- 
tion. The  best  method  of  diagnosis  is  direct  examination  by  a  Briining's 
tube,  when  the  oesophagus  can  be  inspected  through  its  whole  length. 
Even  here  care  must  be  taken  to  mop  away  all  mucus  and  secretion,  which 
may  conceal  some  small  body  such  as  a  fish  bone.  It  may  here  be  insisted 
upon  that  in  every  case  an  attempt  should  be  made  to  remove  the  foreign 
body  by  manipulations  through  the  Briining's  tube.  In  the  great 
majority  of  cases  this  will  be  successful.  The  advantages  of  extraction  in 
this  way  are  obvious  :  there  will  be  an  immediate  relief  from  all  symptoms, 
there  will  be  no  external  wound,  and  there  will  be  no  danger  of  celluhtis  or 
mediastinal  suppuration  which  so  often  prove  fatal  after  oesophagotomy. 

At  the  same  time  the  operation  of  oesophagotomy  can  scarcely  be 
regarded  as  obsolete,  though  it  will  be  less  frequently  called  for  than 
formerly.  Thus  the  foreign  body  may  be  too  large  or  too  firmly  impacted 
for  removal  through  the  Briining's  tube,  or  the  accident  may  happen 
where  these  special  instruments  are  not  available.     In  any  case  the  body 

649 


650  OPERATIONS  ON  THE  HEAD  AND  NECK 

should  be  removed  ag  soon  as  possible  :  if  left,  ulceration,  perforation  of 
the  oesophagus,  and  deep  suppuration  in  the  neck  may  very  quickly  occur. 

It  must  be  remembered  that  the  precise  site  of  the  foreign  body  is  not 
always  marked  by  any  external  swelling  or  resistance,  nor  by  accurately 
referred  pain  ;  ^  furthermore,  bougies  occasionally  give  very  slight  indica- 
tions of  the  presence  of  bodies  (even  rough  ones)  in  the  oesophagus  or 
pharynx. 

Operation.  The  head  being  somewhat  extended  and  turned  to  the 
right  ^  side,  and  the  skin  of  the  neck  sterilised,  the  surgeon  makes  an 
incision  three  inches  long  from  just  above  the  thyroid  cartilage  to  within 
half  an  inch  of  the  sterno-clavicular  joint, ^  a  little  in  front  of  the  anterior 
border  of  the  sterno-mastoid  (Fig.  274).  Skin  and  f asci  ae  being  divided,  the 
anterior  jugular  or  its  branches  secured,  the  cellular  tissue  in  front  of  the 
above-mentioned  muscle  is  opened  up  with  a  director,  and  the  pulsation  of 
the  artery  and  the  bodies  of  the  cervical  vertebrse,  fifth  and  sixth,  felt  for. 
The  omo-hyoid  may  be  drawn  down,  but  it  is  best  to  divide  this  muscle  at 
once,  and,  if  it  be  needful  to  seek  for  the  foreign  body  low  down  in  the  neck, 
the  sterno-hyoids  and  sterno-thyroids  also.  The  sterno-mastoid  and  large 
vessels  are  now  drawn  outwards,  and  the  trachea  ^  inwards,  with  retrac- 
tors, the  thyroid  gland  probably  showing  plainly  on  the  inner  side,  and  the 
internal  jugular,  if  distended,  on  the  outer.  The  presence  of  the  inferior 
thyroid  behind  the  carotid  sheath,  and  that  of  the  recurrent  laryngeal 
running  up  in  the  groove  between  the  trachea  and  oesophagus,  must  be 
remembered.  Throughout  these  steps  of  the  operation  the  bleeding 
must  be  most  carefully  arrested,  and  the  deeper  part  of  the  wound,  with 
the  important  structures  around  it,  kept  quite  dry. 

If  the  foreign  body  cannot  be  felt  projecting  in  the  oesophagus,  e.g. 
behind  the  cricoid,  the  mouth  should  be  opened  with  a  gag,  and  a  bougie 
or  probang  passed,  as  the  flaccid  tube  walls  are  naturally  in  contact. 
When  the  oesophagus  lies  unusually  deep,  follo-vNang  round  the  thyroid  or 
cricoid  cartilage  "with  a  sterilised  finger  will  find  it. 

When  the  site  of  the  foreign  body  has  been  made  out,  or  when,  failing 
this,  it  is  decided  to  open  the  oesophagus  low  down  and  to  pass  probes,  &c., 
a  clean  incision  must  be  made  as  far  back  as  possible,  so  as  to  avoid  the 
recurrent  laryngeal  filaments.^ 

When  the  tube  has  been  opened,  and  any  bleeding  from  its  walls 
arrested,  the  opening  is  dilated  by  dressing-forceps,  by  a  probe-pointed 

^  In  a  case  recorded  {Brit.  Med.  Journ.,  May  7,  1904)  by  Dr.  A.  Fullorton,  a  halfpenny 
had  remained  lodged  in  the  oesophagus  for  seven  months  without  definite  symptoms  till 
three  weeks  before  the  child's  admission,  when  ulceration  probably  commenced  and  the 
child  brought  up  foul  fluid.  A  radiographic  examination  showed  the  coin  to  lie  opposite 
the  third  and  fourth  thoracic  vertcbra>.  An  attempt  to  remove  it  by  the  mouth  wa" 
unsuccessful.  A  week  later  the  coin  was  successfully  removed  by  cesophagotomy  ;  it 
lay  four  and  a  half  inches  below  the  opening  in  the  oesophagus,  and  was  hooked  up  to 
this  by  a  bent  probe.  The  wound  in  the  oesophagus  was  sutured  by  catgut.  Feeding 
by  the  mouth  was  commenced  in  forty-eight  hours.  Mr.  G.  H.  Makins  has  recorded  a 
case  of  cesophagotomy  for  the  extraction  of  an  impacted  tooth-plate  (Clin.  Soc.  Trans., 
vol.  xxxi,  p.  II). 

^  The  oesophagus  lies  more  to  the  left  side,  and  operating  on  the  left  side  allows  of 
freer  movement  of  the  right  hand,  while  the  left  is  at  liberty  to  move  the  larynx,  &c. 

3  If  the  neck  is  very  stout,  or  if  the  parts  are  swollen,  &c.,  the  incision  may  be  from 
just  below  the  angle  of  the  jaw  to  close  to  the  sternum. 

*  The  larynx  should  not  onlj-  be  drawn  to  the  right,  but  tilted  over  to  this  side  also, 
as  this  brings  up  the  oesophagus. 

5  Mr.  Cock  (Guy's  Hospital  Beforts,  1868,  p.  3)  drew  attention  to  this  point.  Both 
his  patients  were  in  the  habit  of  singing ;  in  the  first  case  (Ibid.,  1858,  p.  229)  a  fine  tenor 
voice  was  replaced  by  a  bass  ;  in  the  second,  in  which  the  oesophagus  was  opened  farther 
back,  the  voice  did  not  suffer. 


(KSOPIIACiOTOMY  G51 

bititoiin',  or  by  curved  forceps  passed  from  the  iiuMitli  uiid  expanded  in  the 
wound.  Even  after  a  free  opening  has  been  made  it  may  be  impossible 
to  dislodge  the  body,  if  this,  a  tooth-plate,  has  projecting  clips,  or  if  it 
is  tiglitly  enil)racetl  by  the  contraction  of  the  a\so])hag('a1  iibres.  In  such 
a  case  tlie  l)ody  should  be  (if  a  tooth-plate)  divided  with  bone-forceps  and 
removed  in  two  portions,  care  being  taken  to  keep  hold  of  each  portion 
with  forceps.^ 

If,  after  exposing  the  oesophagus,  the  foreign  body  cannot  be  felt — 
which  will  rarely  happen— metallic  probes  or  soft  bougies  should  be 
passed  through  the  wound  in  the  oesophagus,  and  the  lower  cervical  and 
the  upper  thoracic  portions  of  this  tube  carefully  explored.  The  question 
may  now  be  considered  :  How  far  down  from  the  oesophagus  can  a  body 
be  extracted  ?  The  most  accessible  part  is,  no  doubt,  its  junction  with 
the  pharynx,  opposite  to  the  cricoid  cartilage,  and  the  first  two  inches 
below  this  point. 

Mr.  Bennet  May  gives  the  following  example  of  successful  extraction 
of  a  foreign  body  at  a  low  level. 

Here  a  child,  aged  7,  had  swallowed  a  halfpenny  three  and  a  half  years  before. 
The  coin  had  ulcerated  through  the  oesophagus  and  ojiened  the  right  bronchus,^ 
lying  partly  in  this  and  partly  in  the  oesophagus.  It  was  removed  successfully  by 
cesophagotomy. 

A  foreign  body  firmly  impacted  at  the  lower  end  of  the  oesophagus 
which  cannot  be  dislodged  by  other  means,  may  be  removed  by  opening 
the  stomach  (gastrotomy)  and  introducing  suitable  forceps  upwards 
through  the  cardiac  orifice. 

When  the  foreign  body  has  been  removed,  the  cjuestion  of  introducing 
sutures  into  the  oesophagus  will  arise.  These  should  only  be  used  when 
the  wound  in  the  gullet  is  clean-cut,  not  bruised,  and  when  the  obstruction 
has  been  quickly  removed  ;  the  sutures  should  be  of  fine  sterihsed  gut. 
Only  the  upper  part  of  the  skin  wound  should  be  closed,  the  rest  being 
left  open  to  the  bottom  to  allow  of  free  drainage,  owing  to  the  danger 
of  sloughing,  pent-up  foul  secretions,  and  blood-poisoning  (p.  649). 
A  drainage-tube  should  be  inserted  to  the  bottom  of  the  wound,  a 
few  sutures  placed  in  the  edges  of  the  wound,  dry  dressings  applied, 
viz.  antiseptic  gauze,  salicylic  wool,  &c.,  if  the  wound  has  not  been 
much  probed  about,  and  there  is  thus  good  reason  to  expect  early  union. 
But  if  ulceration  of  the  soft  parts  has  been  found,  if  they  are  inflamed, 
emphysematous,  &c.,  the  wound  should  be  left  open,  drained  to  the 
very  bottom,  and  boracic  acid  fomentations  frequently  applied. 

After-treatment.  If  the  patient  is  in  good  condition,  if  the  foreign 
body  has  been  removed  early,  or  if  the  patient  has  been  able  to  swallow 
liquids  in  the  interval  between  the  accident  and  the  operation,  he  may 
be  fed  for  the  first  few  days  by  nutrient  enemata  and  nutrient  supposi- 
tories, and  only  a  little  ice  given  occasionally  by  the  mouth.     But  if  the 

^  Lawson,  Clin.  Soc.  Trans.,  vol.  xviii,  p.  292. 

^  The  proximity  of  important  parts  to  the  thoracic  portion  of  the  oesophagus  is  well 
known.  Thus,  in  Path.  Soc.  Trans.,  vol.  xix,  p.  219,  is  recorded  the  case  of  a  man  who 
swallowed  a  bone  which  lodged  in  the  oesophagus  opposite  to  the  arch  of  the  aorta. 
Death  took  place  suddenly  on  the  fifth  day  from  perforation  of  the  aorta  and  haemorrhage, 
after  a  slight  exertion.  Mr.  Eve  {Clin.  Soc.  Trans.,  vol.  xiii,  p.  174)  gives  a  case  in 
which  a  fish-bone,  impacted  in  the  oesophagus,  wounded  the  heart  fatally.  It  was 
thought  that  the  position  of  the  fish-bone  was  perhaps  due  to  previous  use  of  the  probang. 
Dr.  E.  G.  L.  Goffe  has  recorded  and  figured  {Proc.  Boy.  Soc.  Med.,  Children's  Sec,  January 
1915,  p.  36)  a  case  in  which  the  arch  of  the  aorta  was  perforated  by  a  safety-pin  impacted 
in  the  oesophagus. 


652  OPERATIONS  ON  THE  HEAD  AND  NECK 

strength  is  not  satisfactory  at  the  time  of  the  operation,  or  if  the  enemata 
are  not  retained,  a  soft  feeding-tube  must  be  made  use  of.  This  should 
be  passed  by  the  mouth  and  retained,  if  not  very  uncomfortable  to  the 
patient,  or  passed  at  intervals.  Towards  the  end  of  the  first  week,  perhaps 
earlier  if  the  wound  is  healing  well,  the  patient  may  be  allowed  to  swallow 
a  little  diluted  wine  or  milk. 


CHIEF  DIFFICULTIES 

(1)  A  fat,  short  neck. 

(2)  Enlarged  veins. 

(3)  Wide  depressors  of  hyoid  bone. 

(4)  Enlarged  thyroid  gland. 

(5)  Unusual  depth  of  oesophagus. 

(6)  Detecting  the  site  of  the  foreign  body. 

(7)  Firm  gripping  of  the  body  by  the  oesophagus. 

(8)  The  foreign  body  may  be  dislodged  during  the  operation. 

Dr.  Lediard  ^  records  the  case  of  a  man  in  whom  emetics  and  sevesal  attempts 
at  removal  had  failed  to  dislodge  a  tooth-plate;  emphysema. of  the  neck  was 
present,  and  some  blood  on  the  forceps  used.  Just  before  oesophagotomy,  a  bougie 
was  thought  to  "  scrape  "  as  it  was  withdrawn.  Nothing  being  felt  when  the 
oesophagus  was  exposed,  a  bougie  was  passed,  and  the  oesophagus  incised  behind 
the  cricoid  cartilage  ;  the  finger  now  could  detect  nothing,  and  a  bougie  passed  on 
seemed  to  feel  the  jilate  near  tlie  stomach.  The  plate  was  passed  nineteen  days 
after  its  impaction  ;  it  measured  an  inch  and  a  half  by  three-quarters  of  an  inch, 
carried  one  incisor,  and  had  "  numerous  sharp  points,  and  a  formidable-looking 
hook  at  one  end."  Though  there  were  no  larjaigeal  symptoms,  the  plate  must 
have  been  lying  behind  the  lower  end  of  the  larynx,  as  the  mucous  membrane  of 
the  gullet  showed  here  several  ecchymoses.  The  djslodgement  of  the  plate  took 
place  either  during  the  passage  of  the  bougie  or  in  the  administi'ation  of  the 
anaesthetic.     The  patient  made  a  good  recovery. 

Causes  oJ  Death.    These  are  chiefly  : 

(1)  Septicaemia,  the  wound  having  become  emphysematous,  sloughy, 
and  the  discharge  most  foul. 

(2)  Exhaustion,  when  the  body  has  been  long  impacted,  and  the 
patient's  health  has  run  down  before  the  operation. 

(3)  Cellulitis. 

(4)  Extension  of  suppuration  to  the  mediastinum. 

CEsophagostomy.  This  has  been  proposed  as  a  substitute  for  gastrostomy. 
Mr.  Reeves,  who  brought  the  subject  before  the  Clinical  Society^  recommended 
this  operation  as  less  dangerous  than  gastrostomy,  and  in  his  belief  that  cancer  of 
the  oesophagus  is  most  frequently  met  with  in  the  upper  part  of  the  tube.  The 
objections,  however,  are  so  great  as  to  have  prevented  any  adoption  of  this  opera- 
tion. They  are  :  (1)  The  risk  of  coming  close  to  a  mass  of  cancer,  which  will  not 
only  not  admit  of  dilatation,  but  which  will  be  rendered  more  active,  sloughy,  &c., 
by  the  necessary  irritation.  (2)  The  fact  that  important  parts  are  close  by,  and  that 
the  relations  of  these  may  very  likely  be  much  altered.  (3)  The  probability  of 
finding  the  oesophagus  altered  near  the  disease,  and  thus,  perhaps,  readily  per- 
forated, admitting  fluids  into  the  pleura,  &c. 

(Esophagectomy.  This  is  another  operation  introduced  only  to  be  abandoned. 
Prof.  Czerny's  case,  it  is  true,  was  temporarily  successful,  the  patient  living  rather 
more  than  a  year  after  the  operation.  But  cases  equally  suitable  from  the  site  of  the 
disease — only  just  out  of  reach  of  the  finger  introduced  from  the  mouth — with  no 
glands  involved,  and  no  adhesions  to  adjacent  parts,  though  symptoms  had  lasted 
five  months,  must  be  quite  exceptional.     Several  of  the  risks  given  above  would 

^  Clin.  Soc.  Trans.,  vol.  xvii,  p.  297. 
"  Ibid.,  vol.  XV,  p.  26. 


REMOVAL  OF  POUCHES  OF  THE  a]SOPlIAGUS    G53 

be  intensified  here,  and  there  would  bo  present  as  well  the  need  of  keeping  the 
fistula  patent.^     De  Q.uorvain  has  collected  a  lunnbcr  of  cascs.^ 

REMOVAL  OF  POUCHES  OF  THE  (ESOPHAGUS 

This  affection  has  in  former  years  been  considered  a  very  rare  one. 
Sir  H.  Buthn,  who  was  one  of  the  earhest  operators,  and  the  first  in  this 
country,^  puUished  ■*  six  cases  which  he   has   seen,  two  of  which  were 


Fig.  275.     Diverticulum  in  Dr.  M.  R.  Richardson's  first  case,  freed  from  its 

connections  and  brought  out  of  the  wound. 

operated  on  by  him,  and  with  success.  In  the  same  periodical  (July  11, 
1903)  he  has  pubhshed  eight  similar  cases.  Dr.  Maurice  Richardson  in 
a  paper  ^  stated  that  fifty-six  cases  had  then  been  recorded  ;  of  these 
eighteen  had  been  operated  upon,  in  most  with  success.  Sir  H.  Butlin, 
in  his  second  paper,  states  his  belief  that  "  the  rarity  of  this  condition 
has  been  greatly  exaggerated,  and  for  this  reason  :  the  symptoms  of  the 
pouch  are  not  generally  known,  and  are  usually  mistaken  for  those  of  a 

1  Sir  H.  Butlin  {Oper.  Surg.  Mah'g.  Dis.,  2nd  ed.)  gives  a  case  of  Prof.  Billroth's, 
where  death  was  caused  by  the  passage  of  the  bougie  into  the  tissues  round  the  oesophagus, 
the  opening  where  the  lower  end  of  the  oesophagus  had  been  stitched  to  the  skin  having 
contracted.  In  Sir  H.  Buthn's  opinion  the  results  of  the  fourteen  operations  collected 
by  De  Quervain  and  others  are  very  discouraging.  Dr.  Chas.  H.  Mayo  has  published 
a  paper  in  which  he  considers  the  diagnosis  and  treatment  of  oesophageal  diverticula 
{Ann.  Svrg.,  1910,  vol.  li,  p.  812). 

2  Arch.  f.  Klin.  Chir.,  1899,  S.  858.       ^  Trans.  Med.-Chir.  Soc.,  1893,  vol.  Ixxvi,  p.  209. 
*  Brit.  Med.  Journ.,  January  1, 1898.  ^  Ann.  of  Surg.,  May  1900. 


654 


opp:ratioxs  ox  the  head  and  neck 


yet  rarer  condition,  \\z.  pouching  of  the  oesophagus  above  a  stricture, 
whether  innocent  or  malignant.  Both  in  Whitehead's  case  ^  and 
Chavasse's,^  gastrostomy  was  performed  under  the  impression  that  the 
patient  was  suffering  from  stricture  of  the  oesophagus,  and  the  real  nature 
of  the  condition  was  only  discovered  after  the  death  of  the  patient."  ^ 
The  following  are  the  chief  symptoms,  as  given  by  Sir  H.  Butlin  in  his 
paper  quoted  above. 

The  pouch  starts,  usually,  at  the  back  of  the  junction  of  the  pharynx 


IT 


Fig.  276.     Isthmus  of  diverticulum  in  Dr.  M.  R.  Richardsons  first  case  after 
excision  of  the  main  portion.     The  probang  is  visible  in  the  oesophageal  opening. 

and  oesophagus  (Fig.  275).  It  occm-s  much  more  frequently  in  males, 
and  the  symptoms  do  not  appear  to  have  been  noticed  before  the  age  of 
40.  Return  of  fragments  of  undigested  food  is  the  one  constant  symptom 
in  every  case,  not  immediately  after  the  food  has  been  taken,  but  many 

1  Lancet,  1891.  vol.  i.  January  3,  p.  11.      ^  pa//^.  Soc.  Trans.,  1891,  vol.  xliii,  p.  82. 

'  In  Mr.  Whitehead's  case,  the  woman,  set.  57,  whose  symptoms  had  existed  eight 
years,  died  six  years  after  a  most  successful  gastrostomy.  Growing  weary  of  this  mode 
of  feeding  and  beheving  her  old  trouble  to  be  cured,  she  resumed  feeding  hy  the  mouth, 
and  allowed  the  gastrostomy  wound  to  close.  Gradually  the  old  dysphagia  returned, 
and  she  sank  from  exhaustion.  In  Mr.  Chavasse"s  case,  the  man.  aet.  49,  apphed  for 
rehef  too  late.  He  was  much  emaciated  from  starvation,  and  sank  two  days  after  the 
gastrostomy.  In  a  case  of  Landauers  {Cenfr.  f.  inn.  Med.,  April  22,  1899),  a  Rontgen 
photograph,  taken  with  thin  leaden  sounds  in  situ,  gave  more  exact  information  as  to 
the  situation  of  the  diverticulum.  At  the  present  day  in  all  cases  of  cesophageal  obstruc- 
tion a  radiographic  examination  should  be  made  after  the  administration  of  bismuth 
emulsion- 


REMOVAL  OF  POUCHES  OF  THE  (ESOPHAGUS    055 

hours  after.  The  return  of  food  is  sometimes  associated  with  severe 
attacks  of  coiijzhing.  After  some  time  a  larger  quantity  of  food  is 
returned,  and  the  patient  becomes  aware  of  some  difficulty  in  swallowing, 
especially  solid  food.  Pressure  on  the  side  of  the  neck,  usually  on 
the  left  side,  causes  fragments  and  liquids  to  return  into  the  mouth, 
and  if  not,  yet  causes  the  escape  of  gas  which  is  developed  and  collects  in 
the  pouch,  and  occasions  much  annoyance  by  gurgling  up  at  frequent 
intervals  during  movements  of  the  head  and  neck.     If  the  pouch  pro- 


FiG.  277.     The  mucous  membrane  of  the  neck  of  the  diverticulum  has  been 

inverted  and  united  by  interrupted  Lembert'.s  sutures  of  catgut.     (Dr.  M.  R. 

Richardson's  first  case.) 

duces  bulging  in  the  posterior  triangle,  about  the  level  of,  or  below  the 
cricoid  cartilage,  this  is  a  very  important  sign,  but  the  absence  of 
bulging  does  not  in  the  least  afiect  the  diagnosis.  A  bougie  is  arrested  at 
a  distance  of  about  nine  inches  from  the  teeth.  It  may  perchance  pass  into 
the  stomach,  ghding  over  the  orifice  of  the  pouch,  but  the  rule  is  that  it 
passes  into  the  pouch  ;  and,  as  the  afiection  becomes  more  pronounced, 
it  may  be  impossible  to  pass  an  instrument  down  the  oesophagus.  If 
the  bougie  be  of  metal  and  slightly  curved,  its  end  may  be  made  to  project 
so  that  it  can  be  felt  and  seen  in  the  side  of  the  neck  (almost  always  the 
left  side),  behind  the  sterno-mastoid.  Wasting  and  loss  of  weight  are 
rarely,  if  ever,  observed  until  the  late  stages  of  the  disease.  In  fact,  the 
patient  may  suffer  from  unmistakable  symptoms  for  years  without  any 


G5G 


OPERATIONS  ON  THE  HEAD  AND  NECK 


sensible  loss  of  weight.  Of  course,  in  those  cases  in  which  the  condition 
is  gradually  producing  death  by  starvation,  wasting  slowly  occurs  during 
the  last  months  or  years.  The  course  of  the  disease  is  very  slow.  The 
size  and  position  of  the  pouch  are  generally  well  shown  by  an  X-ray 
examination  after  the  patient  has  swallowed  a  dose  of  bismuth  emulsion. 
Operation.  The  patient  being  under  the  influence  of  an  ana?sthetic,^ 
it  would  be  well,  if  this  has  not  been  already  done,  to  adopt  .Sir  H.  Butlin's 
advice  and  pass  a  shghtly  curved  metal  bougie  into^the  jjouch,  and,  if 


Fig.  278.     The  outer  layers  of  the  oesophagus  have  been  closed  with  silk  sutures. 
(Dr.  M.  Pv.  Richardson's  first  case.) 


possible,  make  its  end  appear  in  the  posterior  triangle,  thus  obtaining  the 
clearest  proof  of  the  presence  of  a  diverticulum.  If  possible,  a  bougie  should 
also  be  passed  beyond  the  orifice  of  the  pouch  into  the  stomach,  so  as  to 
prove  that  there  is  no  strictm-e  of  the  oesophagus.  A  long  incision  is  then 
made  along  the  anterior  border  of  the  left  sterno-mastoid  from  the  hyoid 
to  just  above  the  sternum.  The  omo-hyoid  is  divided,  the  superior 
thyroid  vessels  severed  between  double  hgatures,  the  carotid  sheath 
drawn  outwards,  and  the  larynx  rotated  on  its  long  axis  by  drawing 
forward  the  left  ala  of  the  thyroid  cartilage  vrith.  blunt  hooks. 

The  pouch  is  then  usuaUy  easily  found  lying  behind  the  junction  of 

^  Dr.  M.  R.  Richardson,  acting  upon  a  suggestion  of  Dr.  Gushing,  had  a  hji^odemiic 
injection  of  atropine  given  before  the  ether  was  administered,  in  order  to  keep  the  mouth 
and  throat  dry.     "  This  plan  worked  admirably." 


REMOVAL  OF  POUCHES  OF  THE  (ESOPHAGUS     657 


the  phiiiynx  and  a3sopliaf?us  and  projecting  to  the  left  side.  If  it  be 
not  found  at  once,  careful  dissection,  aided  by  the  passage  of  a  bougie,  will 
detect  its  position.  It  is  then  grasped  by  forceps,  sepai'ated  fioni  the 
surrounding  tissues,  and  drawn  upwards  out  of  the  wound.  The  following 
are  some  of  the  methods  of  ilealing  with  it.  8ir  H.  Butlin  in  his  two  cases 
cut  away  the  pouch  from  above  downwards,  the  margins  of  the  wound 
being  drawn  together  with  eight  sutures  of  fine  silk  as  the  sac  was  cut 
away.     Bleeding  does  not  seem  to  give  any  trouble  at  this  stage.     Another 


oesopKaCjUS 


:V.  of  pouch 


Pouch 


Fig.  279.     The  situation,  shape,  and  size  of  the  diverticulum  in  Dr.  M.  R. 
Richardson's  second  case. 

method,  that  of  Mr.  Barrow,^  is  that  of  turning  back  a  cufE  of  the  fibrous 
coat  of  the  oesophagus  and  suturing  this  over  the  gap  left  in  the  mucous 
membrane  after  the  removal  of  the  pouch. 

Qaite  a  different  method  is  that  employed  by  Girard,  of  Berne. ^  To 
avoid  opening  the  oesophagus,  he  has  twice  invagiuated  the  pouch  so  that 
it  projects  into  this  tube.  The  orifice,  which  after  inversion  points 
externally,  is  closed  by  three  layers  of  sutures.  Both  of  these  cases  were 
successful,  though  in  one  a  fistula  followed  which  closed  later.  The  pouch 
probably  becomes  atropltied,  as  it  no  longer  obstructed  the  passage  of 
food.  Dr.  A.  E.  Halstead,  of  Chicago,  relates  a  case  successfully  treated 
bv  this  method.^ 


1  Lancet,  April  8,  190-5. 
^  Ann.  of  Surg.,  1904,  vol.  i,  p.  171. 
SURGERY  I 


2  Congr.  Franc.,  1896. 


42 


658 


OPERATIONS  ON  THE  HEAD  AND  NECK 


As  he  states,  it  is  only  adapted  to  diverticula  of  small  size,  and  cases  where  the 
lumen  of  the  cesojihagus  below  the  diverticulum  is  normal.  He  was  able  to  demon- 
strate one  source  of  the  obstruction  caused  by  the  diverticula  :  "  The  lower  border 
of  the  neck  of  the  diverticulum  acted  as  a  valve,  projecting  into  the  lumen  of  the 
resojihagus.  Upon  introduction  of  the  sound,  it  came  into  contact  with  this  valve- 
like projection,  which,  upon  further  pressure,  was  forced  down  and  completely 
obstructed  the  oesophagus,  and  diverted  the  sound  into  the  diverticulum."  The 
technique  adopted  was  as  follows  :  After  the  sac  had  been  freed  from  its  attach- 
ments, "  a  purse-string  suture  of  catgut  was  passed  round  the  neck  with  the  sound 
in  the  sac.     The  sound  was  then  withdrawn,  and  the  sac  inverted  and  invaginated 


Pyi^yu-Yix 


of 


? 


OXLC 


\ 


Fig.  280.     Posterior  view  of  the  pharynx  and  cesophagus  in  Dr.  M.  R.  Richard- 
son's second  case.     The  pouch  has  been  cut  off,  leaving  a  circular  margin.     The 
dotted  line  shows  the  incision  through  the  neck  and  margin  of  the  pouch,  and 
the  constriction  of  the  resophagus. 


into  the  cesophagus.  The  purse-string  suture  was  then  tied.  Three  sutures  of 
catgut  were  then  passed  through  the  neck  of  the  inverted  sac.  These  did  not 
penetrate  the  lumen  of  the  diverticulum.  Over  these  sutures  the  longitudinal 
muscular  layer  of  the  oesophagus  was  united  by  interrupted  catgut  sutiu"es.  A 
third  layer  of  catgut  sutures  transverse  to  these  was  introduced.  By  these  the 
inferior  constrictor  was  brought  down,  covering  the  first  sutures.  A  large-sized 
bougie  could  be  passed  without  cUfiiculty  into  the  stomach."  For  five  days  nutrient 
enemata  alone  were  given.  After  this  milk  was  swallowed  easily,  and  without 
leakage. 

Dr.  Richardson  treated  his  cases  shown  in  Figs.  275  to  282  as 
follows  : 

In  the  first  case  (Figs.  275-278)  "  the  tip  of  the  index  finger  could  be  thrust 
into  the  cesophagus  through  the  circular  base  of  the  pouch.  This  was  removed  by 
cutting  through  the  isthmus  close  to  the  pharyngeal  opening..  The  mucous  mem- 
brane was  inverted  into  the  oesophagus  and  fastened  together  by  a  few  interrupted 
fine  catgut  sutures.  The  other  layers  were  also  inverted  and  fastened  by  inter- 
rupted Lembert's  stitches  of  silk." 


REMOVAL  OF  POUCHES  OF  THE  (ESOPHAGUS     659 


In  tlie  second  case  (Figs.  280-282)  when  "  the  index  finger  was  passed  care- 
fully througli  the  neck  of  the  poueh  into  the  (esophagus  a  constriction  (Fig.  280) 
lined  with  friable  mucous  inenihrane  was  found  here.  Passage  of  the  finger  through 
this  constricted  ]>ortion  resulted  in  a  longitudinal  tear,  which  seemed  to  involve 
the  greater  jiart  of  the  lining.  The  jn'obang,  after  Ijcing  j)asse(l  hy  this  constriction, 
could  at  one  time  he  ])assed  into  the  stomach  ;  at  another  it  could  not.  The 
ce-sophagus  just  Ijclow  the  opening  of  the  pouch  had  the  diameter  of  a  lead  j)encil  ; 
externally,  from  the  diverticulum  to  as  far  as  the  dissection  extended,  it  was  per- 
fectly normal.  Although  th(^  mucous  membrane  seemed  normal,  it  was  not,  for 
it  gave  way  under  the  gentlest  pressure  of  the  finger.     There  Wixa  coastriction  at 


Fig.  281.     The   pouch   and   oe.so- 

phagus  after  the  incision.     (M.  R. 

Richardson.) 


Fig.  282.  The  condition  of  the 
parts  after  vertical  suturing  of  the 
pouch  and  transverse  suturing  of 
the  oesophagus.  (M.R.Richardson.) 


that  place,  caused  either  by  real  pathological  changes  or  disuse.  The  tear  in  the 
oesophagus  was  converted  into  a  longitudinal  slit  by  extending  the  inci,sion  down- 
wards in  the  posterior  wall  through  the  lower  border  of  the  isthmus  of  the  sac, 
and  through  the  constriction  (Figs.  280-281).  Fearing  the  formation  of  a 
l^ermanent  organic  constriction  at  the  site  of  the  laceration,  a  portion  of  the  pouch 
was  utilised  to  enlarge  the  chameter  of  the  contracted  oesophagus.  To  accomplish 
this  end  a  considerable  circular  margin  was  left  about  the  opening  o'  the  sac 
(Fig.  280).  The  lower  portion  of  the  margin  was  brought  dowiiward  and  placed  in  the 
gap  made  by  the  divided  posterior  surface  of  the  narrowed  cesophagu.s.  The  effect 
of  this  procedure  was  to  increase  the  lumen  of  the  oesophagus  by  the  small  area 
of  tissue  taken  from  the  pouch  (Fig.  281).  The  subsequent  effect  of  this  plastic 
operation  showed  its  advantage,  for  at  no  time  was  there  the  least  obstruct' on  to 
the  passage  of  the  probang  into  the  stomach.  After  making  as  good  a  joint  as 
possible  at  the  beginning  of  the  oesophagus,  I  closed  the  mouth  of  the  pouch  by 
inverting  the  margins  remaining  after  excision,  uniting  them  by  interrupted  Lembert 
sutures."'  As  was  expected,  leakage  took  place,  the  wound  giving  escape  to  about 
half  the  quantities  swallowed.  The  wound  ultimately  closed  entirely,  the  patient 
regaining  normal  deglutition  and  perfect  health. 

Owing  to  the  very  great  risk  of  leakage,  some  form  of  drainage  must 
be  provided  in  every  case  where  a  diverticulum  has  been  removed. 


660  OPERATIONS  ON  THE  HEAD  AND  NECK 

Either  a  di-ainage-tiibe  or  gauze  wicks,  or  both,  or  gauze  packing  must 
be  employed.  Only  the  two  ends  of  the  wound  are  to  be  closed,  though 
salmon-gut  sutures  of  reserve  may  be  placed  in  the  rest  of  the  wound, 
to  be  tightened  when  the  necessity  for  drainage  has  ceased,  as  the  wound 
is  sometimes  very  slow  in  closing. 

Sir  H.  Butlin's  advice  ^  on  the  closure  of  the  wound  and  the  after-treat- 
ment is  as  follows  :  "  The  less  the  tissues  below  the  pouch  are  disturbed, 
the  better.  If  they  are  widely  opened  up,  there  is  a  liability  to  septic 
inflammation  spreading  down  into  the  posterior  mediastinum.  No 
attempt  should  be  made  to  close  the  external  wound,  however  carefully 
the  opening  of  the  neck  of  the  pouch  has  been  stitched  up.  It  should  be 
drained  by  a  soft  tube.  On  the  other  hand,  it  is  very  desirable  to  close 
the  opening  into  the  oesophagus,  for,  although  the  stitches  always  give  way 
at  the  end  of  three  or  four  days,  the  surrounding  tissues  are  by  this 
time  sufficiently  recovered  to  render  the  risk  of  spreading  septic  inflamma- 
tion much  less  probable.  If  the  pouch  is  of  long  standing,  and  if  it  is  of 
large  size,  a  soft  tube  should  be  passed  into  the  stomach  and  retained 
as  long  as  is  necessary  for  feeding.  If  the  patient  cannot  or  will  not 
permit  this,  or  vomits  the  tube,  it  must  be  passed  over  a  guide  every  time 
food  is  taken,  otherwise  almost  all  the  food  will  pass  out  through  the 
wound  in  the  neck.  If  this  cannot  be  done,  a  tube  should  be  introduced 
into  the  stomach  through  the  wound  in  the  neck,  and  retained  there  until 
healing  is  ne-arly  accomplished." 

1  Brit.  Med.  Journ.,  July  11,  1903. 


CHAPTER  XXXII 

OPERATIONS  ON  THE  SPINAL  ACCESSORY,  UPPER 
CERVICAL  NERVES,  AND  SYMPATHETIC 

PARTIAL  NEURECTOMY,  OR  NERVE-STRETCHING 

Indications.  In  cases  of  spasmodic  torticollis  in  which  :  (1)  All  previous 
palliative  treatment  has  failed,  e.g.  large  doses  of  conium,  massage, 
galvanism  of  the  affected  side,  and  faradisation  of  the  opposite  muscles. 
(2)  The  spasms  so  severe  and  constant  as  to  interfere  with  the  patient's 
talving  food  or  enjoying  sleep  and  to  cause  real  suffering,  (3)  The  only 
nmscles  affected  are  the  sterno-mastoid,  or  the  sterno- mastoid  and 
trapezius. 

Anatomy  of  the  Spinal  Accessory  Nerve.  The  relations  of  this  nerve 
are  of  very  great  importance,  as  it  is  frequently  exposed  and  may  easily 
be  accidentally  divided  in  the  removal  of  tuberculous  glands  and  other 
deep-seated  growths  in  the  neck.  The  spinal  or  external  part  of  this 
nerve,  having  left  the  skull  by  the  jugular  foramen,  is  directed  backwards 
in  front  of,  or  behind,  the  internal  jugular  vein,  and  appears  below  the 
digastric  and  the  occipital  artery  (Fig.  161).  In  this  part  of  its  course 
it  passes  in  front  of  and  then  turns  backwards  below  the  transverse 
process  of  the  atlas  :  This  is  the  surest  anatomical  guide  to  the  position 
of  the  nerve.  If  then  descends  obliquely  outwards  to  the  sterno-mastoid 
muscle,  and  disappears  under  this  at  a  distance  of  two  inches  from  the 
apex  of  the  mastoid  process.  Having  usually  perforated  the  muscle, 
the  nerve  passes  across  the  posterior  triangle,  to  end  in  the  deep  surface 
of  the  trapezius.  While  passing  through  or  under  the  sterno-mastoid 
the  nerve  communicates  with  branches  from  the  second  cervical.  Having 
emerged  from  the  muscle,  it  communicates  with  the  second  and  third 
nerves,  and  is  often  in  intimate  connection  with  the  great  auricular  and 
small  occipital.  When  under  the  trapezius,  it  is  joined  by  branches  of 
the  third  and  fourth  cervical. 

Operations  for  Partial  Neurectomy.  The  nerve  may  be  found  by 
two  different  incisions. 

A.  Along  the  anterior  border  of  the  sterno-mastoid,  so  as  to  come 
upon  this  nerve  before  it  perforates  this  muscle. 

B.  Along  the  posterior  border  of  the  muscle  ;  the  surgeon  finding 
the  nerve  ?s  it  emerges  here  to  cross  the  posterior  triangle  to  gain  the 
trapezius,  and  following  it  up  to  a  point  above  its  branches  to  the  sterno- 
mastoid,  so  as  to  paralyse  this  muscle  also.  The  first  of  these  operations 
is  much  preferable,  and  for  these  reasons: 

(1)  Though  the  nerve  lies  more  deeply  at  the  anterior  than  at  the  pos- 
terior border  of  the  muscle,  it  is  here  a  single  nerve,  and  not  likely  to  be 
confomided  with  other  nerves,  e.g.  branches  of  the  second  and  third 
cervical  which  also  emerge  at  the  posterior  border  to  supply  the  skin. 
Furthermore,  in  this  latter  position  the  spinal  accessory  is  often  found 

661 


662  OPERATIONS  ON  THE  HEAD  AND  NECK 

in  close  connection  with  the  small  occipital  and  great  auricular,  as  these 
two  nerves  appear  at  the  posterior  border  and  curve  upwards. 

(2)  By  finding  the  nerve  at  the  anterior  border  of  the  muscle,  paralysis 
of  the  sterno-mastoid  is  better  ensured.  When  the  nerve  is  found  at  the 
posterior  border  and  followed  up  into  the  muscle  before  division,  there 
IS  always  an  uncertainty  as  to  whether  some  branch  to  the  muscle  may 
not  have  come  ofE  above  the  point  at  which  the  surgeon  has  divided 
the  nerve.  And  though  the  nerve  is  more  superficial  in  the  posterior 
triangle,  it  is  difficult  to  make  certain  whether  it  is  the  spinal  accessory 
or  one  of  the  superficial  cervical  nerves  which  emerge  close  to  it  from 
behind  the  muscle. 

(3)  The  transverse  process  of  the  atlas  is  a  sure  guide  to  the  nerve 
in  this  situation. 

A.  Operation  in  front  of  the  Sterno-mastoid.  The  parts  having  been 
shaved  and  sterilised,  and  the  head  suitably  raised  and  turned  to  the 
opposite  side,  the  surgeon  makes  a  free  incision  along  the  anterior  border 
of  the  sterno-mastoid  for  three  inches,  commencing  at  the  apex  of  the 
mastoid  process  and  ending  about  two  inches  below  the  angle  of  the  jaw. 
Skin,  fasciae,  and  platysma  being  di\"ided,  the  anterior  border  of  the 
sterno-mastoid  is  clearly  defined,  and  draw^i  strongly  backwards  so  as 
to  put  the  nerve  on  the  stretch.  In  doing  this  the  posterior  and  lower 
part  of  the  parotid  may  have  to  be  drawn  forward  if  this  gland  overlap  the 
muscle.  The  wound  being  then  thoroughly  dried,  the  operator  searches 
for  the  nerve  with  a  director  in  the  fatty  connective  tissue  which  lies 
between  the  muscle  and  the  carotid  sheath.  If,  in  doing  this,  he  keep  for 
his  landmark  the  angle  of  the  jaw,  he  is  almost  certain  to  be  on  a  level 
with  the  point  where  the  nerve  enters  the  muscle.  If  this  landmark  fail 
him,  he  should  define  the  lower  border  of  the  digastric,  and,  tracing 
upwards  the  posterior  belly  of  this  muscle,  feel  for  the  transverse  process 
of  the  atlas,  between  the  front  of  which  process  and  the  posterior  belly 
of  the  digastricthe  nerve  emerges  to  pass  backwards  to  the  sterno-mastoid. 
The  small  branch  from  the  occipital  artery  which  accompanies  the  nerve 
will  give  no  trouble  ;  and  if  in  the  deeper  parts  of  the  wound  only  a 
director  or  a  blunt  dissector  be  used,  neither  the  occipital  artery  nor  the 
internal  jugular  vein  will  be  injured.  A  full  inch  of  the  nerve  should 
be  removed. 

B.  Operation  below  or  at  the  Posterior  Border  of  the  Sterno-mastoid. 
To  find  the  nerve  in  this  situation  an  incision  should  be  made  two  inches 
long,  along  the  posterior  border  of  the  sterno-mastoid,  the  centre  of 
the  incision  corresponding  to  about  the  centre  of  this  border  of  the 
muscle.  The  fascia  being  slit  up  to  the  same  extent,  the  trapezial  branch 
of  the  nerve  is  sought  for  as  it  emerges  from  the  sterno-mastoid  to 
cross  the  posterior  triangle.  It  will  be  found  a  little  above  the  centre 
of  the  wound,  and  should  be  traced  through  the  muscle  till  the  common 
trunk  is  discovered  above  its  division  into  branches  for  the  trapezius 
and  sterno-mastoid.     Half  an  inch  of  the  nerve  should  then  be  cut  out. 

Mr.  Jacobson  has  operated  on  the  following  three  cases  : 

In  the  first,  in  1878,  the  nerve  was  found  in  the  posterior  triangle,  and  after 
tracing  it  upwards  a  portion  of  the  common  trunk  was  removed  in  the  substance  of 
the  sterno-mastoid.  In  the  second  case,  in  1894,  the  nerve  T^as  found  at  the  anterior 
border  of  the  muscle,  the  angle  of  the  jaw  being  taken  as  a  guide.  Both  patients 
were  middle-aged  women,  the  subjects  of  severe  spasmodic  torticollis.  In  each  case 
some  of  the  deep  cervical  muscles  supplied  by  the  upper  cervical  nerves  were  affected, 
and  in  neither  was  the  result  satisfactory.     In  the  first  no   permanent  benefit  can 


OPERATIONS  ON  THE  SPINAL  ACCESSORY        GG8 

be  said  to  liave  resulted.  In  the  second  the  relief  was  considerable,  and  the  patient 
has  hitherto  declined  further  operation  in  the  form  of  division  of  the  posterior 
branches  of  the  cervical  nerves.  Atrophy  of  the  sterno-mastoids  followed  in  each 
case. 

In  the  tliinl  case,  as  l)c)th  sterno-mastoids  were  affected,  excision  of  part  of  each 
spinal  accessory  was  performed  above  the  sterno-mastoid.  While  the  muscle  on  the 
left  side  remained  paralj'sed,  the  right  contracted  afterwards  as  vigorously  as  before. 
There  was  no  doubt  whatever  that  the  nerve  had  been  found  and  ])art  removed,  for 
it  was  absolutely  quiescent  for  three  weeks  after  the  operation.  Whether  the  return 
to  activity  was  due  to  reunion  taking  place,  or  to  the  additional  nerve -sujiply  from 
the  second  cervical,  must  remain  doubtful.  The  same  result  has  occurred  to  Mr. 
Harsant,  surgeon  to  the  Bristol  Royal  Infirmary.^  This  case,  of  twenty  years"  dura- 
tion, was  rendered  further  unfavourable  by  the  number  of  muscles  involved.  Tlius, 
when  the  head  was  fixed  by  the  sterno-mastoids  and  trapczii  in  rigid  spasm,  the 
platysma.  occipito-frontalis,  and  orbicularis  palpebrarum  were  also  in  violent  action, 
the  arms  were  rigid,  and  the  abdominal  recti  were  powerfully  contracted.  Though 
on  each  side  three-quarters  of  an  inch  of  the  spinal  accessories  were  removed,  it  is 
stated  that  some  weeks  later  "  there  was  no  actual  paralysis  of  either  sterno- 
mastoid  or  trapezius,  which  all  appeared  to  contract  violently  at  times." 

There  is  no  comparison  between  the  two  methods,  that  in  which 
the  nerve  is  fomid  at  the  anterior  border  of  the  muscle  being  infinitely 
easier  and  more  satisfactory. 

A  very  interesting  contribution  to  the  literature  of  this  subject  is  a 
paper  by  Mr.  Ballance.^ 

His  patient,  a  woman  of  -48,  was  a  good  instance  of  the  distress  and  misery  due 
to  spasmodic  torticollis.  Di^^sion  of  the  right  spinal  accessory  in  the  anterior 
triangle  gave  most  decided  relief.  At  the  end  of  four  months,  when  the  history 
ceases,  the  patient  is  reported  to  have  been  "  much  better  and  stouter.  The  face  is 
happy  and  tranquil.  There  is  neither  headache  nor  pain,  and  sleep  and  appetite 
are  good.  The  control  of  the  movements  of  the  head  is  perfect  as  long  as  she  is  not 
excited,  and  so  long  as  the  head  is  not  raised  so  that  the  eyes  are  directed  much  above 
the  horizontal  plane  in  whieli  they  lie.  .  .  .  The  right  sterno-mastoid  and  trapezius 
are  atrophied." 

Division  of  the  spinal  accessory  deserves  a  further  trial,  even  if  the 
relief  given  be  not  permanent.  No  serious  loss  of  function  occurs  after 
division  of  the  nerve.  Though  there  is  some  dropping  of  the  shoulder  and 
atrophy  of  the  trapezius  the  arm  can  still  be  raised  and  the  head  rotated. 

The  chief  fear  is  that  other  muscles  are  or  will  become  involved, 
as  in  the  cases  previously  described.  Thus,  Mr.  Ballance  writes  of  his 
patient  :  "  Since  the  operation,  it  has  been  certain  that  some  of  the 
muscles  supplied  by  the  upper  spinal  nerves  are  liable  to  spasm.  It  would 
be  strange  if  it  were  not  so,  considering  the  intimate  connections  between 
the  second,  third,  and  fourth  spinal  nerves  and  the  spinal  accessory,  in 
the  sterno-mastoid,  trapezius,  and  posterior  triangle,  together  with  the 
fact  that  some  of  the  fibres  of  the  spinal  accessory  are  connected  with  the 
same  cells,  or  with  cells  in  the  immediate  neighbourhood  of  those  from 
which  arise  the  motor  rootlets  of  the  cer\dcal  spinal  nerves." 

The  following  conclusions  may  be  drawn  with  regard  to  the  operative 
treatment  of  spasmodic  torticollis  :  (1)  Palliative  treatment  \vi\\  be  of 
little  permanent  value,  and  the  earlier  surgery  is  resorted  to  the  better  the 
outlook.  (2)  The  most  common  combination  of  spasm  is  that  invohnng 
the  sterno-mastoid  on  one  side  and  the  posterior  rotators  on  the  other,  the 

1  Bristol  Med.-Chir.  Journ.,  1896. 

2  St.  Thomas's  Hospital  Reports,  vol.  xiv,  p.  95.  Other  successful  cases  will  be  found 
recorded  by  Prof.  Annandale  (Lancet.  1897,  vol.  i,  p.  555)  and  by  Mr.  Southam,  ibid.,  1881, 
vol.  ii.  p.  369). 


664  OPERATIONS  ON  THE  HEAD  AND  NECK 

head  being  held  in  the  position  of  sterno-mastoid  spasm  with  the  addition 
of  retraction  through  the  greater  power  of  the  posterior  rotatorc.^ 

(3)  Operation  on  the  spinal  accessory  may  afford  relief,  even  if 
other  muscles  than  the  sterno-mastoid  are  affected.  On  the  other  hand, 
the  affection  previously  limited  to  the  sterno-mastoid  may  spread  to  other 
muscles  in  spite  of  this  operation. ^  (4)  No  fear  of  disabling  paralysis 
need  deter  us  from  recommending  operation,  as  the  head  can  be  held  erect 
even  after  the  most  extensive  resection. ^  (5)  It  is  clear  from  Mr. 
Harsant's  cases  as  well  as  the  others  already  mentioned  that,  after  un- 
doubted resection  of  portion  of  the  spinal  accessory,  spasmodic  action 
of  the  sterno-mastoid  may  still  persist.  (G)  The  need  of  resorting  to 
surgery  early  in  these  cases  has  already  been  pointed  out.  The  disease 
will  certainly  spread  from  one  muscle  to  another,  from  one  group  to 
another,  the  abnormal  condition  of  one  nerve-centre  extending  to  other 
closely  adjacent  centres.  Further,  it  is  here  as  in  traumatic  epilepsy 
of  any  duration  (p.  273)  ;  over-excitabihty  of  one  or  more  nerve-centres 
becomes,  if  left  too  long,  a  permanently  established  condition,  and 
with  it  over-activity  of  the  muscles  which  are  physiologically  associated 
with  those  nerve-centres. 

Treatment  of  Congenital  Torticollis.  Here  the  essential  condition  is  a  con- 
traction of  the  sterno-mastoid,  though  in  old-standing  and  advanced  cases  there 
will  be  also  a  secondary  contraction  of  certain  of  the  deep  muscles  of  the  neck.  In 
early  or  slight  cases  treatment  by  manipulation  or  by  mechanical  means  should 
be  tried,  and  if  there  is  any  suspicion  of  congenital  syphilis  anti-syiihilitic  treatment 
should  also  be  carried  out.  If  these  are  not  successful,  or  if  the  deformity  is  too 
advanced  for  them  to  offer  any  prospect  of  success,  operative  treatment  is  indicated. 
Either  of  the  following  operations  may  be  employed  : 

(a)  Subcutaneous  division  of  the  Sterno-mastoid.  The  muscle  should  be  divided 
about  an  inch  above  the  clavicle.  The  skin  of  the  neck  having  been  carefully 
sterilised,  a  sharj)  pointed  tenotomy  knife  is  introduced,  from  the  outside  if  the 
right  muscle  is  contracted  and  from  the  inside  in  the  case  of  the  left.  The  external 
jugular  vein  must  be  carefully  avoided  and  the  knife  pushed  deep  to  the  muscle, 
which  is  now  made  tense  by  an  assistant  rotating  the  head.  The  knife  is  now 
turned  so  that  the  cutting  edge  is  directed  towards  the  skin,  and  the  muscle  is  divided 
by  a  series  of  sawing  movements. 

{b)  Division  of  the  St erno- Mastoid  through  an  Open  Incision.  A  transverse 
incision  is  made  through  the  skin  and  fasciae  a  short  distance  above  the  clavicle. 
The  margins  of  the  sterno-mastoid  having  been  defined  a  director  is  passed  beneath 
it  and  tlie  muscle  is  completely  cut  across.  Any  further  contracted  bands  of  fascia 
are  now  felt  for  by  the  finger  and  are  then  divided.  All  vessels  are  then  secured 
and  the  wound  is  closed. 

The  two  Operations  compared.  The  great  advantage  of  the  first  method  is  the 
absence  of  any  noticeable  scar.  Its  chief  disadvantage  is  that  the  whole  of  the 
contracted  structures  may  not  be  divided.  Thus  contracted  bands  of  fascia  may 
very  easily  escape,  and  it  is  quite  possible  that  the  muscle  may  be  transfixed  by 
the  knife  so  that  its  deeper  fibres  escape  division.  Another  disadvantage  is  that 
the  external  jugular  may  be  cut,  or  even  the  imi^ortant  structures  beneath  the 
sterno-mastoid  may  be  damaged. 

The  great  advantage  of  the  oj^en  operation  is  that  all  contracted  structui'es  may 
be  identified  and  then  thoroughly  divided.  Vessels  can  be  avoided,  and  any 
abnormal  vein  can  be  secured  before  being  cut  across.  The  only  objection  is  the 
scar,  but  if  primary  union  be  secured,  this  should  not  be  unsightly.  On  the  whole, 
then,  the  open  operation  is  to  be  recommended. 

After-Treatment.  After  the  operation  the  head  should  be  fixed  by  a  plaster  of 
Paris  case  or  other  apparatus  in  a  position  of  slight  over-correction.  This  must  be 
worn  for  three  weeks  ;  after  this  time  the  patient  should  \^ear  a  poroplastic  collar, 
which,  fitting  comfortably  over  the  shoulders  and  the  ui>per  part  of  the  thorax, 
supports  the  head  in  the  correct  position.  This  apparatus,  which  should  be  removed 
daily  for  massage  and  manipulations,  must  be  worn  for  some  months. 

1  Dr.  Maurice  H.  Richardson  and  Dr.  G.  L.  Walton,  Amer.  Journ.  Med.  Sci.,  1895. 
No.  cix,  p.  27.  2  iiioi. 


OPERATIONS  ON  THE  SPINAL  ACCESSORY        065 

Resection  of  some  of  the  Branches  of  the  Upper  Cervical  Nerves.     In 
those  cases  of  spasmodic  torticollis  where,  after  resection  of  part  of  one 


Fig  283.  A,  A,  Trapezius.  B,  B,  Sterno-mastoid.  C,  C,  Splenius.  D,  D,  L. 
anguli  scapulae.  E,  Complexus.  F,  Rhomboideus  minor,  a,  a.  Occipital 
arteries,  b.  Transverse  or  superficial  cervical,  c,  Superficial  cervical.  d,d. 
Branches  of  deep  cervical,  e,  Cutaneous  branch  of  posterior  auricular.  1,  1, 
Great  occipital  nerve.  2,  Third  cervical  nerve.  3,  Fourth  cervical  nerve. 
4,  Fifth  cervical  nerve.  .5,  5,  Small  occipital  nerve.     (Godlee.) 

spinal  accessory,  mischief  still  persists  in  muscles  of  the  opposite  side, 
this  step  has  been  practised  by  Mr.  Noble  Smith,i  and  by  Prof.  Keen,^  and 
Prof.  Krause  for  occipital  neuralgia.^ 

1  Brit.  Med.  Journ.,  1891,  vol.  i,  p.  753. 

2  Journ.  Nerv.  and  Ment.  Dis.,  December  1889.  .       _^^ 

3  Von  Bergmann's  Syst.  Prac.  Surg.,  American  translation,  vol.  i,  p.  u/9. 


G66 


OPERATIONS  ON  THE  HEAD  AND  NECK 


The  following  are  the  chief  steps  in  the  operation  detailed  by  this 
authority  : 


Fig.  284.  A,  A,  Trapezius.  B,  Sterno-mastoid.  C,  C,  Splenius.  D,  D,  L. 
anguli  scapulae.  E,  E,  Complexus.  F,  Rhomboideus  minor.  G,  Trachclo- 
mastoid  and  transversalis  cervicis.  H,  Semispinalis.  I.  Rectus  0.  posticus 
major.  J,  Rectus  C.  pcsticus  minor.  K,  Obliquus  superior.  L,  Obliquus 
inferior,  a,  a.  Occipital  artery,  h,  Princeps  cervicis.  c,  Vertebral,  d.  Deep 
cervical,  e,  Superficial  cervical.  1,  Suboccipital  nerve.  2.  2,  Great  occipital. 
3, 3,  Third  cervical.  4,  Fourth  cervical.  5,  Fifth  cervical.  *  Transverse 
process  of  atlas,  f  Articular  process  of  axis..  J  Spinous  process  of  axis. 
*\  Spine  of  seventh  cervical.     (Godlec.) 

The  incision  through  the  thick  skin  begins  at  the  occiput  near  tlic  middle  lino 
and  3  cm.  below  the  external  occijiiUil  ])rotubcrauce.  Carried  outwardsand  slightly 
downwards  to  a  point  2  cm.  from  the  i\\)  of  the  mastoid,  it  now  runs  oliliquely  down- 
wards and  forwards  to  the  posterior  edge  of  the  sterno-mastoid,  and  ends  a  little  below 
the  level  of  (he  hyoid  bone.     The  greater  part  of  the  incision  runs  within  the  limits 


RESECTION  OF  THE  CERVICAL  SYMPATHETIC       607 

of  tlu>  hairy  scalp.  'I'lu-  gtvat  occipital  nerve  is  foiiiul  hy  dissecting  tlie  u])pcr  lip 
of  the  wound  upwards.  It  conu>s  through  the  upper  lateral  margin  of  tin-  thin 
tra|)e'/,ius  to  enter  tiie  dense  fatty  tissue  of  this  region  along  a  horizontal  line  2  em. 
below  the  external  oeei])ital  ])rolul)erance,  and  at  a  varying  distaiu^e  fronn  the  middle 
line.  The  trajn'/aus  nuist  be  divided  or  dis{)laced  inwanlw  according  to  its  develop- 
ment, the  splenius  and  sc^nispinalis  also  eut  through  transversely  as  far  as  is  necessary 
U^  give  acees.s  to  the  deeper  ])arts.  The  nerve  is  followed  to  where  it  tvu-ns  round, 
the  infei'ior  oblicjue  where  it  is  resected.  Prof.  Krause  considers  the  existence  of 
the  third  occipital  constant.  It  lies  along  the  inner  side  of  the  great  occipital. 
It  nuist  be  followed  back  through  the  semisj)inalis,  over  and  below  the 
inf(>i'ioi'  oblique  to  its  exit  between  the  second  and  third  vertebra'.  The  small 
oeeipital  and  great  auricular  will  be  exposed  by  the  above  incision  wliere  they  appear 
at  tiu>  posterior  edge  of  the  sterno-mastoid,  at  about  the  level  of  the  hyoid  bone. 
In  following  them  backwards  towards  the  spinal  colunni  the  sterno-mastoid  is  to  be 
displaced  forwards  and  the  splenius  and  other  museles  backwards.  Care  must  be 
taken  of  the  spinal  accessory,  which  frequently  communicates  with  the  super- 
ficial cervical  nerves.  The  most  troublesome  bleeding  will  be  met  with  in  the  deeper 
part  of  the  wound,  and  is  only  to  be  controlled  by  compression.  Thiersch's  method 
of  avulsion  (p.  .364)  is  not  to  be  employed  here  owing  to  the  proximity  of  a  very 
imi)ortant  part  of  the  spinal  cord,  and  the  fact  that  the  phrenic  may  arise  in  part  from 
the  third  nerve.  An  electric  head  light  will  be  found  heljiful  in  dealing  with  the  deeper 
part  of  the  wound.  The  divided  muscles  should  be  united  by  buried  sutures.  The 
wound  should  be  drained.  Figs.  28.3  and  284  illustrate  the  anatomy  of  this  intricate 
region. 

RESECTION  OF  THE  CERVICAL  SYMPATHETIC  FOR 

EXOPHTHALMIC  GOITRE,  ETC. 

Owing  to  the  uncertainty  of  the  results  and  the  dangers  accompanying 
partial  thyroidectomy  in  exophthalmic  goitre  (p.  015),  some  surgeons 
in  recent  years,  relying  on  the  suggestion,  originally  put  forward  by 
Trousseau,  that  the  three  cardinal  phenomena  of  the  disease  are  due  to 
some  disturbance  of  the  cervical  sympathetic,  have  practised  removal 
of  these  ganglia.  This  method  of  treatment  does  not  appear  to  be  based 
on  sound  foundations,  or  to  be  followed  by  good  results  with  sufficient 
constancy  to  justify  our  resorting  to  it.  Thus,  even  if  morbid  chajiges 
in  the  ganglia  were  constantly  present  in  this  disease  (a  postulate  which 
cannot  be  conceded)  any  attempt  to  explain  the  three  cardinal  symptoms 
of  exophthalmic  goitre  is  unsatisfactory.  Thus,  while  the  exophthalmos 
and  the  goitre  may  be  explained  by  paralysis,  the  third  chief  feature,  the 
excited  heart's  action,  means  irritation,  not  paralysis,  of  the  above 
ganglia.  It  must  be  remembered  that  the  removal  of  the  sympathetic 
chain,  always  a  difficult  operation,  is  rendered  more  so  by  the  presence 
of  the  goitre,  and  that  those  points  which  have  been  fully  alluded  to  above, 
viz.  the  poor  vitality  of  the  patient,  the  risks  of  the  anaesthetic,  the  dangers 
of  thyroidism,  have  to  be  faced  here  also. 

•  With  regard  to  the  results  of  this  mode  of  treatment  of  exophthalmic 
goitre,  they  do  not  seem  to  be  any  more  constantly  beneficial  than  those 
following  partial  thyroidectomy,  and  this  is  especially  the  case  with 
reference  to  those  nervous  symptoms  which  are  so  frequent  and  distressing 
a  feature  in  this  disease.  Of  this  operation  Mr.  Berry  ^  says,  after  con- 
sidering published  results  :  "  These  results  do  not  seem  to  me  very 
encouraging.  I  have  never  performed  the  operation  myself,  nor  do  I 
feel  at  all  inclined  to  recommend  it." 

Jaboulay,  who  first  gave  prominence  to  it,^  gives  in  the  second  jiaper  eleven 
cases,  and  speaks  of  the  operation  as  especially  preferable  to  partial  thyi-oidectomy 
in  those  cases  in  which  the  goitre  is  not  a  prominent  feature.  For  Jaboulay \s  later 
results  see  Jaboubay  and  Chalier.^ 

1  Loc.  i^npra  cif.         ^  Lyon  Mei..  Feliruary  7.  1S97  ;    Prrssc  Med.,  February  12,  1898. 
3  Li/on  MH.,  1911,  vol.  cvi,  p.  .501. 


668  OPERATIONS  ON  THE  HEAD  AND  NECK 

B.  Farquhar  Curtis,  of  New  York,  discusses  the  various  operations  forcxopli- 
thalmic  goitre,^  with  special  reference  to  the  merits  of  thyroidectomy  and  sympa- 
thectomy. Having  met  with  three  deaths  in  eleven  cases  of  thyroidectomy  from 
acute  thyroidism  alone,  without  wound  complications,  and  attracted  by  the  results 
claimed  by  Jonnesco  for  complete  bilateral  removal  of  the  cervical  sympathetic,  Dr. 
Curtis  operated  in  seven  cases,  but,  as  there  were  two  deaths  from  acute  thyroidism, 
and  one  probably  due  to  the  amesthetic,  his  results  have  not  been  better.  While  it 
is  allowed  that  it  was  early  to  judge  of  final  results,  it  is  claimed  that  "  three  cases 
were  cured,  one  improved,  none  unimjuoved."  Three  cases  died.  Operation.  The 
following  points  are  emphasised.  The  incision  should  be  along  the  anterior  bolder  of 
the  sterno-mastoid,  the  large  vessels  exposed  and.  with  the  goitre,  displaced  to  the 
inner  side,  the  sympathetic  trunk  exposed  in  the  middle  of  the  wound,  and  traced 
to  the  uj)per  ganglion.  The  latter  is  isolated  by  forcible  retraction  of  the  upper 
angle  of  the  wound  in  a  good  light,  the  nerve  clamped  just  above  the  ganglion,  and 
this  body  twisted  out.  The  nerve  is  then  followed  down,  and  the  second  and  third 
ganglia  isolated  and  removed.  The  inferior  thyroid  artery,  whieli  may  have  nerve 
filaments  in  front  of  and  behind  it,  may  need  ligature. 

The  second  ganglion  is  often  small  or  fused  with  the  third.  The  third  is  often 
fused  with  the  first  dorsal,  and  will  have  to  be  separated  with  scissors  or  knife  after 
blunt  isolation.  "  I  look  upon  this  part  of  the  ojjeration  as  the  most  difficult, 
becau.se  of  the  de[jth  of  the  ganglion  and  the  proximity  of  important  structures. 
The  recognition  of  the  nerve  also  presents  serious  difficulties  in  some  cases.  It  is 
very  variable  in  size  and  appearance.  In  any  case  it  shoidd  be  a  cardinal  rule  not  to 
inflict  any  damage  upon  a  structure  supposed  to  be  the  nerve  until  it  has  been  proved 
to  be  the  sympathetic  by  tracing  it  to  either  the  ujjper  or  lower  ganglion." 

The  bilateral  removal  of  the  sympathetic  should  be  done  in  two  stages,  with  an 
interval  long  enough  to  jjermit  the  jjatient  to  recover  from  the  effects  of  the  first 
operation.  A  trial  should  be  given  to  local  analgesia,  but  owing  to  the  increased 
difficulties  due  to  the  jjresence  of  the  goitre,  the  success  of  this  is  doubtful. 

The  other  conditions  for  which  removal  of  the  cervical  sympathetic  has  been 
chiefly  practised  are  ejjilepsy  and  glaucoma. 

With  regard  to  epilepsy,  Jonnesco  claims  a  certain  proportion  of  cures,  but  the 
interval  that  had  elapsed  is  too  short  to  allow  of  a  judgment  of  any  value  as  to  the 
final  results.  According  to  Braun's  more  recent  experience,  the  ojjeration  is  negative. 
In  the  case  of  glaucoma,  the  results  of  Jonnesco,  who  first  removed  the  cervical  sym- 
pathetic in  1897,  are  given  by  Mr.  Burghard.^  Later  results  will  be  found  nmeh  less 
favourable.  Wilder,  of  Chicago,  gives  •'  a  detailed  report  of  seven  cases  of  removal  of 
the  cervical  sympathetic  still  under  observation  in  his  own  practice,  and  adds  briefly 
the  results  of  operations  by  others  on  fifty-four  cases.  The  results  are  not  very 
encouraging.  In  certain  of  the  cases  in  which  improvement  at  first  followed  the 
operation,  relapses  are  reported.  The  following  sequeltc  of  the  operation  have  been 
noticed  :  myosis,  ptosis,  congestion  of  conjunctiva,  hoarseness  or  aphonia,  dysphagia. 
Wilder  is  inclined  to  advise,  "  In  acute  glaucoma,  and  in  the  subacute  with  inter- 
missions, practise  first  iridectomy,  and  if  it  fails,  do  sympathectomy.  In  simple 
glaucoma  use  myotics  five  times  a  day  ;  if  they  suffice,  continue  them.  If,  in  spite  of 
their  systematic  employment,  the  vision  fails,  do  sympathectomy." 

An  interesting  paper  by  Mr.  Burghard  on  excision  of  the  superior 
cervical  ganglion  will  be  found  in  the  British  Medical  Journal,  vol.  ii, 
19rX),  October  20,  p.  1175.  The  operation  was  performed  on  three 
occasions  for  very  different  conditions  :  in  the  first  case,  for  the  relief 
of  subacute  glaucoma  ;  in  the  second,  for  the  removal  of  an  enlarged 
epitheliomatous  gland  adherent  to  the  upper  ganglion  ;  and  in  the  third, 
for  a  variety  of  false  neuj'oma  which  had  attacked  the  ganglion.  Here 
the  middle  ganglion  was  removed  as  well.  The  operation  was  successful 
in  the  second  and  third  cases,  in  the  first  no  benefit  followed. 

Operations  on  the  Brachial  Plexus  These  have  been  chiefly  performed  in  cases 
of  laceration  of  the  plexus,  for  compression  by  scars,  exostoses,  &c.,  and  lastly  in 
that  form  of  birth-paralysis  in  which  the  muscles  chiefly  affected  are  the  deltoid, 
biceps,  and  brachialis  anticus.     Surgery  is  not  likely  to  be  successful  in  curing  a  case 

1  Trans.  Amer.  Surg.  Assoc,  190.3,  p.  303.  ^  Loc.  infra  cit. 

^  Journ.  Amer.  Med.  Assoc,  Februarv  2,  1904. 


RESECTION  OF  THE  CERVICAL  SYMPATHETIC    669 

of  the  first  descrijition  whore  several  of  the  lower  cervieal  nerves  have  given  way  at 
the  level  of  their  spinal  attachments.  Mr.  Thorburn  '  relates  in  detail  a  case  of 
operation.  }XTfornied  about  seven  months  after  the  injury,  resulting  in  recovery  of 
sensation  and  certain  movements  of  the  shoulder  to  an  imjK-rfcct  degree.  As  is  so 
frequently  the  case  in  hospital  practice,  the  patient  took  no  pains  to  contribute 
her  share  of  the  after-treatment.  Compression  cases  are.  of  course,  more  favourable. 
Dr.  R.  Kennedy,  of  Glasgow.^  records  a  case  of  practically  complete  recovery  after 
operation  on  a  scar  involving  the  plexus.  He  also  deals  here  with  the  subject  of 
birth-paralysis  alluded  to  above.  Three  cases  of  ojx-ration  for  this  condition  are 
given.  In  one,  in  which  sufficient  time  had  elapsed,  the  result  was  most  satisfactory, 
flexion  of  the  forearm  and  abduction  of  the  shoulder  being  regained. 

Mr.  Tubl)y  ^  has  proved  that  in  some  of  these  cases  of  paralysis  of  the  upixr  root 
of  the  brachial  plexus  dating  to  birth,  muscle-grafting  may  be  employed  with  benefit. 
To  remedy  the  inability  to  Hex  the  elbow,  the  triceps  is  exposed  by  a  long  incision  at 
the  back  of  the  arm  much  as  for  the  musciUospiral  nerve  (p.  185),  and  brought  for- 
ward below.  The  nerve  having  been  foimd  and  di-awn  aside,  the  outer  head  of  the 
trice})s  is  detached  from  the  tendon  above  the  olecranon  and  stripj)ed  upwards  for 
three  or  four  inches.  The  biceps  is  next  exjwsed  and  cleaned  in  its  lower  part.  An 
aperture  having  been  made  in  this  muscle  two  inches  above  the  elbow,  the  strip  of 
triceps  is  drawn  through  from  behind  forwards  and  tirml}'  pleated  do\\"n  (Fig.  48, 
p.  106).  In  two  cases  voluntary  flexion  of  the  elbow  joint  was  obtained  in  four  to 
six  weeks. 

To  obtain  abduction  at  the  shoulder  joint,  part  of  the  pectoralis  major  and 
trapezius  were  detached  from  the  clavicle  aud  miited  to  each  other  and  then  attached 
to  the  deltoid  or  humerus.     The  result  may  be  said  to  be  promising. 

1  Brit.  Med.  Joiini..  Mav  5,  1900. 
-  Ibid.,  1903.  vol.  i.  p.  29S. 
^  Ibid.,  vol.  ii,  p.  975. 


CHAPTER  XXXIII 
LIGATURE  OF  THE  ARTERIES  OF  THE  HEAD  AND  NECRi 

LIGATURE  OF  THE  TEMPORAL  ARTERY 

Indications.     These  are  very  few,  viz.  : 

(1)  Wounds,  e.g.  stabs  and  gunshot  injuries. 

(2)  Aneurysm,  usually  traumatic.  These  are  by  no  means  uncommon 
and  should,  as  a  rule,  be  treated  by  excision. 

Guide.  A  line  drawn  upwards  over  the  root  of  the  zygoma,  midway 
between  the  condyle  of  the  jaw  and  the  tragus. 

Relations.  Given  off  behind  the  jaw,  this  vessel  passes  up,  midway 
above  the  two  points,  over  the  zygoma,  and  at  a  point  14-  or  2  inches  higher 
up  it  divides  into  its  anterior  and  posterior  branches.  Lying  at  first 
in  the  parotid  gland,  it  is  covered  a  little  higher  up  by  a  dense  fascia 
passing  from  the  parotid  to  the  ear,  by  the  attrahens  aurem,  often  a 
lymphatic  gland,  and  one  or  two  veins  which  lie  superficial  but  close  to  it. 
Some  branches  of  the  facial  nerve  cross  it,  while  the  auriculo -temporal 
nerve  accompanies  it  closely.  Higher  up  the  artery  and  its  branches  are 
subcutaneous. 

Operation.  The  parts  having  been  shaved  and  sterilised,  the  head 
fitly  supported  and  turned  to  the  opposite  side,  an  incision  about  one  inch 
long  is  made  in  the  line  of  the  artery  so  as  to  expose  it  just  above  the 
zygoma.  The  dense  subcutaneous  tissue  and  the  strong  parotid  fascia 
being  clearly  divided,  the  artery  must  be  accurately  defined,  and  the 
vein  being  di'aAvn  to  one  side,  usually  backwards,  the  ligature  should 
be  passed  from  behind  forwards,  care  being  taken  to  include  only  the 
artery. 

Arteriotomy.  A  few  words  may  be  said  here  about  this  obsolete  operation. 
The  surgeon  having  defined  the  anterior  division  of  the  temporal,  steadies  the  vessel 
by  placing  his  finger  just  beyond  the  jjoint  which  he  intends  to  ojien,  and  then  with 
a  small  sharp  scalpel  lays  open  the  vessel  till  it  is  about  half  cut  through.  The 
blood  required  having  been  removed,  he  divides  the  vessel  completely,  so  as  to  allow 
the  ends  to  retract,  applies  a  pad  of  sterilised  gauze,  and  retains  this  in  position 
with  the  twisted  or  knotted  bandage  for  the  head.  The  jjad  should  not  be  removed 
for  four  or  five  days. 

LIGATURE  OF  THE  FACIAL  ARTERY 

Indications.  These  are  much  the  same  as,  but  still  fewer  than,  those 
for  ligature  of  the  temporal  artery. ^  Ligature  of  the  artery  is  often 
required  in  the  course  of  operation  in  the  submaxillary  region,  e.g.  removal 
of  malignant  glands.  The  vessel's  course  is  divided  into  a  cervical  and  a 
facial  part. 

^  Ligature  of  the  thyroid  arteries  has  already  been  considered  (p.  030). 

^  The  reader  is  advised  to  take  evcrj'  opportunity  afforded  upon  the  dead  body  to 
tie  these  and  other  arteries,  though  apparently  so  small  and  unimportant,  as  only  by 
such  practice  can  dexterity  be  really  acquired. 

670 


tj(;atuuk  of  tiik  ocxumtal  artery 


071 


Fig.  285.  A,  Incision  for 
ligature  of  the  superficial 
temporal.  B,  Incision  for 
ligature  of  the  facial.  C, 
Incision  for  ligature  of  the 
lingual.  1),  Incision  for 
ligature  of  the  common 
carotid.  E,  Incision  forliga- 
ture  of  the  vertebral  or  the 
inferior  thyroid. 


Cervical  Part.  Tlic  vessel  is  reached  by  an  incision  similar  to  that 
for  the  extiMiuil  carotid  (p.  ()9.'i)  or  the  lingual  (p.  ()74).  In  either  of 
these  cases  it  would  be  found  just  below  the  posterioi'  belly  of  the  digastric 
and  the  stylo-hyoitl,  these  nuiscles  being  di'awn  upwards  to  enable  the 
surgeon  to  ligature  the  vessel  just  before  it 
enters  tlie  submaxillary  gland. 

Relations  in  the  Neck.  The  facial  artery 
is  given  oil"  just  above  or  in  connection  with  the 
lingual,  about  an  inch  above  the  bifurcation  of 
the  connnoii  carotid.  It  passes  upwards  and 
inwards  to  the  lower  jaw,  being  covered  by 
skin,  fascia  and  platysma,  the  digastric  and 
stylo-hyoid,  and  embedded  in  the  submax- 
illary gland,  to  which  structure  the  vein  lies 
superficial.  The  tortuous  outline  of  the  vessel 
is  well  known.  The  vein,  running  a  straighter 
course,  lies  posterior  to  the  artery. 

Facial  Part.  The  artery  is  readily  secured 
by  a  small  horizontal  incision  just  below 
the  jaw  in  front  of  the  masseter  muscle,  the 
anterior  border  of  which  should  be  first  defined, 
this  being  easily  done  on  the  living  subject  by 
telling  the  patient  to  throw  it  into  action.  The 
incision  should  be  made  carefully,  so  as  to 
avoid  any  branches  of  the  facial  nerve  which 
may  lie  in  the  way.  The  artery  will  now  be 
felt  when  rolled  upon  the  bone  by  a  finger. 
The  ligature  should  be  passed  from  behind  forwards  so  as  to  avoid 
the  adjacent  vein. 

LIGATURE  OF  THE  OCCIPITAL  ARTERY 

Indications.  (1)  Stabs.  (2)  Gunshot  wounds.  (3)  In  the  treatment 
of  arterial  varix,  cirsoid  aneurysm,  or  aneurysm  by  anastomosis  on 
the  head  (p.  690).  (4)  For  haemorrhage  from  an  abscess  in  the  neck. 
Sir  W.  Mitchell  Banks  ^  published  a  most  instructive  case  : 

A  weakly  man,  aged  32,  had  had  a  suppurating  gland  incised  three  weeks  before 
admission.  Poultices  were  applied,  and  a  week  after,  during  a  violent  attack  of 
coughing,  blood  burst  from  the  wound  "  like  a  tap  being  turned  on."  Three  times 
afterwards  hinemorrhage  ensued,  pressure  being  applied  in  vain.  On  admission  he 
was  in  the  last  stage  of  exhaustion.  The  right  side  of  the  neck  from  ear  to  clavicle 
was  occupied  by  a  great  fluctuating  swelling.  In  front  of  the  sterno-mastoid,  about 
half  way  down,  was  the  original  incision,  from  which  a  little  sanious  discharge  was 
issuing.  Behind  the  muscle  a  piece  of  skin  about  an  inch  square  was  actually 
sloughing  from  the  subjacent  pressure.  Under  ether,  and  in  a  good  light,  the 
original  incision  was  enlarged  upwards  and  downwards,  and  a  quantity  of  putrid 
broken-down  clot  turned  out.  Then  a  similar  incision  was  made  behind  the  sterno- 
mastoid  through  the  sloughing  skin.  Everything  being  mopped  and  cleaned  up, 
blood  was  found  to  be  trickling  down  from  somewhere  very  high  up.  To  get  at  it, 
the  sterno-mastoid  and  skin  over  it  were  cut  clean  across,  thus  uniting  the  two 
vertical  incisions  by  a  transverse  one.  The  muscle  was  dissected  upwards,  exposing 
the  sheath  of  the  carotid  vessels,  but  still  the  blood  always  kept  running  from  some 
deep-seated  point  high  up.  At  last  this  was  reached,  just  in  front  of  the  transverse 
process  of  the  atlas.  From  it  arterial  blood  issued,  and  an  aneurysm-needle  was 
thrust  through  the  tissues  on  each  side  of  it  and  ligatures  applied,  which  at  once 
checked  all  further  bleeding.     The  vessel  was  the  occipital  artery  not  far  from  its 

1  Clinical  Notes  upon  Ttro  Years  Work  at  the  LiverjMol  Royal  Infirmary,  p.  161. 


672  OPERATIONS  ON  THE  HEAD  AND  NECK 

origin.     Into  it  the  abscess  had  made  its  way.     The  patient  was  very  near  to 
death's  door,  but  ultimately  recovered. 

Relations.  A  posterior  branch  of  the  external  carotid,  the  occipital 
comes  ofE  opposite  to  or  a  little  above  the  facial  just  below  the  digastric. 
It  at  first  ascends,  having  the  hypoglossal  nerve  hooking  round  it,  under 
the  digastric,  stylo-hyoid,  and  parotid,  and  crossing  the  internal  carotid, 
internal  jugular,  vagus,  and  spinal  accessory.  Having  reached  the 
interval  between  the  transverse  process  of  the  atlas  and  the  mastoid 
process,  it  now,  in  the  second  part  of  its  course,  turns  horizontally  back- 
wards, grooving  the  mastoid  portion  of  the  temporal  bone,  covered  by 
the  sterno-mastoid,  splenius,  digastric,  and  trachelo- mastoid,  and  lying 
on  the  complexus  and  superior  oblique.  In  the  third  part  of  its  course 
it  runs  vertically  upwards,  piercing  the  trapezius,  and  ascending  tor- 
tuously in  the  scalp. 

Operations.  (1)  If  the  artery  require  securing  low  down,  this  may  be 
effected  much  as  in  tying  the  external  carotid,  an  incision  being  made 
along  the  anterior  border  of  the  sterno-mastoid,  the  deep  fascia  opened, 
and  the  digastric  and  hypoglossal  nerve  exposed. 

(2)  To  tie  the  artery  behind  the  mastoid  process,  e.g.  when  it  has 
been  wounded  by  a  stab  in  the  neck,  the  following  steps  should  be  taken  : 
The  parts  being  sterilised  and  the  head  at  first  being  placed  in  much  the 
same  position  as  for  ligature  of  the  carotids,  an  incision  is  made  from  the 
tip  of  the  mastoid  process  rather  obliquely  upwards,  so  as  to  lie  over  a 
point  midway  between  the  mastoid  and  the  external  occipital  protuber- 
ance. The  tough  skin  and  fascia  being  incised,  the  sterno-mastoid,  in 
part  at  least,  with  its  strong  aponeurosis,  and  next  the  splenius  capitis, 
must  be  divided,  together  with  any  fibres  of  the  trachelo-mastoid  that 
are  in  the  way.  The  wound  being  somewhat  relaxed  by  turning  the 
head  over  to  this  side,  retractors  deeply  inserted,  and  an  electric  lamp 
used  if  needful,  the  artery  will  be  found  deep  down  between  the  mastoid 
process  and  the  transverse  process  of  the  atlas.  In  separating  it  from  its 
vein,  one  or  more  veins  varying  in  size  may  be  met  with,  forming  com- 
munications between  the  occipital  and  mastoid  veins,  and  thus  with  the 
lateral  sinus.     The  wound  should  therefore  be  kept  rigidly  aseptic. 

LIGATURE  OF  THE  LINGUAL  ARTERY  (Fig.  286) 

Indications.  (1)  Before  the  removal  of  the  tongue.  This  subject  has 
been  considered  at  p.  535.  (2)  After  removal  of  the  tongue,  to  arrest 
haemorrhage.  (3)  In  cases  of  tongue  cancer  not  admitting  of  operation, 
in  the  hope  of  checking  the  rate  of  growth,  diminishing  the  foetor,  profuse 
sahvation,  &c.  This  step  is  uncertain  as  to  the  amount  of  good  which  it 
effects,  and  any  good  that  it  may  do  will  not  be  long-lived.  (4)  In  cases 
of  macroglossia  this  operation  may  be  tried  before  removing  a  wedge- 
shaped  piece  of  the  tongue  ;  it  would  require  to  be  performed  on  both 
sides,  and  would  be  attended  with  considerable  difficulty  in  a  child.  It 
might  do  too  much. 

Relations.  The  lingual  artery  arises  about  a  quarter  of  an  inch  above 
the  superior  thyroid,  often  in  common  with  the  facial,  and  at  a  point  oppo- 
site to  the  great  cornu  of  the  liyoid  bone.  It  first  ascends  to  a  point  rather 
above  the  level  of  the  hyoid  bone,  then  descends  somewhat  and  runs  just 
above  the  great  cornu,  and  finally,  ascending  to  the  under  surface  of  the 
tongue,  it  runs  forwards  with  a  tortuous  course  to  the  tip  as  the  ranine. 


LIGATURE  OF  THE  LINGUAL  ARTERY 


073 


For  pi'actical  purposes  the  relations  of  the  ai'tery  may  be  subdivided 
into  tlin'e  parls  —  tlie  first,  before  it  gets  under  the  liyo<^lossus  ;  the 
second,  while  it  lies  beneath  this  muscle  ;  and  the  third,  beyon<l  this  muscle. 

In  the  first,  it  runs  very  deeply,  though  only  covered  by  the  skin, 
platysma,  and  fascia,  facial,  lingual,  and  some  pharyngeal  veins  ;  it  lies 
upon  the  middle  constrictor  and  the  external  laryngeal  nerve. 

In  the  second  fart  of  its  course  the  artery  again  lies  upon  the  middle 
constrictor,  and  is  now   covered  by  the  hyoglossus,    hypoglossal,  part 


SUBMAXILLARY      GLAND 


MYLO-HYOID 


HYPO-QLOSSAL  N>:- 
RAHIMB  y.--- 


POST.   S£LLY  OF 
DIGASTRIC 


Fig.  286.     Ligature  of  the  lingual  artery. 

of  the  mylo-hyoid,  and  the  lower  border  of  the  submaxillary  gland.  From 
this  part  come  off  the  four  branches  of  the  artery — the  hyoid  at  the  outer 
or  posterior  edge  of  the  hyoglossus,  the  dorsalis  linguae  under  this 
muscle,  and  the  sublingual  and  ranine  at  its  anterior  border,  thus  allowing 
room  for  placing  a.  ligature. 

The  third  'part  lies  in  the  mouth  and  runs  along  the  under  surface  of 
the  tongue  up  to  the  point  of  the  frenum.  It  is  only  covered  by  mucous 
membrane.  A  vein  runs  with  it,  and  a  large  branch,  of  the  gustatory 
nerve. 

Operations,  (i)  Ligature  under  tJie  Hyoglossus.  (ii)  Ligature  of  the 
First  Part  of  the  Artery. 

(i)  The  vessel  is  usually  tied  while  under  the  hyoglossus  muscle, 
owing  to  the  useful  guide  which  the  great  cornu  of  the  hvoid  bone  forms, 
and  this  is  the  operation  which  will  be  described  here  (Fig.  286).  If  tied 
as  a  preliminary  to  removal  of  the  tongue  (p.  535),  the  ligature  may  be 
applied  close  to  its  origin  by  an  incision  similar  to  that  for  the  external 
carotid  (p.  693),  so  as  to  make  sure  of  getting  behind  the  dorsalis  hnguse. 
The  parts  being  sterihsed,  the  head  suitably  supported  and  turned  to  the 
opposite  side,  and  the  lower  jaw  firmly  closed,  the  surgeon,  standing  or 

SURGERY   I  43 


674  OPERATIONS  ON  THE  HEAD  AND  NECK 

seated  on  the  same  side,  steadies  the  tissues  between  his  left  finger  and 
thumb,  and  makes  a  curved  incision  with  its  centre  just  above  the  great 
cornu  of  the  hyoid  bone  (a  point  previously  carefully  noted),  and  reaching, 
e.g.  on  the  left  side,  from  just  below  and  to  the  left  of  the  symphysis 
downwards,  backwards,  and  then  upwards  towards  the  angle  of  the  jaw, 
ending  just  anteriorly  to  the  line  of  the  facial  artery. 

The  incision  divides  skin,  superficial  fascia,  and  platysma  ;  the  deep 
fascia  is  then  opened,  and  any  branches  of  the  anterior  jugular,  facial, 
or  communicating  branch  with  the  temporo-maxillary  vein  are  secured 
carefully  so  that  the  wound  may  be  kept  as  dry  as  possible.  The  lower 
border  of  the  submaxillary  gland,  which  probably  projects  into  the 
wound,  is  turned  upwards  ^  and  the  hypoglossal  nerve  sought  for,  which 
lies  deeper,  and  is  a  good  guide  to  the  hyoglossus.  Lower  down  in  the 
neck  is  the  glistening  tendon  of  the  digastric  attached  to  the  hyoid  bone. 
The  hyoglossus  baing  defined,  the  hyoid  bone  is  carefully  steadied  by  the 
finger-nail  or  tenaculum,  a  director  passed  under  the  hyoglossus,  and 
this  muscle  divided  cautiously.  In  doing  this  the  lingual  vein  must  be 
carefully  looked  for  either  on  the  muscle  or  beneath  it,  with  the  artery. 
The  artery  having  been  found  under  the  muscle  just  above  the  hyoid  bone, 
it  should  be  traced  backwards,  so  as  to  apply,  if  possible,  the  ligature 
behind  the  origin  of  the  dorsalis  linguse. 

All  oozing  must  be  checked  before  the  wound  is  closed. 

Guides  and  Aids  to  finding  the  Artery.  (!)  A  sufficiently  free  incision. 
(2)  Carefully  defining  the  hypoglossal  nerve,  and  remembering  the 
relative  position  of  the  submaxillary  gland,  the  digastric  tendon,  and  the 
great  cornu  of  the  hyoid  bone\  (3)  Keeping  the  wound  bloodless. 
(4)  Incising  the  hyoglossus  between  the  great  cornu  of  the  hyoid  and 
where  the  hypoglossal  nerve  crosses  it. 

Difficulties.  (1)  Matting  of  the  parts  from  old  cellulitis.  (2)  Presence 
of  large  veins.  (3)  Depth  of  the  wound,  and  oozing  low  down  from 
the  severed  hyoglossus.  (*i)  In  one  case  Dr.  Shepherd  ^  found  the 
digastric  so  extensively  tied  do^^^l  to  the  hyoid  bone  by  the  deep  cervical 
fascia  as  to  require  separation.  (5)  The  position  and  condition  of  the 
lingual  vein  alike  are  at  times  perplexing.  Usually  two  small  vense 
comites  accompany  the  artery,  while  the  main  vein  lies  on  the  hyo- 
glossus ;  occasionally  it  lies  under  it,  with  its  artery.  Billroth,^  who  has 
tied  the  lingual  artery  twenty-seven  times,  tied  the  vein  for  the  artery 
in  one  case,  as  was  verified  at  the  necropsy.  "  Every  surgeon  knows  the 
difficulty  of  tying  the  lingual  artery  in  old  people  ;  the  vessel  lies  so  deep 
that  it  is  very  difficult  to  distinguish  it  from  the  thick-coated  distended 
veins,  especially  when,  owing  to  heart  disease — as  in  this  case^ — the  veins 
pulsate.  Never  previously  had  I  met  with  a  lingual  vein  of  such  thick- 
ness." (6)  Abnormal  position  of  the  lingual  artery  itself.  This  is  rare, 
but  the  artery  may  lie  higher  than  usual  ;  it  may  pierce  the  hyoglossus  ; 
occasionally  one  lingual  is  minute  or  absent.  (7)  The  submaxillary  gland 
may  be  unusually  large  and  occupy  much  of  the  space  between  the  jaw 
and  the  hyoid  bone. 

(ii)  If  the  vessel  cannot  be  found  beneath  the  hyoglossus,  or  if  the  con- 
dition of  the  soft  parts  is  such,  owing  to  cellulitis  matting  or  enlargement 

^  The  submaxillary  gland  should  be  gently  handled,  and  not  cut  into.  Otherwise  in 
the  one  case  troublesome  swelling,  in  the  other  temporary  weeping  of  saliva,  or  even  a 
fistula,  will  be  the  result. 

"  Ann.  of  Surfj..  vol.  ii,  No  11,  p.  359. 

^  Clinical  Surgery,  jj.  11,3. 


LICATIHK  OF  THE  C0M:M()X  CAlUmD  GT.', 

of  <iljnuls,  as  to  ])r('Vi'iit  any  attempt  hciii^'  iiia<l«*  here,  the  siiiLTeoii  must 
cut  down  ujjon  tlie  first  pmt  eithei-  l)y  an  incision  similar  to  the  above  hut 
h^ss  curved,  and  lutniin^  from  the  centre  of  the  hyoid  bone  just  above 
the  great  cornu  to  the  anterior  bortler  of  tlie  stenio-niastoid,  or  by  one 
simihir  to  that  used  for  hf2;ature  of  the  external  carotid,  with  its  centre 
ojij)osite  to  the  hyoid  l)one. 

The  dilliculties  are  not  «i;reat.  It  is  only  necessary  to  remember  that  : 
(I)  The  artery  itself  is  not  constant  in  position  here,  varieties  occuriin<,' 
frequently  in  the  height  at  which  it  comes  oil  from  the  external  carotid, 
whether  alone,  or  in  common  with  the  facial.  (2)  Large  veins,  e.g.  the 
lingual  and  facial,  will  certainly  be  present. 

LIGATURE  OF  THE  COMMON  CAROTID  (Figs.  285,  287) 

Indications.  (1)  In  Wounds  of  the  Trunk  itself.  Owing  to  the 
ra])i(lly  fatal  issue  of  such  injuries,  the  surgeon  is  not  often  called  upon 
to  meet  them.  Cases  indicating  ligature  for  wounds  of  the  trunk  may 
be  grouped  as  follows  :  (a)  for  immediate  haemorrhage  ;  (6)  for  secondary 
haemorrhage  ;   (c)  for  gunshot  injuries. 

{a)  For  Immediate  Hcemorrhage.  Ligature  of  the  common  trunk 
is  here  rarely  called  for,  as  above  stated.  In  civil  practice  such  cases 
may  occasionally  occur  in  cut-throat.  If  the  surgeon  arrive  in  time,  he 
should  arrest  the  haemorrhage,  while  waiting  for  assistance,  by  thrusting 
one  or  more  fingers  into  the  wound,  and  making  pressure  on  the  bleeding- 
point,  remembering  that  but  slight  force  is  required  if  the  pressure  is  on  the 
right  spot.  If  the  patient  has  to  be  removed  any  distance,  finger  pressure 
must  be  kept  up,  or  the  wound  plugged  with  a  sterilised  sponge  or  aseptic 
gauze,  and  the  head  kept  rigidly  still.  Pressure  with  a  finger  or  with 
a  sponge  on  a  holder  should  be  kept  up  on  the  bleeding-point  while  the 
wound  is  enlarged,  and  the  opening  in  the  carotid  secured  by  ligature 
placed  above  and  below  it. 

(b)  For  Secondarj/  Hcemorrhage.  A  remarkable  instance  of  punctured 
wound  of  the  common  carotid  in  which  the  vessel  was  tied  for  secondary 
haemorrhage,  in  the  pre-Listerian  era,  is  thus  recorded  by  Mr.  Durham  '  : 

A  child,  aged  9,  was  wounded  with  glass,  owing  to  an  explosion  of  Indrogen 
gas.  When  admitted  into  Guy  s  Hospital,  under  the  care  of  Mr.  Hilton,  the  child 
was  cold  and  blanched,  but  the  bleeding,  which  had  been  profuse,  had  entirely 
ceased.  There  was  a  wound  about  an  inch  long  "in  the  left  carotid  region."  On 
the  eighth  day  after  the  accident  haemorrhage  recurred,  and  the  common  carotid 
was  tied.  Nine  days  later  slight  bleeding  took  place,  but  was  arrested  by  ])]ugging 
the  wound  with  a  sponge.  Repeated  epistaxis  occurred,  which  weakened  the  child 
perceptiblj''.  The  sloughs  became  very  offensive,  but  there  was  no  further  bleeding 
from  the  wound  for  eighteen  days,  when  a  considerable  quantity  was  lost. 

At  the  necropsy  the  common  carotid  was  found  to  have  been  traversed  by  a 
sharp-jjointed  fragment.  Behind  the  wounded  vessel  was  an  abscess  implicating 
the  sympathetic.  Mr.  Durham  thought  that  if  a  ligature  had  been  applied  on  the 
distal  as  well  as  on  the  proximal  side  the  child's  life  would  have  been  saved. 

Another  case  of  secondary  haemorrhage  has  been  recorded  by  Mr. 
Rivington.^  It  is  an  excellent  instance  of  the  way  in  which  the  carotid 
may,  at  anytime,  be  wounded  from  within,  and  not  from  outside,  by  a 
foreign  body  penetrating  the  pharynx. 

A  boy,  aged  9,  six  days  after  swallowing  a  small  plaice-bone,  was  admitted 
to  the  London  Hospital  with  stiffness  and  tenderness  of  the  neck,  a  small  tender  lump 

1  System  of  Surgery,  vol.  i,  p.  739. 

2  Trans.  Med.-Chir.  Soc,  vol.  Ixix,  p.  63. 


C76 


OPERATIONS  ON  THE  HEAD  AND  NECK 


on  the  left  side  ^  opposite  to  the  cricoid  cartilage,  profuse  salivation  and  inability  to 
swallow  solid  food.  On  the  ninth  and  eleventh  day  hemorrhage  took  place,  on  the 
latter  occasion  to  the  amount  of  half  a  pint.  The  following  account  of  the  operation 
by  which  the  injiu'ed  vessel  was  found  and  secured  will  be  most  instructive  to  every 
operating  surgeon,  owing  to  the  difficulties  which  presented  themselves.  An 
incision  was  made  along  tlie  edge  of  the  sterno-mastoid  for  several  inches.  The 
muscle  was  found  glued  to  the  subjacent  parts  by  recent  adhesions.  Above  the 
anterior  belly  of  the  omo-hyoid  was  a  dark  patch  about  the  size  of  a  fourpemiy 
piece,  caused  by  extravasated  blood  looming  through  the  fascia.     The  fascia  over 


COMMON    CAROTID  A. 
AHS/^    HyPOGLOSSI^  \ 

STERNO-MASTOID  - 

INT.  JUGULAR.    V. 

MIDDLE    THYROID   K-' 


.THYRO-HYOID 
SUR  THYROID  A. 

,  OMO-HYOID 


ARTERY    TO  STERNO-MASTOIiy 


■STERNO- 


FiG.  2S7.     Suiyical  unatuun  ui  iUl  common  carotid. 


the  large  vessels  being  divided,  a  probe  was  passed  down  into  a  cavity  containing 
clot  hollowed  out  behind  the  vessels  and  on  the  inner  side.  Owing  to  the  uniform 
discoloration  of  artery,  vein,  nerves,  fascia,  and  areolar  tissue  by  the  extravasated 
blood,  the  structm-es  met  with  being  all  dark  and  equally  stained,  could  scarcely 
be  recognised.  The  descendens  hypoglossi  could  not  be  seen,  nor  the  vagus 
chstinguished,  though  carefully  looked  for.  More  clots  being  tmned  out  from  the 
cavity,  in  one  of  these  the  fish-bone  was  found.  A  gush  of  blood  Avliich  took  place, 
evidently  from  the  distal  end,  was  arrested  partly  by  pressure  and  ]iartly  by  pulling 
forward  the  vessels  with  a  blunt  hook.  The  wounded  vessel  being  found,  a  ligatui'e 
was  passed  closely,  as  it  was  thought,  around  it.  both  above  and  below  the  seat 
of  injury.  Owing  to  the  danger  of  subjecting  the  jiatient  to  a  fiu'ther  loss  of  blood, 
there  was  no  time  to  make  a  prolonged  dissection,  and  it  was  thought  prudent  to 
divide  the  artery  at  the  seat  of  the  wound  to  make  siue  that  no  branch  was  given 
off  between  the  ligatru'es.  Xo  evidence  of  ill  effects  from  the  divided  vagus,  save 
perhaps  slight  cough  and  difficulty  in  swallowing,  had  been  noticed  during  life. 
The  patient  died  ten  days  after  the  operation,  and  at  the  necropsy  it  was  foiuid 
that  the  vagus  had  been  divided.  Two  gangrenous  abscesses  in  the  left  half  of  the 
brain,  which  were  probably  alreadj^  in  progress  prior  to  the  operation,  were  the 
cause  of  death. 

^  The  left  common  carotid  is  more  exposed  to  danger  in  these  cases  from  the  passing 
of  the  oesophagus  somewhat  to  this  side. 


LIGATURE  OF  THE  COMMON  CAROTID  077 

(c)  Division  of  the  Common  Carotid  l)v  i^misliot  injuries  is  usually 
fatal  at  outw 

(2)  In  Aneurijsm  of  (lie  Carotid..  AN'licu  an  undoubted  aneuiysni  of 
this  vessel  exists,  and  is  increasing  in  spite  of  pressure,^  or  where  this 
cannot  be  made  use  of,  the  artery  should  be  tied,  on  the  cardiac  side 
of  the  aneurysm  if  possible,  or,  failing  this,  distally. 

The  "  old  "  operation  for  aneurysm  is  described  at  p.  195,  Matas's 
operation  is  described  at  p.  5.'i. 

Dr.  Mendes,  of  Bahia,  advocates  ^  extirpation  of  ordinary  aneurysm 
of  the  common  carotid,  and  records  two  cases  in  which  this  step  was 
successful.  In  neither  case  is  the  report  as  full  and  precise  as  is  usually 
the  case  with  French  surgeons. 

The  patients  were  62  and  04.  In  the  fir>;t  tlio  history  was  one  of  sixteen  months. 
The  aneurysm  was  as  large  as  a  mandarin,  its  njiper  limit  a2)])arently  blending  with 
the  j)aroticl.  An  incision  having  been  made  from  the  lobule  of  the  ear  to  just  above 
the  clavicle,  a  preliminary  ligature  was  placed  around  the  lower  part  of  the  artery. 
The  vagus  was  separated  with  difficulty  front  the  sac.  In  the  attempt  to  get  above 
the  upper  extremity  of  the  sac.  which  reached  as  high  as  the  mastoid  and  appeared 
to  enter  the  skull,  a  tear  was  made  in  the  sac  leading  to  profuse  haemorrhage,  stopped 
at  once  by  tightening  the  preliminary  ligature.  The  account  of  the  steps  taken  at 
this  critical  stage  is  brief  and  very  obscure.  A  ligature  was  thrown  round  the 
upper  part  of  the  sac,  and  this  was  cut  through  two  centimetres  below  the  ligature. 
The  cut  end  was  then  closed  by  sutures.  The  sac  must  either  have  collapsed,  or 
forci pressure  must  have  been  employed.  The  rest  of  the  sac  and  the  vessel  down 
to  the  first  ligature  were  then,  jjresumably,  removed.  But  no  details  are  given  on 
this  point,  nor  whether  the  internal  carotid  was  involved.  The  patient  recovered 
and  was  well  fourteen  months  later. 

In  the  second  case,  which  was  of  eleven  months  duration,  the  swelling,  the  size 
of  a  fist,  occupied  the  upper  two-thirds  of  the  carotid  region.  The  common  carotid 
was  tied  low  down  and  divided  between  the  ligature  and  a  jmir  of  forceps.  A  tear 
made  in  the  internal  jugular  vein  during  the  separation  of  the  sac  was  sutured. 
Great  difficulty  was  met  with  in  getting  above  the  upper  end  of  the  sac,  which  was 
intimately  blended  with  the  parotid.  It  is  to  be  gathered  that  a  ligature  was 
finallj'  placed  above  the  sac,  which  reached,  in  this  case  also,  as  high  as  the  mastoid. 
Here,  again,  no  details  are  given  where  they  are  most  needed.     The  patient  recovered. 

(3)  In  Aneurysm  of  the  Innominate  or  Aortic  Arch.  The  question  of 
the  advisabiUty  of  Kgaturing  the  carotid,  either  together  with  the  sub- 
clavian or  alone,  especially  in  the  case  of  the  left  common  carotid,  is 
considered  in  the  treatment  of  thoracic  aneurysm  (p.  723). 

(4)  In  Orbital  Aneurysm,  where  the  symptoms  are  becoming  aggravated, 
or  where  pressure  has  failed,  or  where  it  cannot  be  endured,  even  in- 
termittently, for  a  few  minutes  only  at  a  time,  and  where  galvano- 
puncture  and  injection  of  coagulating  fluids  are  set  aside  owino;  to 
their  uncertainty  and  riskiness.  It  would  probably  be  well  to  tie  and 
resect  any  especially  enlarged  veins  at  the  inner  angle  of  the  orbit  at  the 
same  time  {vide  infra). 

Of    fifty-three    cases, ^    viz.    twenty-one    idiopathic    and    thirty-two 

^  This  may  be  applied  to  the  artery,  or  the  sac,  or  both.  In  the  former  ease  the 
artery  should  be  compressed  above  the  transverse  process  of  the  sixth  cervical  vertebra, 
to  avoid  making  pressure  on  the  vertebral  at  the  same  time.  If  pain,  vertigo,  sick- 
ness. &c..  prevent  a  fair  trial  of  digital  pressure,  an  anaesthetic  may  be  tried,  but  as  Mr. 
Barwell  points  out  (Encycl.  of  Surg.,  vol.  iii,  p.  498),  there  may  be  much  difficulty  in 
deciding  how  far  the  syncope,  &c..  which  may  be  present,  are  due  to  the  anaesthetic  or  to 
the  pressure.  Another  means  of  keeping  up  pressure  on  the  common  carotid  is  that 
suggested  by  Rouge,  in  wliich  the  sterno-mastoid  being  relaxed,  the  surgeon  insinuates 
his  fingers  behind  one  border  and  his  thumb  behind  the  other  border  of  the  muscle,  and 
thus  compresses  the  artery  between  them. 

2  Rev.  de  Chir..  April  190.5. 

*  Rivington.  Diet,  of  Surg.,  vol.  ii,  p.  131. 
SURGERY  I  43' 


678  OPERATIONS  ON  THE  HEAD  AND  NECK 

traumatic,  in  which  the  common  carotid  was  tied,  thirteen  of  the  former 
were  cured  and  seventeen  of  the  latter.  The  above  writer,  speaking  of 
this  mode  of  treatment,  says  it  is  "  at  present  the  most  successful  and 
satisfactory  means  of  treating  orbital  aneurysm.  It  should  not  be  prac- 
tised on  patients  advanced  in  years,  or  on  those  with  heart  disease,  or  with 
evident  atheromatous  degeneration  of  the  arteries."  The  latter  statistics 
of  Bodon,  quoted  by  Dr.  Murray,^  confirm  the  success  of  ligature  of  the 
common  carotid  in  this  disease  if  the  arteries  are  healthy.  He  collected 
in  1899  fifty-eight  cases  of  traumatic  exophthalmos  treated  by  ligature 
of  the  common  carotid.  Twenty-six  were  cured,  twenty  improved,  six 
were  not  improved,  and  six  died  chiefly  from  infective  causes  and  haemor- 
rhage, conditions  less  likely  to  occur  at  the  present  time.  Bodon  also 
collected  six  cases  in  which  both  common  carotids  were  tied  without  any 
deaths,  and,  with  one  exception,  with  cure  or  improvement. 

Dr.  W.  F.  Murray  reports  a  case  with  many  points  of  interest.^  Thus, 
while  the  blow  had  been  on  the  left  side  of  the  head,  it  is  probable  that 
both  internal  carotids  had  been  ruptured,  as  the  exophthalmos,  &c., 
were  marked  on  both  sides.  The  left  common  carotid  was  tied  three 
months  after  the  injury,  a  step  followed  by  great  relief  on  both  sides. 
A  year  and  a  half  later  the  exophthalmos  had  reappeared,  being  most 
marked  on  the  left  side  ;  the  subconjunctival  veins  were  engorged,  and 
the  supra-orbital  vein  was  much  enlarged.  Pulsation  had  returned  in 
the  external  carotid  and  superior  thyroid  arteries.  Dr.  Murray  con- 
sidered that  this  indicated  complete  return  of  the  collateral  circulation 
and  increase  in  the  pressure  in  the  cavernous  sinuses,  and  that  it  would 
have  been  wiser  to  tie  the  internal  carotid.  As  in  two  cases  of  reappear- 
ance of  the  trouble  resection  of  the  branches  of  the  veins  at  the  inner 
angle  of  the  orbit  has  been  most  successful,  this  step  was  advised,  but 
declined  by  the  patient. 

(5)  In  Aneurysms  of  the  External  or  Internal  Carotid.  These  are  very 
rare.  Two  cases  of  aneurysm  of  the  former  vessel  have  been  published 
in  recent  years  : 

Sir  H.  Morris  3  recorded  one  in  which,  after  faihire  of  ligatiire  of  the  common 
carotid,  the  old  operation  of  incising  the  sac  was  ])erformed,  and  ligatures  jjJaced 
on  the  facial  and  lingual  arteries,  and  ujjon  the  main  trunk  of  the  external  carotid 
above  the  sac,  with  ultimate  recovery. 

The  second  case  was  published  by  Mr.  Heath  *  in  order  to  prove  that  ligature 
of  the  common  carotid  alone  is  sufficient  to  cure  some  cases  of  aneurysm  of  the 
external  carotid. 

The  occurrence  of  anem-ysm  here  in  a  woman,  aged  23,  was  accounted  for  by 
the  state  of  the  cardiac  valves  and  the  liability  for  embolism  to  occur  in  consecjuence 
of  detachment  of  a  vegetation.  There  was  a  smooth,  rovmd,  ])ulsating  swelling 
just  below  the  right  mastoid  jirocess,  reaching  down  to  about  the  level  of  the  upper 
border  of  the  thyroid  cartilage.  It  had  the  size  and  shape  of  half  a  small  orange. 
The  right  tonsil  was  somewhat  pushed  inwards,  the  right  temporal  pulse  was 
markedly  weaker  than  the  left,  and  the  tongue  deviated  much  to  the  right,  the 
right  half  being  a  good  deal  wasted.  The  common  carotid  was  tied  and  the  wound 
healed  ;  pulsation  in  the  aneurysm  had  stopped  on  the  tenth  day,  and  on  the 
eighteenth  the  sac  was  smaller  and  quite  hard.  All  seemed  to  be  doing  well  till  the 
thirty-third  day  after  the  operation,  when  loss  of  speech  occm-red  somewhat 
suddenly,  followed  by  right  hemiplegia,  and  death  on  the  thirty-fifth  day,  this 
being  brought  about  by  cerebral  embolism  taking  jjlace  through  the  left  carotid, 
the  aneurysm  being  solidified  throughout. 

Aneurysm  of  the  internal  carotid  is  equally  rare. 

1  Loc.  infra  cit.  ^  Ann.  of  Surg..  March  1904. 

=»  Med.-Chir.  Tran.'i.,  vol.  Ixiv,  p.  1.  «  Rid.,  vol.  Ixxxiii,  p.  69. 


LUiATlKK  OF  TIIK  COMMON  CAHOTIl)  (iTD 

Tlic  followiiiir  is  ;i  hiicf  aljstiact  of  such  Ji  cas(^ '  in  wliicii  (he  (•(jininoii  and 
external  c-arotids  wi-ic  tied,  togetlier  with  the  superior  thyroids,  successfully. 

The  internal  tnnik  was  affected  with  atheroma  to  such  an  extent  that  the 
ligature  could  not  be  a|)|)lied  to  this  vessel.  The  operation  was  jierfornied  July  24, 
1SS:5.  Till-  tu!nour  rajjidly  diminished  in  si/e,  the  patient  leaving  the  hospital  on 
the  twtnty-ninth  day  «fti  r  Ihc  operation.  She  was  living  anrl  well  four  3'ears  after 
the  above  tlate. 

(())  In  Arterio-venous  Aneurysms.  This  matter  has  recently  received 
adtUtional  attention  from  the  origin  of  these  aneurysms  in  wounds 
by  small  bullets  of  high  velocity.  The  experience  of  Mr.  G.  H. 
Makins,  C.B.,  on  this  subject  has  already  been  given  (p.  189).  In  the 
Journal  of  the  Royal  Army  Medical  Corps,  June  1905,  this  authority 
gives  the  further  history  of  five  cases  of  arterio-venous  aneurysm  of 
the  neck,  and  draws  the  following  conclusions  :  (a)  A  special  difficulty 
met  with  in  the  neck  is  the  exact  localisation  of  the  point  of  communi- 
cation. Thus  in  the  cases  detailed  in  the  above  paper  there  was  a  doubt 
in  one  whether  the  common  carotid  or  the  inferior  thyroid  was  the  artery 
implicated  ;  in  another  whether  one  or  two  of  the  carotids  were  invaded  ; 
in  two  others  the  localisation  to  either  the  innominate,  carotid,  or  sub- 
clavian had  to  be  considered  ;  and  in  the  fifth  case  time  alone  allowed  the 
carotid  to  be  definitely  fixed  upon  as  the  wounded  trunk.  (6)  In  con- 
sidering a  local  operation,  the  risk  to  the  cerebral  circulation  of  simul- 
taneous ligature  of  both  common  carotid  artery  and  internal  jugular  vein 
has  to  be  considered,  (c)  The  extreme  severity  of  the  operation  itself,  as 
judged  by  recorded  cases,  seems  to  render  the  local  incision  of  the  aneurysm 
inadvisable,  except  under  circumstances  of  extreme  urgency,  {d)  Mr. 
Makins'  "  own  view,  therefore,  is  in  favour  of  allowing  time  for  the 
consolidation  and  contraction  of  the  sac,  and  then  the  application 
of  a  proximal  ligature  when  practicable,  in  all  cases  involving  the 
great  vessels  of  the  neck."  It  is  pointed  out  by  Mr,  Makins  that 
the  five  cases  illustrate  the  tendency  to  spontaneous  cure  exhibited 
by  aneurysms  resulting  from  wounds  of  healthy  vessels.  In  the  two  in 
which  a  proximal  ligature  was  applied  to  the  common  carotid,  seven 
and  six  weeks  respectively  after  the  injury,  recovery  was  ultimately 
so  complete  that  both  the  officers  returnecl  to  active  service. 

The  following  case  is  quoted  from  the  Report  on  Surgical  Cases  noted 
in  the  South  African  War,  edited  by  Surg. -Gen.  Stephenson  : 

P.  239.  Case  99.  Wounded  at  Paardeberg.  Entrance  (Mauser)  to  right  of 
pomum  Adami  ;  exit  ant.  margin  of  left  trapezius,  and  two  inches  below  angle  of 
jaw.  Some  haemorrhage,  which  ceased  without  operation.  Wound  healed,  leaving 
symptoms  oi  an  arterio-venous  aneurysm  at  the  point  of  bifurcation  of  common 
carotid.  Swelling,  thrill,  and  pulsation  over  an  area  an  inch  and  a  half  in  diameter, 
and  loud  machinery  murmur  audible  to  patient  when  lying  on  injured  side  ;  left 
eyeball  appeared  prominent  ;  voice  weak  and  husky,  with  some  cough,  giddiness  ; 
pulse  100  and  irregular  and  somewhat  irritable.  It  was  thought  that  the  lesion 
might  be  on  the  internal  carotid,  and  on  the  sixty-second  day  an  attempt  \yas 
made  to  place  a  ligature  below  it,  but  the  sac  of  the  aneurysm  was  found  extended 
over  the  point  of  bifurcation.  "  The  vein  vibrated  visibly,  quivering  in  exact 
consonance  with  the  palpable  thrill."  The  ligature  was  placed  on  the  main  trunk 
beneath  the  omo-hyoid.  Patient  made  a  good  recovery,  and  pulsation  ceased 
but  thrill  persisted  ;  six  months  later  sac  small  ;  pulse,  110  to  120  ;  thrill  slight  ; 
voice  strong  and  good.  "  Aneurysm  is  either  at  bifurcation  of  common,  or  on 
immediate  commencement  of  internal,  carotid.  Ligature  of  external  carotid  will 
probably  cure  it  "  (Mr.  Makins). 

1  Dr.  Wyeth,  Ann.  of  Surg.,  August  1887,  p.  114. 
SURGERY  1  43" 


080  OPERATIONS  ON  THE  HEAD  AND  NECK 

(7)  In  Hoemorrhagecausedhy  Ulceration  of  the  Throat  after  Scarlet  Fever. 
This  is  a  rare  but  most  dangerous  complication  of  ulceration  of  the 
throat,  and  is  usually  brought  about  either  by  sloughing  of  the  soft  parts, 
or,  as  in  the  case  mentioned  below,  by  the  opening  of  an  artery  or  vein 
into  an  abscess  cavity. 

Dr.  Mahomed  communicated  a  case  to  the  Clinical  Society  ^  in  which  this  com- 
plication occurred  in  a  patient  aged  21,  Secondary  sore  throat,  after  an  ordinary 
convalescence,  was  noticed  on  the  fifty-fourth  day,  with  much  swelling  on  the  left 
side  of  the  neck,  followed  by  severe  bleeding  (to  forty  ounces)  from  the  moiith  on 
the  fifty-eighth  clay.  The  left  common  carotid  was  tied  by  Mr.  Pepper  on  the 
fifty-ninth  day.  Five  and  a  half  ounces  of  pus  were  brought  up  soon  after  the 
operation,  and  the  swelling  of  the  neck  and  jjharynx  subsided,  a  good  recovery 
ultimately  taking  place. 

The  common  carotid  was  selected  for  ligature  in  preference  to  the 
external,  since  it  allowed  the  operation  to  be  performed  quite  clear  of  the 
infiltrated  tissues,  and  thus  conferred  a  greater  immunity  from  secondary 
haemorrhage.  Moreover,  had  the  original  bleeding  come  from  the 
ascending  pharyngeal,  ligature  of  the  external  carotid  might  have  failed 
to  arrest  it,  as  the  place  of  origin  of  the  former  vessel  is  variable. 

The  next  groups  of  cases,  8  to  11,  may  call  for  ligature  of  the  external 
carotid  rather  than  of  the  common  trunk.  With  reference  to  them  it 
nmst  be  remembered  that  ligature  of  the  common  carotid  must  be  resorted 
to,  not,  as  has  too  often  been  the  case,  on  account  of  the  greater  facility 
with  which  this  vessel  can  be  tied,  but  only  when  the  state  of  the  patient 
or  the  condition  of  the  parts  either  primarily,  from  an  anatomical  point 
of  view,  or,  later  on,  after  secondary  hsemorrhage,  does  not  admit  of  tying 
the  external  carotid  itself.^ 

(8)  In  Incised  or  Punctured  Wounds  near  the  Angle  of  the  Jaw.  In  these 
cases,  as  in  those  below,  a  correct  diagnosis  as  to  the  vessel  or  vessels 
injured  is  by  no  means  easy  when  a  sharp  weapon  has  passed  obliquely 
and  deeply  behind  the  angle  of  the  jaw.  By  such  a  wound  either  the 
external  or  the  internal  carotid  or  some  branches  of  the  former  may  be 
laid  open.  A  careful  dissection  can  alone  clear  up  the  source  of  the  bleed- 
ing, and,  whenever  it  is  possible,  this  should  be  resorted  to  ;  where  the 
circumstances  do  not  admit  of  this,  the  surgeon,  relying  upon  the  extreme 
rarity  of  injury  to  the  internal  carotid  from  its  protected  position,^  will 
be  abundantly  justified  in.  tying  the  external  carotid.  Ligature  of  the 
common  trunk  is  less  reliable,  though,  if  resorted  to  on  account  of  its 
simplicity,  it  may  be  defended  by  cases  like  those  briefly  alluded  to  by 
Mr.  Le  Gros  Clark,^  in  which  he  successfully  tied  the  common  carotid  for 
profuse  arterial  haemorrhage  due  to  stabs  near  the  angle  of  the  jaw. 

"  The  injury  was  inflicted  in  the  same  way,  and  with  the  same  form  of  instru- 
ment, in  both  instances — a  pointed  table-knife  was  plunged  downwards  and  inwards 
behind  the  angle  of  the  jaw.  The  bleeding  was,  in  each  case,  controlled  only  by 
direct  pressure  with  the  fingers  in  the  wound  ;  and  whilst  this  pressure  was  main- 
tained I  tied  the  artery.  Not  an  untoward  symptom  accompanied  or  followed 
either  of  these  operations," 

1  Trans.,  vol.  xvi,  p.  21. 

2  In  some  of  these  cases  the  haemorrhage  may  be  arrested,  and  the  dangers  of  tying 
the  common  carotid  avoided,  by  the  temporary  closure  of  this  vessel  by  a  loop  of  stout 
catgut  applied  as  at  p.  385. 

3  Mr.  t!ripps  {Med.-Chir.  Trans.,  vol.  Ixi,  p.  235)  shows  that  out  of  eighteen  cases  in 
which  the  bleeding  vessel  was  identified,  the  internal  carotid  was  found  only  to  have  been 
wounded  twice  alone,  and  once  in  conjunction  with  the  external. 

*  Led.  on  Surg. -Diagnosis,  Shock,  and  Visceral  Le.sions,  p.  222. 


LIGATURE  OF  TIIK  COMMON  CAROTID  081 

(U)  In  punctured  wounds  through  the  mouth.  Here,  too,  the  common 
carotid  lias  Ix'oii  tied  in  some  cases  successfully,  while  in  others  this  step 
has  been  followed  by  repeated  luemorrhages  and  death. 

The  followiiiL'  ease  may  be  quoted  as  an  instance  of  the  former  result  : 

A  child  fell  while  carrying  the  sharp  end  of  a  parasol  in  his  mouth,  the  point 
being  thrust  forcibly  to  the  hack  of  the  fauces  and  very  nearly  coming  through  the 
skin  at  the  side  of  the  neck.  Considerable  haMuorrhage  occurred  at  once,  and  also 
about  a  Meek  later.  Ten  days  later  a  gusii  of  artcjial  blood  followed  on  coughing. 
The  common  carotid  artery  was  tied,  and  the  case  ended  successfully. 

(10)  In  Hosmorrhagefrom  Carcinoma  of  the  Mouth,  e.g.  Tongue  or  Fauces. 
This  subject  is  alluded  to  at  p.  672.  It  would  be  better  surgery  to 
tie  the  lingual  in  the  case  of  tongue  cancer,  or,  if  the  growth  be  farther 
back,  to  deal  with  the  external  carotid  (p.  (588)  and  ascending  pharyngeal, 
and,  only  if  this  be  foinul  impossible,  to  ligature  the  common  trunk. 

(11)  InHcemorrhage  after  Removal  or  Incision  of  Tonsils  (p.  477),  or 
from  an  Abscess  about  a  Tonsil.  These  cases  are  infrequent,  but  when 
they  do  occur,  are,  in  a  large  proportion  of  instances,  most  dangerous. 
The  possible  sources  of  the  haemorrhage  are  very  numerous,  viz.  :  (1)  one 
of  the  tonsillar  arteries  ;  (2)  the  tonsillar  venous  plexus  ;  (3)  the  ascend- 
ing pharpigeal  ;  (4)  the  internal  carotid.  Haemorrhage  from  the  last 
two  is  much  more  likely  to  occur  in  suppuration  in  or  around  the  tonsil 
than  in  wounds  inflicted  during  operation  on  it. 

The  following  is  a  good  instance  ^  of  a  tonsillar  abscess  proving  fatal 
from  haemorrhage  : 

A  man,  aged  39,  was  admitted  with  severe  tonsillar  abscess,  which  soon  burst 
with  the  escape  of  a  little  blood.  About  sixteen  ounces  were  lost  on  the  third  day, 
bleeding  again  recurring  on  the  fourth  and  fifth.  The  left  common  carotid  was 
now  tied  ;  thirty  hom-s  afterwards  twenty-two  ounces  were  lost,  and  the  patient 
died.  There  was  an  abscess  cavity  around  the  left  tonsil  which  communicated 
with  the  left  internal  carotid. 

Mr.  Morrant  Baker  has  recorded  a  case  of  suppuration  around  the 
tonsil  dating  to  an  injury. 

Here  the  vessel  injured  was  the  ascending  pharyngeal,  but  too  short  a  time 
elapsed  between  the  ligature  of  the  common  carotid  and  the  death  of  the  patient 
to  say  whether  the  operation  would  have  been  successful. 

A"^  man,  aged  2.3,  was  admitted  with  symptoms  of  acute  tonsillitis,  the  parts 
being  tense,  elastic,  and  prominent  at  one  sjiot.  A  puncture  was  only  followed  by 
the  escape  of  blood.  The  patient  now  gave  a  history  of  having  fallen  two  days 
before  when  di'unk  and  having  grazed  his  tliroat  with  a  clay  pipe  :  this  had  been 
followed  by  very  little  bleeding.  The  temperature  went  up  to  105°,  and  arterial 
hfemorrhage  occurred  on  the  third  day  after  admission.  A  probe  passed  through 
the  puncture  showed  that  a  considerable  cavity  existed  ;  this  was  plugged  w  ith  lint 
soaked  in  tr.  ferri  perchlor.  The  next  day  haemorrhage  recurred  to  the  amount  of 
half  a  pint  ;  when  ether  was  given  the  bleeding  again  came  on,  nearly  suffocating  the 
patient.  On  exploring  the  cavity  -with  a  finger-tip,  a  bit  of  clay  pipe  was  with- 
drawn ;  the  ca\'ity  was  again  plugged  and  the  common  carotid  tied.  The  patient 
died  without  rallying  three  hours  later.  A  wound  was  found  in  the  ascending 
pharyngeal  artery. 

Given  a  case  of  haemorrhage  from  the  tonsil  (whether  from  a  wound  or 
an  abscess)  which  resists  other  treatment,^  including  well-applied  pressure 
kept  up  with  a  padded  stick  inside  the  mouth  and  a  finger  behind  the  angle 
of  the  jaw,  and  the  use  of  one  or  two  sutures  (p.  477),  the  surgeon  should 
tie  the  external  carotid  as  Ioav  do^yu  as  possible,  placing  a  Hgature  on  the 

1  Mr.  Pitts.  St.  Thomas's  Hosjntal  Bejiorts,  vol.  xii,  p.  131. 

-  Every  care  should  be  taken  throughout  to  keep  the  wound  in  the  tonsil  as  aseptic 
as  possible. 


682 


OPERATIONS  ON  THE  HEAD  AND  NECK 


ascending  pharyngeal  as  well,  if  this  vessel  can  be  identified.  If  the 
bleeding  is  from  one  of  the  tonsillar  vessels  it  would  be  thus  arrested  ; 
only  if  these  steps  fail  should  the  common  trunk  be  tied. 

(12)  In  HcBmorrhage  after  Operations  on  the  Neck  or  Jaw.  In  Hcemor- 
rhage  secondary  to  Gunshot  Injuries.  In  both  these  cases  the  parts  may 
be  so  altered  that  it  is  quite  impossible  to  find  the  bleeding-point,  and 
the  soft  parts  may  be  so  damaged,  matted  together,  &c.,  that  the  surgeon 
may  be  driven  to  tie  the  common  carotid,  and  to  trust  to  this  and  to 


-PMTYSMA 
DEEP  CERVICAL    FASCI/t 

MIDDLE    THYROID  V. 

CAROTID  SHEATH 
~  3TERHO  -  THYROID 


\  COMMON  CAROTID 
A. 

-^-OMO-HYOID 


ARTERY    TO  STERHO--MASTOID 

Fig.  288.     Ligature  of  the  common  carotid. 

plugging   the   wound,   rendered  as  aseptic   as   possible,   with  strips  of 
sterilised  gauze,  and  firm  pressure  over  all. 

(13)  To  arrest  the  Growth  of  Aneurysm  by  Anastomosis  on  the  Side  of 
Face,  Head,  and  Neck.  The  treatment  of  this  condition  is  discussed  at  p.  690. 
It  is  shown  there  that  ligature  of  the  external  carotid  cannot  usually 
be  looked  upon  as  sufficient  without  other  measures,  owing  to  the  free 
anastomosis  between  the  branches  of  the  opposite  vessels.  8till  less  is  liga- 
ture of  the  common  carotid  likely  to  be  successful,  and  this  step  should  only 
be  resorted  to  when  ligature  of  the  external  carotid  is  impossible  from  the 
disease  extending  too  low  down  ;  when  from  its  creeping  towards  the 
orbit,  or  to  the  back  of  the  upper  jaw,  it  is  probable  that  there  is  a  free 
anastomosis  between  the  branches  of  the  external  and  internal  carotid 
through  the  ophthalmic  ;  or  when  the  ascending  pharyngeal  is  sure 
to  be  involved,  but  this  branch  cannot  be  separately  ligatured. 

(14)  To  arrest  the  Progress  of  Malignant  Growths  which  cannot  he 
operated  on,  or  which  are  recurrent,  and  which  derive  their  Blood-supply 
from  the  Internal  as  well  as  the  External  Carotid.  This  operation,  first 
performed  by  Mott,  has   been   tried  in  cases  of    malignant  disease  of 


LIGATUKK  OK  TIIK  COMMON  CAROTID  G8;J 

the  antiuni,  iioso,  &c.,  where  the  growth  Ciuiiujt  otherwise  be  attacked, 
and  is  increasing  very  I'apidly,  cansing  fr('(|uent  bleeding,  intense  pain, 
and  threatening  to  interfere  with  degkitition  and  respiration.  The 
results,  however,  have  not  been  encouraging. 

Lme.  From  the  sterno-clavicular  articuhition  to  a  point  midway 
between  the  angle  of  the  jaw^  and  the  mastoid  process. 

Guide.     The  above  line  and  the  inner  edge  of  the  sterno-mastoid. 

Relations.  The  conunon  carotids,  as  far  as  their  relations  in  the  neck 
go,  extend  from  the  sterno-clavicular  articulation  to  the  upper  border  of 
the  thyroid  cartilage,  along  a  line  from  the  above  joint  to  a  point  midway 
between  the  jaw  and  the  mastoid  process. 

In  Front 

Skin  ;  fasciae  ;  platysma  ;  superficial  branches  of  transverse  cervical 
nerve,  and  anterior  jugular. 

Sterno-mastoid ;  sterno-thyroid  ;  sterno-hyoid ;  omo-hyoid ;  sterno- 
mastoid  artery. 

Superior  and  middle  thyroid  veins,  and  often  a  communicating  branch 
between  anterior  jugular  and  facial  veins,  along  the  anterior  border  of 
sterno-mastoid. 

Descendens  hypoglossi,  usually  on  the  sheath,  sometimes  within  it. 

Anterior  jugular  vein  (below). 

Sheath. 

Outside  O  Inside 

Internal  jugular  (closer  Common  carotid  Pharynx, 

on  left  side).  Larynx. 

Trachea. 
Thyroid    gland   and 

vessels. 
Recurrent  laryngeal. 
Behind 

Rectus  capitis  anticus  major. 

Longus  colli ;   scalenus  anticus. 

Inferior  thyroid  artery  and  recurrent  laryngeal. 

Vagus. 

Sympathetic. 

Sheath. 

Operation.  Two  sites  are  usually  described,  according  as  the  vessel 
is  tied  above'^or  below  the  omo-hyoid. 

A.'^^6oue  tlieJJmo-Hyoid  (Fig.  288).  Also  known  as  "  the  seat  of 
election,"  owing  to  the  greater  facility  with  which  this  operation  is  usually 
performed. 

The  parts  being  sterilised,  the  shoulders  are  sufficiently  raised,  and  the 
chin  at  first  drawn  a  little  upwards,  while  the  head  is  turned  to  the 
opposite  side,^  so  as  to  define  the  anterior  border  of  the  sterno-mastoid.^ 

^  Turning  the  head  strongly  to  the  opposite  side  should  be  avoided,  as  it  brings  the 
muscle  over  the  artery.  Mr.  Barwell  {Encycl.  Surg.,  vol.  iii,  p.  498)  gives  the  following 
practical  hint :  "  In  certain  aneurysmal  cases  (aortic  and  innominate)  the  anaesthetised 
patient  cannot  breathe  while  his  head  is  thrown  back  ;  the  anaesthetist  is  obliged  to 
insist  on  bending  it  forward,  and  the  operator  has  to  get  at  the  vessel  under  very  trying 
circumstances,  since  in  that  posture  it  lies  much  deejier,  and  the  ramus  .of  the  jaw  is 
terribly  in  the  way." 

^  Not  always  easy  on  the  dead  subject,  or  when  the  parts  are  infiltrated. 


684  OPERATIONS  ON  THE  HEAD  AND  NECK 

The  siu'geon.  standing  usually  on  the  same  side,  makes  an  incision 
about  three  inches  long,  with  its  centre  opposite  to  the  cricoid  cartilage, 
in  the  line  of  artery,  through  the  skin,  platysraa,  and  fasciae,  exposing 
the  anterior  border  of  the  sterno-mastoid.  Any  superficial  veins  are 
now  drawn  aside,  or  tied,  before  di\'ision,  A\'ith  double  ligatures.  The 
deep  fascia  at  the  anterior  border  of  the  sterno-mastoid  is  now  divided, 
and  the  cellular  tissue  beneath  opened  up,  usually  bringing  into  view  the 
upper  border  of  the  omo-hyoid,  which,  if  in  the  way,  is  drawn  down  with 
a  blunt  hook,  or  divided.  The  edge  of  the  sterno-mastoid  is  now  drawn 
outwards,  and  the  pulsations  of  the  artery  felt  for  just  above  the  omo- 
hyoid.^ In  clearing  the  tissues  which  remain  over  the  vessel,  troublesome 
haemorrhage  may  arise  from  the  superior  and  middle  thyroid  veins, 
especially  if  the  respiration  be  embarrassed  ;  more  rarely  the  sterno- 
mastoid  artery  is  cut,  and  requires  a  ligature.  The  sheath  is  next 
exposed,  and  opened  well  to  the  inner  side,  avoiding  the  descendens 
hypoglossi,  which  usually  lies  to  the  front  and  outer  side  of  the  sheath. 
Other  difficulties  which  may  now  be  met  with  are  an  enlarged  thyroid 
lobe  overhanging  the  artery  or  overlapping  of  it  by  the  internal  jugular 
when  much  distended.  The  coats  of  this  vessel  are  so  thin  that,  if  it 
bs  much  swollen,  it  is  easily  punctured,  the  result  being  that  the  wound 
is  flooded  with  blood.  It  is  best  avoided  by  opening  the  sheath  well  to 
the  inner  side,  but,  if  it  still  give  trouble,  it  should  be  drawn  aside  with  a 
blunt  hook,  or  pressure  should  be  made  on  it  by  an  assistant,  in  the  upper 
angle  of  the  wound.  If  it  should  be  opened,  firm  pressure  should  be  made 
on  this  spot  with  a  sterilised  swab,  and  the  artery  tied  at  a  fresh  place 
above  or  below.  As  soon  as  the  ligature  is  tightened  the  haemorrhage 
will  cease,  and  firmly  applied  pressure  outside  the  wound  for  forty-eight 
hours  will  suffice  to  prevent  any  recurrence.  If,  after  wounding  the 
vein,  attempts  be  continued  to  tie  the  artery  at  the  same  place,  the  wound 
in  the  vein  is  almost  certain  to  be  made  larger.  Other  methods  are  to 
take  up  the  wound  in  the  vein  with  a  tenaculum  and  secure  the  opening 
(if  small)  with  a  purse-string  or  other  sutures  of  fine  sterilised  catgut  or 
silk.  If  this  fail,  or  in  the  case  of  a  larger  wound  in  the  vessel,  this 
should  be  secured  between  double  ligatures.  See  also  "  Treatment  of 
Injuries  of  the  Vessels,'"  p.  57. 

The  sheath  having  been  opened  well  to  the  inner  side  ^^ith  a  careful 
nick  of  the  knife,  the  artery  is  now  cautiously  and  sufficiently  cleaned,  the 
inner  edge  of  the  sheath  being  held  with  forceps  while  this  side  of  the 
vessel  is  cleaned,  and  then  the  outer  in  the  same  way,  and,  finally,  the 
posterior  aspect,  the  point  of  Watson  Che}Tie's  director  being  kept  most 
scrupulously  in  contact  with  the  vessel  here.^  The  needle  is  then  passed 
from  without  inwards,  being  kept  most  carefully  close  to  the  artery, 
especially  behind,  so  as  to  avoid  including  the  vagus. 

In  this,  as  in  every  other  artery  whose  relations  are  important,  the 
fewer  of  these  relations  that  the  surgeon  sees  the  more  masterly  and 
successful  will  his  operation  be. 

In  a  deeply  lying  artery,  in  addition  to  relaxing  the  parts  by  flexing 
forward  the  head  and  depressing  the  chin,  the  sterno-mastoid  must  be 
drawn  outwards  and  the  larynx  inwards  with  retractors,  while  the  omo- 

^  If  the  bifurcation  be  a  low  one,  that  vessel  is  chosen  which,  on  compression,  is  found 
to  be  connected  with  the  disease  or  injun-. 

2  Opening  the  sheath  on  the  inner  side  and  cleaning  the  vessel  properK^  are  the  two 
best  safeguards  against  accidents.  For  a  hint  which  maj*  be  helpful  in  recognising  the 
artery  on  the  dead  subject,  a  footnote  (p.  687)  may  be  referred  to. 


LIGATURE  OF  THE  (OMMOX  CAROTID  685 

liyoid  is  drawn  downwards  with  a  blunt  hook  or  divided.  The  pulsation 
of  the  artery  is  then  felt  for,  or,  where  this  is  feeble  or  absent,  the  rolling 
ofthe  artery  as  a  flat  cord  under  the  finger  is  made  out. 

B.  Ligature  below  the  Omo-h>/oid.  Here  the  artery  lies  much  deeper, 
and  has  tlie  recurrent  laryngeal  nerves  behind  it  ;  on  the  left  side,  the 
internal  jugular  vein  lies  very  close  to  the  artery  ;  on  the  right,  there  is  a 
distinct  interval  between  the  two  vessels. 

The  patient's  head  and  the  operator  being  in  the  same  position  as  at 
p.  684,  an  incision  three  inches  long  is  made  in  the  Une  of  the  artery,  from 
below  the  cricoid  cartilage  to  just  above  the  sterno-clavicular  joint, 
exposing,  as  before,  the  anterior  edge  of  the  sterno-mastoid.  This  is 
drawn  outwards  and,  if  needful,  divided  or  detached  below  by  making 
a  short  incision  outwards  along  the  cla\'icle.  In  this  case  the  anterior 
jugular  vein  must  be  carefully  looked  for  as  it  passes  outwards  in  the  root 
of  the  neck  under  the  sterno-mastoid.  The  depressors  of  the  hvoid  bone 
next  come  into  view  ;  of  these  the  sterno-hyoid,  overlying  the  broader 
sterno-thyroid,  is  certain  to  be  seen.  If  the  omo-hyoid  is  coming  up  at 
this  level,  it  lies  external  to  the  others.  In  such  it  is  to  be  drawn  out 
while  the  other  two  are  pulled  inwards,  any  of  the  three  being  divided, 
on  a  director,  if  needful.  At  this  stage  one  or  more  of  the  inferior  thyroid 
veins  may  come  into  view,  much  swollen.  The  pulsation  of  the  artery 
being  felt  for,  or  the  flattened  artery  felt  slipping  beneath  the  finger  when 
pressed  upon,  the  sheath  is  to  be  opened  well  to  the  inner  side,  retractors 
being  usually  required  at  this  stage.  Care  must  be  taken  of  the  internal 
jugular,  especially  on  the  left  side,  as,  if  distended,  it  may  conceal  the 
artery. 

When  the  carotid  is  sufficiently  cleaned,  the  needle  is  passed  from 
without  inwards,  avoiding  the  recurrent  lar}Tigeal  nerve  behind  by 
keeping  very  close  to  the  artery. 

Temporary  Ligature  of  the  Carotid.  Mr.  Rivington  and  Sir  F.  Treves  ^ 
have  drawn  attention  to  this  method,  believing  that  the  ligature  of  main 
arteries  is  resorted  to  too  often,  as  there  is  sufficient  evidence  to  show  that  in  most 
cases  it  is  only  temporary  arrest  of  the  current  that  is  required. 

This  method  should  certainly  receive  a  further  trial,  on  account  of  the  risks  of 
cerebral  mischief  after  ligature  of  the  carotid,  and  also  because,  as  Sir  F.  Treves 
says,  pressure  upon  the  carotid  cannot  be  successfully  maintained  for  a  serviceable 
length  of  time. 

The  artery  being  exposed  in  the  ordinary  way,  a  thick  piece  of  soft  catgut  is 
passed  round  it  and  tied  in  a  very  loose  loop.  By  pulling  on  the  loop,  the  blood- 
current  is  at  once  arrested,  and  restored  when  the  tension  is  relaxed.  2 

The  following  are  abstracts  given  by  Sir  Frederick  : 

(1)  Probable  Wound  of  Superior  Thyroid  Artery.  A  young  man  was  admitted 
with  a  deep,  profusely  bleeding  wound  about  the  level  of  the  great  cornu  of  the 
hyoid.  A  fragment  of  glass  driven  in  by  a  bursting  soda-water  bottle  had  been 
removed.  The  patient  was  blanched  and  almost  insensible.  It  being  "  ob\-iously 
useless  to  attempt  to  find  the  bleeding -point  while  blood  was  welling  up  from  so 
deep  a  wound."  a  temporary  ligatiu-e  was  placed  round  the  common  carotid. 
Traction  on  this  arrested  all  bleeding,  and  was  maintained  for  half  an  hour.  On 
relaxing  the  catgut  no  ha-morrhage  occurred.  The  loop  was  left  in  situ  for  four 
days,  and  then  removed.  The  bleeding  was  supposed  to  come  from  the  superior 
thyroid. 

(2)  Hcemorrhagefrom  Internal  Carotid.  A  child,  aged  3.  had  profuse  haemorrhage 
from  the  right  ear,  and  vomited  blood.  This  recurred,  and  the  right  common 
carotid  was  ligatured,  when  the  bleeding  ceased.  The  next  day  haemorrhage 
recurred,  blood  having  evidently  been  brought  round  by  the  left  carotid.     As  there 

1  Lancet,  January  21,  1888,  p.  111. 

^  Crile's  artery  clamps  may  be  employed  for  this  purpose. 


686  OPERATIONS  ON  THE  HEAD  AND  NECK 

is  no  case  on  record  ^  of  recovery  after  ligature  of  both  common  carotids  when  the 
interval  between  the  occlusion  of  the  two  vessels  was  less  than  some  weeks,  Sir 
F.  Treves  simply  placed  a  loop  of  catgut  round  the  left  carotid,  and  had  traction 
on  it.  The  child  never  bled  again,  but  sank  exhausted  six  days  after  the  second 
operation. 

(3)  Hccmnrrhage  probably  from  External  Carotid,  after  Impalement  with  a  Spike. 
A  man,  aged  41,  fell  twenty-six  feet  upon  a  railing-spike,  which,  entering  just  in 
front  of  the  left  ear,  passed  through  the  upper  jaws,  and  entered  the  mouth  through 
the  hard  palate  on  the  right  side.  After  removal  of  the  spike,  Ijlood  welled  up  freely 
from  the  wounds  and  nose.  Traction  made  on  a  catgut  loop  jmssed  round  the  left 
common  carotid  arrested  this.  A  weak  pulse  could  be  felt  in  the  temporal  on  the 
fourth  day,  and  on  the  seventh  the  loop  was  removed.  The  case  did  well.  It  is 
not  stated  how  long  traction  was  maintained. 

(4)  Huiinorrliage  during  an  Operation.  In  this  case  the  loojj  was  placed  around 
the  artery  prior  to  removing  a  large  malignant  tumour  of  the  neck.  Very  free 
bleeding  occurred  during  the  oj^eration,  but  was  always  checked  by  traction  on 
the  loop.     Without  this  the  oj^eration  would  have  been  very  difficult. 

Dr.  G.  Crile,  of  Cleveland,  U.S.A.,  recognising,  as  we  all  do,  the  limit  of  safe 
range  in  the  severer  operation  on  the  head  and  neck  due  to  hemorrhage,  the 
immediate  blood  loss,  later  infective  pneumonia,  and  the  fact  that,  while  permanent 
closure  of  the  external  carotids  is  permissible,  that  of  the  common  is  attended  with 
much  risk,  has  devised  experimentally  and  carried  out  successfully  the  temporarij 
closure  of  the  carotids  by  special  clamps.^ 

The  technique  is  as  follows  :  In  cases  where  the  trunks  of  the  vagi  or  their 
superior  laryngeal  branches  are  likely  to  be  interfered  with,^  one-hundredth  of  a 
grain  of  atropine  should  be  injected  twenty  minutes  previous  to  making  the  incision, 
in  order  to  prevent  possible  inhibitory  action  upon  the  heart.  The  artery  is  closed 
by  small  clamps  with  blades  protected  by  india-rubber  and  capable  of  delicate 
and  accurate  closure  by  a  .screw.  Surgeons  of  this  country  will  at  once  recognise 
their  close  similarity  to  Mr.  Makins'  intestinal  clamps.  In  operations  in  which 
blood  may  enter  the  air  passages,  Trendelenberg's  position  should  be  employed. 
This  ])artially  makes  up  for  the  lowered  cerebral  blood -pressure  which  results  from 
closure  of  the  carotid,  while,  from  cases  published,  it  does  not  api)ear  to  increase 
the  venous  and  capillary  ha>morrhage  to  any  Tnateri;il  degree.  In  applying  the 
clamps  the  walls  need  only  to  be  approximated,  not  compressed.  This  is  effected 
by  the  delicate  control  of  the  screw,  and  by  keeping  the  blades  exactly  parallel 
with  each  other.  Dr.  Crile's  experiments  on  nineteen  dogs  showed  that  a  clamp 
properly  adjusted  could  be  left  in  position,  in  the  absence  ot  infection,  from  twenty- 
four  to  forty-eight  hours,  without  serious  injury  to  the  artery.  The  release  of  the 
clamp  should  be  made  slowly,  the  field  of  the  operation  being  carefully  inspected 

1  Dr.  Simpson,  Surg.-Capt.  Ind.  Med.  Service,  records  the  following  very  interesting 
case,  which  has  an  important  bearing  on  the  above  statement :  Case  of  Resection 
of  the  Right  Upper  Jaw  for  Sarcoma,  with  Ligature  of  both  Common  Carotids. — The 
patient  was  aTclugu  lad,  about  18  years  of  age,  admitted  into  the  Madras  General 
Hospital  while  Dr.  Simpson  was  acting  as  surgeon.  Prior  to  the  resection  the  right 
common  carotid  was  tied  with  the  view  of  diminishing  the  hemorrhage  at  the  operation. 
One  week  elapsed  between  the  ligature  of  the  artery  and  the  removal  of  the  jaw.  During 
that  interval  Dr.  Simpson  and  Dr.  Smyth  came  to  the  conclusion  that  there  would  be 
no  immediate  danger  in  occluding  the  other  common  carotid,  if  need  arose.  Dr.  Simpson 
began  the  operation  (on  the  eighth  day  after  ligature  of  the  right  carotid)  by  exposing 
the  left  common  carotid  at  the  level  of  the  cricoid  and  passing  a  piece  of  elastic  tubing 
round  it.  This  was  tightened  gently,  and  produced  no  effect  upon  the  patient,  who  was 
well  under  the  influence  of  chloroform.  With  the  assistance  of  Dr.  Smyth,  Dr.  Simpson 
removed  the  jaw,  this  being  done  almost  bloodlessly.  On  relaxation  of  the  tubing, 
sharp  haemorrhage  ensued.  In  preference  to  attempting  to  arrest  this,  and  thus  causing 
much  delay — a  matter  of  great  importance — a  ligature  was  substituted  for  the  tubing, 
and  the  artery  was  tied.  The  patient  made  an  uninterrupted  recovery,  and  six  months 
later  was  known  to  be  in  good  health.  There  seemed  danger  at  first  of  sloughing  along 
the  lines  of  separation  of  the  jaw,  and  irrigation  was  constantly  employed  for  the  first  two 
or  three  days.  The  case  will  be  found  published  in  the  Trans.  South  Ind.  Branch  Brit. 
Med.  Assoc,  vol.  v.  No.  3. 

^  Ann.  of  Surg.,  vol.  xxxv,  1902,  p.  441. 

^  In  two  cases  where,  in  spite  of  injection  of  a  hundredth  of  a  grain  of  atropine, 
manipulation  of  the  vagus  caused  the  pulse  to  fall  from  about  90  to  56.  the  application 
of  2  per  cent,  solution  of  cocaine  to  the  nerve  led  to  a  prompt  return  of  the  pulse  to 
its  previous  rate. 


LTGATUKE  OF  TIIK  COMMON  (  AUOTIl)  OST 

for  ,iiiv  vessels  \\liiili  may  lia\c  hecii  oNcilookcd.  When  the 'rrciulclcnbcr^  iwsitiou 
lias  bei'ii  employed  it  is  safer  (o  restoie  (Ik-  patient  to  tlic  lioi'i/.ontal  ])osili(Mi  \>vi(nv 
iTlcawing  the  carotid.  Sixtooii  cases  arc  given  which  in  severity  wen;  well  cali-ulated 
to  test  Dr.  ("rile's  nietliod.  They  inchide  cases  of  removal  of  e])ithelionia  of  the 
tongue,  floor  of  mouth  and  glands,  growths  of  the  parotid,  removal  of  upper  jaw, 
congenital  growths,  na'void.  and  other  of  neck  and  orbit,  lioth  common  carotids 
were  closed  in  ten  cases.  There  were  no  deaths  attributable  to  the  method,  'i'he 
ages  of  the  patients  varied  from  7  months  to  ()i)  yeais 

In  every  case  the  ciiculation  was  resumed  at  once  on  the  release  of  the  clamps. 
There  were  no  appreciable  elTecls  on  the  vessi>l  walls,  and  no  later  cierebral  effects. 
Less  an*stlietic  was  necessary  with  closed  arteries,  es])ecially  in  th(!  tuises  in  which 
the  common  carotids  were  closed.  In  the  latter  case  there  may  be  end)arrassed 
breathing,  especially  later.  Wholly  or  ])artially  releasing  one  or  both  carotids 
gave  material  and  immediate  assistance.  The  time  occujued  was  much  diminished, 
as  the  field  of  o])ei"ation  was  quite  bloodless.  The  amount  of  blood  lost  was  strikingly 
less,  as  was  also  the  difficulty  in  keeping  l)lood  from  the  respiratory  ti'act.  The 
application  of  the  clamp  is  easily  accomplished,  the  incision  being  prolonged  if 
needful  for  removal  of  glands,  &c. 

Difficulties  and  possible  Mistakes  during  Ligature  of  the  Common 
Carotid.  ( 1 )  Altered  condition  of  the  soft  parts,  e.g.  matted  and  cede  ni- 
tons, from  the  close  contiguity  of  an  aneuiysm,  from  a  previous  trial  of 
pressure  ;  or  loaded  with  blood  or  inflammatory  products,  as  in  the  case 
of  a  wound.  (2)  Presence  of  an  aneurysm  encroaching  upon  the  incision. 
(3)  Not  hitting  the  edge  of  the  sterno-mastoid.  This  muscle  may  be 
drawn  over  the  artery  if  the  chin  be  too  much  forced  to  the  opposite  side. 
The  chin  should  be  kept  about  midway  between  the  acromion  and  the 
episternal  notch  on  the  opposite  side  (Barwell).  (4)  Great  enlargement 
of  the  superior  and  middle  thyroid  veins,^  (5)  An  enlarged  and  over- 
lapping thyroid  gland.  (6)  A  large  internal  jugular  overlapping  the 
artery.  (7)  Opening  the  sheath  towards  its  outer  side,  and  so  coming 
down  upon,  and  perhaps  injuring,  the  vein.^  (8)  Including  one  of  the 
nerves  ^  in  relation  with  the  artery,  e.g.  the  descendens  hypoglossi,  the 
vagus,  or  the  sympathetic  (p.  675). 

Causes  of  Failure  and  Death  after  Ligature  of  the  Common  Carotid. 
(1)  Cerebral  complicatioyis ,  e.g.  impaired  nutrition  and  softening.  Sir 
J.  E.  Erichsen  thinks  that  "  cerebral  symptoms  "  (he  does  not  say  whether 
he  means  fatal  ones  or  not)  are  liable  to  occur  in  twenty-five  per  cent,  of 
ligatures  of  the  common  carotid.  They  may  come  on  almost  at  once,  or 
some  days  after  the  operation.     The  same  surgeon  divides  them  into 

^  Mr.  Barwell  (Intcrnat.  Encycl.  Surg.,  vol.  iii,  p.  499)  says  that  the  superior  thyroid 
vein,  very  full  and  turgid,  sometimes  runs  in  front  of,  more  often  behind,  the  carotid. 
"  I  suppose  it  is  the  effect  of  the  ansesthetic  which  causes  this  to  swell  to  the  size  of  a 
cedar  pencil." 

2  On  the  dead  body,  esi^ecially,  there  is  a  risk  of  mistaking  the  flaccid  jugular  for 
fascia,  on  opening  it,  unless  the  sheath  has  been  opened  over  its  front  and  inner  part  as 
should  always  be  the  practice.  Another  hint  may  be  useful.  In  a  body  injected  with 
formalin,  owing  to  the  clotting  of  the  blood  in  the  vein,  this  vessel  may  appear  thick, 
and  give  the  impression  of  an  injected  artery.  The  latter  will  be  known  by  its  wliite 
colour  and  eni])ty  condition. 

*  "  The  descendens  hypoglossi  lies  usually  on  the  outer  part  of  the  sheath,  and  will 
rarely  be  endangered  if  that  structure  is  opened  as  above  described  ;  but  it  is  well  to  see 
that  it  is  out  of  the  line  taken  by  the  director  ;  if  its  absence  there  be  verified,  it  need  not 
be  hunted  up  elsewhere.  The  pneumogastric  lies  in  the  interval  between  the  artery  and 
vein  in  the  back  part  of.  but  not  loose  in,  the  sheath  ;  each  of  the  vessels,  as  well  as  the 
nerve,  has  a  compartment,  strongly  walled  to  itself  ;  while  the  sympathetic,  behind  the 
sheath,  is  also  separated  by  a  thick  fascia  from  the  vessels.  If  these  anatomical  positions 
be  maintained,  both  nerves  are  saved.  Young  operators  are  sometimes  made  anxious 
and  embarrassed  by  unnecessary  cautions,  yet  sometimes  the  parts  do  not  quite  main- 
tain their  proper  positions.  Hence  it  is  well,  befoi'e  tightening  the  ligature,  to  see  that 
it  includes  the  artery  only  "  (Barwell,  loc.  supra  cit.). 


688  OPERATIONS  ON  THE  HEAD  AND  NECK 

two  sets  :  (a)  the  early  ones,  resulting  from  the  too  small  supply  of 
arterial  blood,  viz.  syncope,  twitchings,  giddiness,  impaired  sight,  and 
hemiplegia  ;  (6)  after  the  above  have  been  present  for  a  few  days,  and 
softening  has  taken  place,  convulsions  and  death  ensue.  It  would  be, 
perhaps,  worth  while,  in  view  of  the  above  mortality,  to  try  pressure 
before  resorting  to  the  ligature,  in  order  that  the  opposite  vessels 
may  become  enlarged.  Pressure  could  only  be  kept  up,  without 
an  anaesthetic,  for  a  few  minutes  at  a  time,  and  care  would  have 
to  be  taken  not  to  apply  it  at  the  intended  site  of  ligature.  The 
temporary  ligature  and  Dr.  Crile's  method  (pp.  685,  686)  also  deserve 
trial.  (2)  Infective  complications.  (3)  Recurrent  fulsation.  In  most 
cases  this  is  due  to  blood  finding  its  way  round  from  the  opposite 
side.  The  pressure,  however,  in  cases  of  aneurysm,  having  been  relieved, 
coagulation,  as  a  rule,  takes  place,  though  slowly.  In  a  smaller  number 
of  cases  the  recurrence  of  the  pulsation  has  been  of  a  more  permanent 
kind,  from  the  ligature  becoming  loosened  or  dissolved,  especially  when 
catgut  has  been  used.  (4)  Suppuration  of  the  sac.  Sir  J.  E,  Erichsen 
states  that  this  is  not  very  micommon.  "  In  the  majority  of  cases  the 
patient  eventually  does  well."  (5)  Hcemorrhage.  This  has  never  been 
a  common  complication,  owing  to  the  absence  of  branches.  It  may  take 
place  from  the  site  of  ligature  ^  or  from  a  suppurating  sac.  It  should 
be  still  more  rarely  met  with  in  the  future,  owing  to  the  modern  treatment 
of  the  wounds.  (6)  Low  forms  of  lung  inflammation.  The  above 
authority  states  that  these  are  not  imcommon.  He  attributes  them  to 
diminished  freedom  of  the  respiratory  movements  owing  to  the  disturbed 
circulation  in  the  brain  and  medulla. 


LIGATURE  OF  THE  EXTERNAL  CAROTID  (Fig.  289) 

This  operation  has  not  received  the  attention  which  it  deserves,  having 
been  too  often  set  aside  for  the  easier  operation  of  ligature  of  the  common 
trunk.  ^ 

Mr.  Cripps,^  discussing  the  ligature  of  the  external  carotid  in  the  treat- 
ment of  haemorrhage  from  pmictured  wounds  of  the  throat  and  neck, 
states  that  the  objections  raised  to  the  above  operation  are  : 

(1)  The  fear  of  secondary  haemorrhage  from  the  seat  of  ligature  due 
to  the  close  proximity  of  its  larger  branches. 

(2)  The  futility  of  the  operation  should  the  wounded  vessel  be  the 
internal  carotid. 

Mr.  Cripps  answers  this  objection  by  comparing  the  rareness  of  a 
wound  of  the  internal  carotid  with  one  of  the  external  or  its  branches. 

He  points  out  that  of  eighteen  cases  in  which  the  bleeding  vessel  was  identified, 
the  internal  one  was  wounded  twice  alone,  and  once  in  conjunction  with  the  external.* 

^  This  danger  would  seem  to  increase  the  lower  down  the  ligature  is  placed.  Mr. 
Barwell  says  that  the  only  fatal  case  of  secondary  haemorrhage  he  has  had  in  this  opera- 
tion followed  the  ligature  of  a  carotid  with  catgut  close  above  the  sterno-clavicular  joint. 
It  is  not  stated  whether  the  wound  was  aseptic  throughout  or  not. 

2  See  a  paper  on  Ligature  of  the  External  Carotid  reporting  seven  cases  by  Dr.  Fisk 
{Ann.  of  Surg.,  1909,  vol.  xlix,  p.  767). 

3  Med.-Chir.  Trans.,  vol.  Ixi.  p.  234. 

*  Mr.  Cripps'  list  is  interesting  to  the  surgeon.  In  the  first  ten  it  is  to  be  presumed 
that  Ugature  of  the  external  carotid  would  have  been  the  wiser  course.  In  two,  the 
bleeding  came  from  the  external  carotid  ;  in  one,  the  lingual  ;  in  one,  the  facial ;  in 
one,  a  tonsillar  branch  ;  in  one,  a  branch  in  the  parotid  gland  ;  in  two,  the  internal 
maxillary  ;  in  one,  the  inferior  dental ;  in  one,  the  middle  meningeal ;  in  one,  the  verte- 


LIGATURE  OF  THE  EXTERNAL  (  AROTTD         G89 

(3)  The  extoniJil  carotid  is  less  easy  to  li<^ature  than  the  eoimnon. 

This  objection  will  not  weigh  with  a  surgeon  who  knows  his  anatomy, 
who  is  in  the  habit  of  operating,  and  who  begins  by  exposing  the  vessel 
at  the  bifurcation  of  the  common  trunk. 

The  advantages  of  the  operation  are  : 

(1)  That  the  circulation  through  the  brain  is  not  in  the  least  interfered 
with.     Consequently  one  large  element  of  danger  is  avoided  (p.  G87). 

(2)  The  incision  made  over  the  external  carotid  can  also  expose  the 
bifurcation  and  the  internal  carotid,  and  may  thus  lead  to  a  direct  ex- 
posure of  the  wounded  vessel. 

Indications,  (i)  Woimds  of  the  Trunk  and  of  its  Branches.  This 
subject  has  already  been  alluded  to.  While  it  cannot  be  denied  that 
the  easier  operation  of  ligature  of  the  common  trunk  has  answered 
in  some  of  these  cases,  it  has  also  certainly  failed  repeatedly.  Con- 
sidering the  rarity  of  wounds  of  the  internal  carotid,  the  surgeon  will  do 
more  wisely,  in  the  case  of  a  wound  over  the  carotid  area,  to  expose  and 
tie  the  external  carotid,  low  down  in  any  case  of  doubt,  so  that  the 
trunk  and  the  internal  carotid  may  be  exposed  as  well,  if  needful. 

Mr.  Rivington  recorded  ^  an  int;eresting  case  of  a  wound  of  the  external 
carotid  by  a  stab  in  the  parotid  region  giving  rise  to  recurrent  attacks 
of  haemorrhage,  and  treated  successfully  by  temporary  ^  ligature  of 
the  common  carotid  and  ligature  of  the  external  carotid  at  the  seat 
of  injury. 

A  man.  aged  31,  was  admitted  into  the  London  Hospital  with  three  wounds,  one 
severing  the  lobule  of  the  left  ear  and  passing  into  the  parotid  gland  below  the 
zygoma,  a  second  behind  the  ear,  and  a  third  over  the  mastoid  process.  Haemorrhage 
occurring  about  a  week  later  was  stopped  by  pressure.  Erysipelas  followed,  and 
an  abscess  was  opened  in  front  of  the  ear.  About  three  weeks  after  the  accident 
hseniorrhage  again  occurred,  being  brought  on  by  a  fit  of  coughing,  blood  running 
out  from  all  the  incisions.  Though  it  was  again  arrested  by  pressure,  Mr.  Rivington 
judged,  from  the  size  of  the  stream  and  the  force  of  the  jet,  that  the  injured  vessel 
must  have  been  the  external  carotid  in  the  parotid  gland. 

On  account  of  the  difficulty  of  securing  the  artery  at  the  seat  of  injury,  and  the 
amount  of  blood  which  would  be  lost  before  this  could  be  accomplished,  and  not 
being  able  to  rely  upon  pressure  on  the  common  carotid  during  the  operation,  Mr. 
Rivington  cut  down  first  on  the  common  trunk  at  its  bifurcation  and  placed  a 
temporary  ligature  round  it,*  tying  this  lightly  so  as  to  stop  the  current  of  blood, 
but  not  to  divide  the  inner  and  middle  coats. 

The  openings  in  the  j^arotid  region  being  explored  and  clots  turned  out,  a  little 
below  the  angle  of  the  jaw  was  fomid  a  hole  from  which  some  blood  issued  in  a 
feeble  stream.  The  external  carotid  was  ligatured  above  and  below  this  spot. 
The  ligature  in  the  main  trunk  was  then  untied,  and  left  in  situ  for  use  if  needed. 
All  bleeding  had  ceased,  and  there  was  no  recurrence.  The  patient  made  a  good 
recovery,  some  weakness  of  the  face  muscles  having  almost  disappeared  when  he 
left  the  hospital. 

Mr.  Rivington  drew  attention  to  the  advantage  of  the  temporary 
ligature  on  the  main  trunk,  rendered  very  evident  by  the  fact  that 
immediately  before  the  operation,  when  the  sponge  was  removed, 
arterial  blood  spurted  out  in  a  Uvely  jet,  whilst  after  the  ligature  a  languid 
stream  only  issued  from  the  distal  side  of  the  hole  in  the  external  carotid. 

bral ;  in  two,  the  internal  carotid  ;  in  one,  the  external  also  was  wounded  ;  in  one,  the 
source  was  close  to  the  bifurcation;  in  two,  the  common  carotid,  at  the  point  of  bifurca- 
tion, was  wounded  ;   in  one,  the  ascending  pharyngeal. 

^  Cliti.  Soc.  Trans.,  vol.  xvii,  p.  79. 

^  Some  cases  in  which  Sir  F.  Treves  at  a  later  date  made  use  of  this  step  are  given 
at  p.  685. 

^  It  remained  uncertain  whether  this  temporary  ligature  was  placed  on  the  external 
or  the  common  carotid. 

SURGERY   I  44 


690  OPERATIONS  ON  THE  HEAD  AND  NECK 

He  further  pointed  out  tliat  the  employment  of  temporary  ligatures, 
either  lighth"  tied  or  left  in  situ  for  use  in  case  of  need,  is  capable  of  wider 
application  in  the  treatment  both  of  hsemorrhage  and  of  aneurysms. 

(ii)  Aneurysm  by  Anastomosis  of  Scalp  and  Side  of  Head  and 
Neck.  Here  the  hgature  of  the  external  carotid  is  made  use  of  as  an 
adjmict  to  local  treatment,  or  where  this  has  failed.  If  the  growth 
is  not  too  large,  it  should  be  excised  with  aseptic  precautions,  tying 
each  vessel  as  it  is  cut.  The  operation  may  be  rendered  partly  evascular 
by  the  use  of  sterilised  india-rubber  tubing  passed  round  the  back  of  the 
head  and  the  lower  jaw,  with  pledgets  of  gauze  over  the  main  vessels, 
e.g.  temporal  or  external  carotid,  posterior  auricular,  and  occii)ital.^ 
Where  the  above  is  not  applicable,  the  external  carotid  may  be  tied  pre- 
liminary to  removing  the  tumour.  When  this  is  being  effected,  any 
sldn  that  is  not  too  much  involved  should  be  preserved.  If  this  is  im- 
possible, the  growth  must  be  taken  away,  with  the  skin  over  it,  the  vessels 
being  secured  as  cut.  Every  care  must  be  taken  to  keep  the  wound 
sterile,  and  thus  promote  rapid  granulation-healing,  completed  by 
Thiersch's  sldn-grafting  (p.  43). 

As  these  cases  are  most  obstinate,  attention  will  be  drawn  to  other 
cases,  proving  that  ligature  of  the  external  carotid  (even  if  performed 
on  both  sides)  is  not  likely  to  be  successful  without  local  treatment  as  well, 
viz.  either  miderrunning  the  vessels  with  pins,  or  excision.  They  are 
recorded  by  Dr.  Bryant,  of  New  York  ^ : 

The  patient,  aged  24,  had  a  well-defined  i^ulsating  tumour  at  the  site  of  a  healed 
scalp-wound  in  front  of  the  left  ear.  The  trunk  and  branches  of  the  temporal  and 
the  occipital  were  concerned  in  the  giowth.  As  this  was  rapidly  increasing,  the 
left  external  carotid  was  tied  with  catgut  about  half  an  inch  above  its  origin.  Tjing 
the  lingua]  artery  also  provided  a  branchless  portion  of  the  external  carotid  about 
an  inch  in  extent.  The  ascending  pharjmgeal  was  sought  for,  but  not  foimd.  All 
pulsation  was  at  once  checked,  and  the  growth  was  also  reduced  to  about  one-third 
of  its  previous  size.  The  operation  was  antiseptic  throughout,  and  when  the 
dressings  were  changed  for  the  fii-st  time  in  ten  days,  a  slight  return  of  pulsation 
was  noticed  in  the  tumovu*.  A  month  after  the  operation,  j)ulsation,  thrill,  and 
bruit  were  nearly  as  strong  as  before,  and  it  was  decided  to  attack  the  tumour 
itself  in  preference  to  tying  the  occipital  and  temporal  branches,  or  the  right  external 
carotid.  The  arterial  circulation  was  admirably  controlled  by  surrounding  the 
head  with  two  strong  rubber  bands,  beneath  which  compresses  were  placed  at  the 
points  where  arteries  passed  to  sujiply  the  scalp. 

Dr.  Bryant  found  on  record  eight  other  cases  of  ligature  of  the  external  carotid 
for  the  cure  of  aneurysmal  tumours  of  the  head,  face,  and  parotid  gland,  in  two  of 
which  both  the  vessels  were  tied  simultaneously.  This  latter  procedm-e  is  not 
reported  to  have  been  successful  in  either  case.  Of  a  total  of  nine  cases,  only  one, 
a  traumatic  aneurysm  of  the  parotid,  was  cured  by  ligature  alone. 

Thus  it  would  appear  that  local  remedies,  viz.  excision  and  under- 
running,  aided  by  ligature  of  the  chief  feeding  arteries,  are  most  likely 
to  be  successful  in  this  disease,  which  so  often  baffles  treatment.  Ligature 
of  the  external  carotid,  on  one  or  both  sides,  will  fail,  o-«Ting  to  the  free 
collateral  circulation,  if  tried  by  itself,  even  in  recent  traumatic  cases 
without  much  general  dilatation  of  the  vessels.  If  used  at  all,  it  should 
be  as  an  adjunct  and  a  prehminary  step  to  diminish  the  vascularity  of  the 
tumour  before  this  is  dealt  with  locally  by  the  methods  above  indicated. 

(iii)  Aneurysm  of  the  External  Carotid.  The  treatment  of  this  rare 
condition  has  been  already  discussed  at  p.  678. 

^  Makka's  clamps  (-tee  p.  255)  would  be  of  service  here. 
2  Ann.  of  Surg.,  August  1887,  p.  116. 


LIGATURP:  of  the  external  carotid         691 

(iv)  (a)  As  a  preparatory  step  to  extirpating  malignant  growths  of 
the  upper  jaw,  pharynx,  &c.,  or  (6)  as  a  palhative  step  where  the  above 
extirpation  cannot  be  attempted. 

(a)  As  a  jneparatory  step  to  extirpating  malignant  growths.  The 
external  carotid  may  be  tied  before  attempting  to  remove  growths  of 
the  parotid,  tonsil,  upper  jaw,  angle  of  lower  jaw,  palate,  or  pterygoid 
region.     The  risk  of  secondary  haemorrhage  is  alluded  to  at  p.  555. 

A  case  has  been  alhided  to  at  p.  528,  in  which  this  step  was  carried  out — one 
of  a  sarcoma  of  the  palate  and  pterygoid  region.  The  first  patient  is  alive  and  well 
five  years  after  the  operation. 

(6)  As  a  palliative  step  where  removal  of  such  growths  as  those  alluded 
to  above  is  impossible.  On  this  point  reference  should  be  made  to  the 
remarks  already  made  at  p.  54:4. 

The  following  cases  ^  are  of  interest  as  bearing  on  this  matter.  In  each  of  these 
cases  repeated  operations  had  been  perfornled  for  removal  of  malignant  diseases 
involving  the  lower  jaw,  floor  of  the  mouth,  and  more  or  less  of  the  tongue.  Rapid 
recurrence  had  taken  place  in  each  case  until,  the  use  of  the  knife  no  longer  appearing 
feasible,  the  only  course  seemed  to  be  starvation  of  the  growth.  Accoidingly  this 
was  attempted  by  simultaneous  ligatures  of  both  the  external  carotids,  by'incisions 
in  the  usual  place,  the  enlarged  lymphatic  glands  found  being  removed.  When  the 
carotids  were  reached,  most  unusual  anomalies  were  found.  The  right  common 
carotid  bifurcated  beneath  the  posterior  belly  of  the  digastric,  which  was  divided 
to  admit  of  passing  the  ligature.  On  the  left  the  bifurcation  was  behind  the  hypo- 
glossal nerve,  which  was  dra-\™  do-nTi,  and  the  ligature  then  passed  just  below  the 
digastric.  The  lingual  and  facial  branches  were  not  seen  on  the  right  side  ;  but 
this  caused  no  appreheasion.  as  the  facial  was  said  to  have  been  tied  some  months 
before,  during  removal  of  the  diseased  submaxillary  gland  on  that  side.  On  the 
left  side  the  branches  of  the  external  carotid  were  normal.  The  malignant  growth 
diminished  in  size  rapidly,  the  discharge  became  scanty,  tliin,  and  watery,  and  the 
ability  to  speak  and  swallow  improved  quickly.  On  the  fifth  day  a  portion  of  the 
growth  on  the  right  side  sloughed  out,  leaving  an  aperture  bounded  by  sloughy 
tissue,  at  the  bottom  of  which  could  be  seen  necrosed  bone  in  the  lower  jaw.  Nine 
days  after  the  operation  profuse  hsemorrhage  took  place,  with  a  fatal  result.  This 
haemorrhage  was  caused  by  sloughing  of  some  of  the  diseased  starved  tissue,  into 
which  the  trunk  common  to  the  facial  and  lingual  passed. 

In  the  second  case  no  h?emorrhage  or  sloughing  followed  on  ligature  of  the 
external  carotids.  For  two  months  the  state  of  the  patient  was  much  improved, 
the  growth  showed  but  little  tendency  to  increase,  and  the  pain  and  dysphagia  did 
not  return.  Then  profound  canceroas  cachexia  set  in,  with  emaciation  and  loss  of 
strength,  beyond  which  there  was  no  note. 

Excision  of  the  External  Carotid.  This  method  has  been  introduced  in  America 
to  meet  the  objectioiLs  which  may  accompany  mere  ligature  of  the  artery,  viz. 
secondary  haemorrhage,  if  the  wound  unavoidably  becomes  septic,  and,  in  the  case 
of  growths,  the  reactivitj^  which  sets  in  when  the  collateral  circulation  is  restored. 
The  following  account  is  taken  from  Dr.  Coley's  article  on  "  Cancer  "  -.^  "  R.  H.  M. 
Dawbarn,  of  Xew  York,  has  originated  a  method  of  dealing  with  inoperable  malig- 
nant tumours  in  regions  deriving  their  blood-sujjply  from  the  external  carotid 
arteries,  which  he  designates  as  '  excision  of  the  external  carotid  arteries.' 
Attempts  to  starve  malignant  tumours  by  cutting  off  the  arterial  supply  had 
previously  been  made,  but  never  systematically.  Four  years  ago  J.  D.  Bryant, 
of  Xew  York,  reported  before  the  Xew  York  Medical  Society  a  case  of  inoperable 
naso-pharjTigeal  sarcoma  which  apparently  disappeared  after  ligature  of  both 
external  carotid  arteries,  the  patient  remaining  well  nearly  ten  years  afterwards. 
Bryant  tried  the  method  on  a  number  of  other  similar  cases,  but  the  results  were 
always  confined  to  temporary  shrinkage  of  the  tumour.  Dawbarn,  reasoning  from 
these  results  that  the  first  case  was  successful  because  there  happened  to  be  present 
poor  anastomic  connections,  and  that  the  other  cases  were  improved  at  first,  but 
later  became  worse  as  soon  as  anastomosis  developed,  conceived  the  idea  of  excising 
the  carotids. 

1  Dr.  Brj'ant,  Ann.  of  Surg.,  August  1887,  p.  121, 

2  Twentieth  Century  Practice  of  Medicine,  vol,  xvii,  p,  405. 
.SURGERY  1  44' 


692  OPERATIONS  ON  THE  HEAD  AND  NECK 

"  The  technique  of  the  operation  is  as  follows  :  Ligature  the  external  carotid  just 
above  its  origin.  Cut  just  above  and  seize  the  upper  cut  end  with  stout  artery- 
forceps.  These  hold  the  vessel  as  a  handle  throughout.  Working  upwards,  tie  off 
between  two  ligatures  and  divide  each  branch  as  reached.  When  tlie  artery  at 
length  disappears  into  the  substance  of  the  parotid  gland,  use  gentle  traction  on 
the  artery  downwards  while  stretching  with  a  dressing-forcejis  a  passage  up  into 
the  gland.  Avoid  the  knife  here,  to  threaten  facial  paralysis  as  little  as  may  be. 
At  length  one  is  able  to  slip  a  single  ligature  about  the  two  terminal  branches  just 
above  their  origin — the  internal  maxillary  and  temporal — and  to  divide  the  end 
of  the  external  carotid." 

Dr.  Dawbarn  has  recently  modified  his  technique.^  After  the  different  branches 
of  the  external  carotid  have  been  found  and  tied,  they  are  cut,  and  the  distal 
portions  injected  with  a  mixture  of  white  paraihn  and  gelatin,  introduced  at  a 
temperature  of  about  1 20°  F.  The  two  trunks  arc  dealt  with  at  an  interval  of  about 
fourteen  days.  The  result  of  his  experience  is  as  follows  :  "  For  sarcomas  the 
result  is  particularly  favourable.  Cases  are  now  on  record  in  which  three,  four, 
five,  six,  and  even  seven  years  after  the  tying  of  the  external  carotid,  there  has 
been  no  recurrence  of  sarcomatous  tumours  which  were  growing  rapidly  before 
the  operation,  but  which  dwindled  im«iediately  afterwards,  and  have  never  again 
resumed  their  malignant  activity.  In  one  very  severe  case  of  sarcoma  of  the  base 
of  the  skull,  in  which  the  tumour  was  very  large  and  had  yielded  somewhat  to  the 
injection  of  Coley's  toxin,  but  had  afterwards  resumed  its  growth,  the  tying  of  the 
external  carotids  led  to  the  gradual  disappearance  of  the  tumour  ;  and  it  has  not 
recurred.  Unfortunately  this  is  not  so  true  for  the  carcinomas.  Improvement 
follows  the  cutting  off  of  the  blood-suj^ply  to  malignant  growths  of  this  kind,  but 
the  relief  is  not  permanent.  In  a  few  instances  there  was  marked  diminution  in 
the  size  of  the  tumour,  followed  by  the  relief  of  symptoms  for  from  a  few  months 
to  a  year.  Recurrence,  however,  has  inevitably  taken  place  in  all  true  carcinomas, 
though  usually  the  patient  has  suffered  very  much  less  before  the  fatal  termination 
than  would  have  been  the  case  had  the  carotid  not  been  tied.  In  every  instance 
the  tumour  has  shrivelled,  and  great  temporary  benefit  has  been  derived  from  the 
operation.-' 

'  (v)  Hmmorrhage  from  Middle  Meningeal  Artery  after  Trefhining.  This 
matter  has  been  considered  at  p.  266,  and  more  fully  in  Gui/s  Hospital 
Reports,  vol.  xliii,  where  it  is  shown  that  severe  haemorrhage  is  not 
uncommon  after  a  wounded  middle  meningeal  has  been  exposed  by 
trephining,  but  that  the  bleeding  will  usually  yield  to  measures  short  of 
ligature  of  the  external  carotid. 

Guide.  The  anterior  border  of  the  sterno-mastoid  above  the  hyoid 
bone. 

Relations.  The  external  carotid  extends  from  the  upper  border  of  the 
thyroid  cartilage  to  a  point  midway  between  the  external  auditory 
meatus  and  the  condyle  of  the  jaw  ;  beyond  this  point  it  is  continued 
on  as  the  temporal,  having  just  before  given  off  the  internal  maxillary. 
In  the  first  part  of  its  course  the  external  is  somewhat  nearer  the  middle 
line  than  the  internal  carotid,  and  is  more  superficial  than  this  throughout. 

In  Front 

Skin ;   fascise ;  platysma ;  nerves  from  transverse  cervical 

and  facial ;   superficial  veins. 
Lingual  and  facial  veins. 
Digastric  and  stylo-hyoid. 

Parotid  ;  facial  nerve  ;  temporo-maxillary  and  other  veins. 
Hypoglossal  nerve. 

^  Intern.  Clinics,  1905,  vol.  i,  p.  112. 


LIGATURE  OF  THE  EXTERNAL  CAROTID 


093 


Inside 
Pharynx. 
Hyoid  bone. 
Ranuis  of  jaw. 
Parotid. 


O 

External  carotid. 


Outside 
Parotid. 

Temporo-maxillary  vein 
when  this  descends  to 
join  the  internal  jugular. 


Behind 
Parotid  gland. 
Superior  laryngeal. 
Glosso-pharyngeal. 
Stylo-glossus  and  stylo-pharyngeus. 

The  veins  in  relation  with  the  external  carotid  vary  a  good  deal.  But, 
in  addition  to  the  lingual  and  facial  crossing  it,  a  number  of  veins  joining 
the  external  and  anterior  to  the  internal  jugular  may  form  a  kind  of  plexus 
round  the  artery,  and  the  temporo-maxillary  may  descend  outside  the 
artery  to  join  the  internal  instead  of  the  external  jugular. 

Branches  ^ 


ANTERIOR 

POSTERIOR 

ASCENDING 

TERMINAL 

Superior 

thyroid. 
Lingual. 
Facial. 

Auricular. 
Occipital. 

Ascending 
pharyngeal. 

Temporal. 
Internal  maxillary, 

Operation.     This  is  performed  at  two  spots  : 

(a)  Below  the  Digastric  (Fig.  289). 

(6)  Above  this  muscle,  behind  the  ramus  of  the  jaw. 

{a)  Below  the  Digastric.  This  is  the  operation  more  frequently 
performed  in  order  to  cut  oli  the  blood-supply  through  all  the  branches 
of  the  artery.  Though  these  are  so  numerous,  and  vary  somewhat, 
there  is  usually  a  spot,  from  one  half  to  three-quarters  of  an  inch,  between 
the  superior  thyroid  and  the  lingual,  on  which  a  ligature  may  be  safely 
placed,  especially  if  the  superior  thyroid  and  Unguals  be  ligatured  as  well. 

To  meet  the  difficulties  which  may  be  encountered,  and  to  expose  the 
desired  vessel  quickly,  the  bifurcation  of  the  common  trunk  must  first 
be  found,  and  the  artery  which  gives  off  branches  traced  upwards. 

The  position  of  the  patient's  head  and  that  of  the  surgeon  being  the 
same  as  at  p.  683,  an  incision  three  inches  long  is  made  in  the  line  of  the 
artery,  from  the  angle  of  the  jaw  to  the  upper  border  of  the  thyroid 
cartilage,  about  a  quarter  of  an  inch  in  front  of  the  anterior  border  of  the 
sterno-mastoid.  This  incision  should  divide  skin,  fasciae,  and  platysma  ; 
any  superficial  veins  being  secured,  the  cellular  tissue  in  front  of  the 
muscle  is  opened  up,  and  the  bifurcation  of  the  common  carotid  and  the 
posterior  belly  of  the  digastric  or  the  hypoglossal  identified  as  guides  to 
the  vessel.  In  doing  this  the  sterno-mastoid  should  be  drawn  outwards, 
any  large  veins,  e.gr.  facial  or  lingual,  pulled  aside  wath  a  strabismus-hook 
or  secured  with  double  chromic-gut  ligatures  before  division.  The  muscle 
or  the  nerve  being  defined,  the  pulsation  of  the  artery  is  felt  for  below  them, 
and  the  vessel  carefully  cleaned  just  above  the  thyroid  cartilage.     The 

^  While  this  is  a  common  arrangement,  it  is  by  no  means  the  only  one.  Very  fre- 
quently one  trunk  gives  off  two  or  three  arteries.  Sometimes  all  the  branches,  save  the 
two  terminal,  arise  very  close  together,  the  external  carotid  constituting  then  an  arterial 
axis.  It  is  the  presence  of  these  branches  which  enables  the  surgeon  to  decide  whether 
he  is  dealing  with  the  external  or  internal  carotid. 


694 


OPERATIONS  ON  THE  HEAD  AND  NECK 


use  of  the  steel  director  or  knife  should  be  most  cautious  on  the  outer 
side  of  the  artery,  where  lie,  below,  the  internal  jugular  and  the  internal 
carotid.  At  the  same  time  the  presence  of  the  descendens  hypoglossi  on 
the  artery  is  to  be  remembered,  and  that  of  the  superior-laryngeal  nerve 
running  obliquely  downwards  and  inwards  behind  the  vessel.     The  needle 


PL/tTYSMA- 


Hyp0ai.03S/il.  N- 


SXT.   C/'KOTJO  .4f 


Fig.  289.     Surgical  anatomy  of  the  external  carotid  artery. 


should  be  passed  from  without.  The  superior  thyroid,  facial,  and  lingual 
should  be  ligatured  at  the  same  time,  and  the  ascending  pharyngeal  if  it 
can  be  found. 

(6)  Aho-ve  the  Digastric,  behind  the  Ramus  of  the  Jaw.  This  operation 
has  the  disadvantage  of  probably  entailing  the  di\'ision  of  important 
branches  of  the  facial  nerve. 

The  head  and  shoulders  being  duly  raised  and  supported,  the  surgeon 
makes  an  incision  downwards  from  the  tragus  of  the  ear,  just  behind  the' 
ramus  of  the  jaw,  dividing  the  skin  and  fasciae.     The  sterno-mastoid  must 
now  be  drawn  outwards,  and  the  digastric  and  stylo-hyoid  downwards,  and 
it  will  probably  be  needful  to  divide  these  latter  muscles  partially  in  order 


LIGATURE  OF  THE  INTERNAL  CAROTID  695 

tt)  socui'c  tlio  artery  before  it  enters  tlic  parotitl  gland,  tliis  structure  being 
drawn  upwards  and  forwards. 

The  needle  may  bo  passed  from  either  side,  as  is  most  convenient  to 
the  surgeon. 

Several  veins  comnumicating  between  the  facial  and  the  external 
jugular  will  probably  cross  the  line  of  incision,  and  must  be  dealt  with. 


LIGATURE  OF  THE  INTERNAL  CAROTID 

Indications.     These  are  extremely  few. 

(1)  Wounds,  usually  Stabs.  The  following  striking  case  is  quoted 
by  Dr.  Liddel,i  and  reflects  the  greatest  credit  on  the  medical  men 
concerned  : 

On  July  31,  1869,  a  man  was  wounded  in  the  neck,  at  the  angle  of  the  lower 
jaw,  by  a  knife,  which  penetrated  several  inches,  opening  tlie  internal  carotid. 
Alarmed  by  the  tremendous  jets  of  arterial  blood.  Dr.  Denning,  in  whose  drug- 
store the  stabbing  occurred,  at  once  compressed  the  carotids.  Happening  to  be 
close  at  hand.  Dr.  A.  T.  Lee  promjitly  cut  down  upon  the  artery  by  the  usual 
incision,  exposed  it  by  careful  dissection,  found  the  bleeding-point,  and  applied  a 
ligature  on  the  cardiac  side  of  it.  Haemorrhage  now  occurring  from  the  upper 
end,  was  arrested  by  a  ligatm-e  on  the  distal  side  of  the  wound.  The  patient  was 
pulseless,  and  death  was  considered  imminent,  but  under  fencrgetic  stimulation 
with  whisky  and  ammonia,  the  circulation  was  soon  restored,  and  the  patient 
made  a  good  recovery,  being  in  active  work  nine  years  later. 

(2)  Aneurysm.^  In  the  non-traumatic  and  sacculated  variety,  which 
is  extremely  rare,  the  decision  as  to  treatment,  if  pressure  have  failed, 
must  lie  between  the  Hunterian  operation  of  ligaturing  the  common 
carotid  or,  if  the  artery  be  soimd,  and  if  there  be  room  above  as  well 
as  below  the  aneurysm,  of  placing  ligatures  above  and  below  the  sac,  and 
opening  this  to  turn  out  the  clots.  But  one  or  both  of  the  above  con- 
ditions may  very  likely  be  absent. 

If  the  aneurysm  be  traumatic,  resulting  from  a  stab  or  gunshot  injury 
in  the  neck,  or  if,  in  spite  of  other  treatment,  it  be  steadily  increasing,  the 
only  operation  likely  to  avail  is  the  old  one. 

The  following  case  is  an  excellent  example  of  the  difficulties  which 
may  be  met  with  in  these  cases,  and  how  they  should  be  dealt  with  : 

Dr.  Prewitt,  of  St.  Louis, ^  has  recorded  the  following  most  interesting  case  of 
traumatic  aneurysm  :  A  negress,  aged  17,  was  shot  with  a  revolver  bullet,  which 
entered  the  cheek  over  the  malar  bone  and  passed  backwards.  Profuse  haemorrhage 
took  place  at  once  from  the  wound  of  entrance,  there  being  none  of  exit.  This 
was  controlled  by  pressure.  A  swelling  quickly  appeared  between  the  ramus  of 
the  jaw  and  the  mastoid  process,  which  three  months  later  was  found  to  project 
into  the  pharyngeal  cavity,  crowding  the  tonsil  over  the  middle  line  and  resting 
against  the  uvula.*     Externally  the  swelling  reached  from  the  temporal  bone  to  the 

^  Intern.  Encycl.  of  Surg.,  vol.  iii,  p.  Ill  ;  Amer.  Journ.  Med.  ScL,  January  1879, 
pp.  124,  143. 

-  Aneurysm  of  the  internal  carotid  here  refers  to  the  cervical  part  of  the  artery. 
The  treatment  of  orbital  aneurysm,  which  often  depends  on  artcrio-venous  communica- 
tion (traumatic  or  idiopathic)  between  the  internal  carotid  and  the  cavernous  sinus,  has 
already  been  considered  at  p.  677.  Matas's  operation  of  endoaneurysmorraphy  might 
also  be  employed  here. 

^  Trans.  Amer.  Surg.  Assoc,  vol.  iv,  p.  233. 

*  With  reference  to  this  tendency  of  internal  carotid  aneurysm  to  project  inwards 
Dr.  Prewitt  thus  quotes  from  Prof.  Agnew  {Surgery,  vol.  i,  p.  591)  :  "  The  deep  situation 
of  the  artery,  covered  as  it  is  externally  by  the  stylo-hyoid,  stylo-pharyngeus,  and  stylo- 
glossus muscles,  and  by  dense  aponeurotic  structures  which  extend  down  to  the  styloid 
process,  prevents  any  very  marked  prominence  of  such  a  tumour  on  the  surface  of  the 
neck,  and,  as  the  artery  is  separated  from  the  pharynx  only  by  the  mucous  membrane 

SURGERY  I  44" 


696  OPERATIONS  OX  THE  HEAD  AND  NECK 

hyoid.  Expansile  pulsation,  well-marked  bruit,  and  thrill  were  present.  Sense 
of  taste  was  lost  in  the  right  Hide  of  the  tongue,  which  was  atrophied,  and.  when 
protruded,  inclined  to  the  right.  Pressure  on  the  common  carotid  arrested  pulsa- 
tion in  the  tumour,  and  caused  some  decrease  in  size.  There  was  no  perceptible 
difference  in  the  right  and  left  temporal  pulses  ;  the  pupils  were  equal.  There 
was  persistent  headache,  and  sometimes  roaring  in  the  right  ear.  Difficulty  in 
swallowing  had  existed  from  the  first.     The  general  condition  was  unsatisfactory. 

It  was  decided  to  tie  the  common  carotid  at  once,  but  though  the  pulsation  and 
thrill  in  the  sac  seemed  arrested  at  first,  they  returned  in  a  few  minutes.  It  was 
then  decided,  as  a  forlorn  hope  (because  the  diagnosis  had  placed  the  opening  of 
the  sac  close  to  the  carotid  foramen),  to  extend  the  incision  upwards  in  front  of 
the  tragas  to  determine  the  feasibility  of  laying  open  the  sac  and  tying  the  vessel 
upon  the  distal  side  of  it. 

A  cautious  dissection  at  the  back  and  upper  part  of  the  sac  showed  that  this 
filled  all  the  space  between  the  mastoid  process  behind  and  the  condyle  and  ramus 
of  the  jaw  in  front,  the  sac  seeming  also  to  blend  with  the  skull  or  to  be  closely 
adherent  to  it.  A  little  reflection  made  it  apparent  that  there  was  no  portion  of 
the  artery  between  the  carotid  foramen  and  the  sac  to  be  tied.  The  wound  was 
washed  out,  drained,  and  closed.  On  the  evening  of  the  eighth  day,  there  having 
been  pyrexia  and  free  suppuration  of  the  wound  in  the  interval,  ha-morrhage  took 
place  from  the  sac.  The  wound  was  enlarged,  and  search  made  with  the  finger 
for  the  orifice  of  the  artery  or  the  carotid  foramen.  The  search  being  fruitless, 
and  it  seeming  certain  that  laying  open  of  the  sac  or  removal  of  the  finger  would  be 
followed  by  speedily  fatal  haemorrhage,  the  sac  was  packed.  Hsemorrhage  did  not 
recur,  but  the  patieijt  died  exhaasted  twenty-five  daj's  after  the  first  oi>eration. 

The  necropsy  was  conducted  under  great  difficulty,  but  it  was  thought  that  it 
was  made  out  that  the  opening  in  the  artery  was  close  to  the  carotid  foramen. 
Death  seemed  largely  due  to  infective  causes,  e.fj.  thrombosis  of  the  inferior  petrosal 
and  lateral  sinuses. 

(3)  At  p.  678  another  indication  is  given,  \\z.  some  cases  of  traumatic 
exophthalmos,  in  which  hgature  of  the  internal  carotid  is  to  be  preferred 
to  that  of  the  common  trunk. 

Line  and  Guide.  These  are  practically  the  same  as  those  given  for 
the  common  carotid.  The  internal  carotid  lies  at  first  outside  and 
rather  behind  the  external  carotid.  Soon  after  its  commencement  it 
becomes  too  deeply  placed  to  admit  of  ligatm-e. 

RELATIONS  IN  THE  NECK 
In  Front 

Skin  ;  fasciae  ;  platysma. 

Stemo-mastoid  ;    stylo-glossus  ;   stylo-pharyngeus. 

Glosso-pharyngeal  nerve. 

H}"poglossal  ner\'e. 

Parotid  gland. 

Occipital  artery. 

Outside  O  Inside 

Internal  jugular.  Internal  carotid.  Pharynx, 

Vagus.  Artery.  Ascending  pharyngeal. 


Tonsil. 


Behind 


Rectus  capitus  anticus  major. 
Superior  laryngeal  nerve. 

and  the  constrictor  muscle,  its  extension  inwards  becomes  an  anatomical  necessity. 
Indeed,  in  this  peculiarity  lies  the  chief  difference  between  aneurjsm  of  the  internal 
carotid  and  aneurysm  situated  at  the  division  of  the  common  trunk." 


LKiATUUK  OF  THE  VERTKURAL  097 

Operation.  This  is  much  the  same  as  that  for  ligature  of  the  external 
carotid.  The  artery  can  be  tied  in  its  first  and  more  superficial  part. 
It  here  lies  outside  and  rather  behind  the  external  carotid.  The  bifurca- 
tion of  the  connnon  trunk  should  first  be  found,  and  the  internal  carotid 
carefully  traced  u])\vards  bein<2;  identified  by  the  absence  of  branches. 

Thus  the  incision  should  be  made  along  the  anterior  border  of  the 
sterno-mastoid,  and  not  just  in  front  of  it,  the  centre  of  the  incision  lying 
about  half  an  inch  above  the  upper  border  of  the  thyroid  cartilage.  The 
sterno-mastoid  being  defined,  and  the  cellular  tissue  opened  up  in  front 
of  it,  the  same  superficial  structures  will  be  met  with  as  in  the  external 
carotid  (p.  ()92).  When  the  carotids  are  found,  the  external  should  be 
drawn  inwards,  and  the  digastric  upwards.  The  needle  should  be  passed 
from  without  inwards,  avoiding  the  internal  jugular  and  the  vagus. 


LIGATURE  OF  THE  VERTEBRAL  ARTERY 

Indications.  (1)  Wounds  and  (2)  Traumatic  Aneurysm  may  be 
considered  together. 

There  is  liable  to  be  much  obscurity  as  to  whether  it  is  the  vertebral 
or  some  other  artery,  e.g.  inferior  thyroid,  ascending  cervical,  common 
carotid,  or,  if  higher  up,  the  occipital,  which  is  affected  ;  and,  when  it  is 
decided  that  it  is  the  vertebral  artery,  it  is  by  no  means  easy  to  carry 
out  satisfactory  treatment.  The  best  course  is  to  enlarge  the  wound,  and 
to  decide,  with  the  finger,  the  relation  of  the  wounded  vessel  and  of  the 
haemorrhage  to  the  transverse  processes  of  the  vertebrae.  The  direction  of 
the  wound  and  the  effect  qf  pressure  below  and  above  the  level  at  which 
the  vertebral  ceases  to  be  compressible,  i.e.  above  the  "  carotid  tubercle  " 
(vide  infra),  will  also  be  helpful. 

If  the  wound  be  low  down,  there  are  about  two  inches  of  the  artery 
available  for  ligature,  and  this  should  be  placed  above  and  below  the 
wound.  But  if,  as  is  more  frequent,  the  wound  is  higher  up  in  the  neck, 
it  will  be  almost  impossible,  even  after  exposing  and  clipping  away  the 
anterior  roots  of  the  transverse  process,  to  find  and  secure  the  artery,  and 
the  best  course  will  be  carefully  to  plug  the  wound,  a  method  successfully 
employed  by  Prof.  Kocher.^ 

Aneurysms  of  the  vertebral  are  always  traumatic.  There  are  about 
twenty-four  ^  cases  on  record  of  aneurysms  and  wounds  of  this  vessel. 
The  situation  varies  much.  Usually  it  is  high  up  near  the  mastoid 
process.^ 

The  difficulty  of  diagnosis  of  wounds  of  the  vertebral  and  other 
arteries,  and  their  results,  has  already  been  alluded  to.  Mr.  Holmes  '^ 
states  that  there  are  eleven  cases  in  which  the  carotid  has  been  tied  for 
wound  or  aneurysm  of  the  vertebral,  of  course  with  no  advantage.  This 
mistake  seems  to  have  arisen  from  forgetfulness  of  the  fact  that,  while 

^  Langenbeck's  Arch.  f.  Klin.  Chir.,  Bd.  xii,  S.  867.  A  full  abstract  of  the  paper 
given  in  the  Syd.  Soc.  Reir.,  1871-1872,  p.  202. 

2  Barbieri,  of  Milan,  quoted  by  Kochcr  (loc.  supra  cit.),  has  collected  sixteen  ;  Pilz 
(Langenbeck's  Arch.  f.  Klin.  Chir.,  Bd.  ix)  has  gathered  together  four.  Then  there  are 
Kocher's,  one  by  Lucke  in  the  same  Arch.,  Bd.  viii,  tS.  78,  and  the  American  case  given 
below. 

'  In  nine,  according  to  Kocher,  the  wound  was  at  or  above  the  second  cervical 
vertebra  ;  in  two  "  at  the  upper  part  of  the  neck  "  ;  in  six  it  was  below  the  second 
cervical  vertebra.  In  four  of  the  latter  it  was  in  the  neighbourhood  of  the  external 
carotid  artery  and  its  branches  :   thus  in  one  the  wound  was  at  the  angle  of  the  jaw. 

4  Lancet,  July  26,  1873. 


698  OPERATIONS  ON  THE  HEAD  AND  NECK 

pressure  on  the  common  carotid  below  the  transverse  process,  of  the 
sixth  cervical  vertebra  will  check  all  pulsation  in  the  carotid,  the  branches 
of  the  carotid,  and  aneurysms  situated  on  them,  it  will  also  check  pulsa- 
tion in  a  vertebral  aneurysm.  Mr.  Holmes  points  out  that  the  above 
''  carotid  tubercle  "  is  higher  up  than  is  usually  supposed,  being  situated 
two  or  three  inches  above  the  clavicle  ;  and  he  lays  down  the  rule  that 
when  a  traumatic  aneurysm  is  situated  in  the  course  of  the  vertebral, 
and  its  pulsations  are  commanded,  however  completely,  by  pressure 
on  the  common  carotid  low  in  the  neck,  it  ought  not  to  be  treated  as  being 
carotid,  or  as  affecting  a  branch  of  the  carotid,  until  it  is  clearly  proved 
that  its  pulsations  are  stopped  by  pressure  applied  above  the  level  at 
which  the  vertebral  ceases  to  be  compressible,  i.e.  above  Chassaignac's 
carotid  tubercle.  Ligature  of  the  vertebral  artery  in  the  first  few  inches 
of  its  course  being  so  very  rarely  available,  compression  of  the  artery  low 
down,  with  the  aid  of  an  anaesthetic,  if  needful,  and  with  the  additional 
help  of  direct  pressure  or  cold  on  the  aneurysm  above,  should  be  made  use 
of. 

Dr.  Weir  ^  records  a  case  of  a  man  stabbed  on  the  right  side  of  the  neck,  about 
three-quarters  of  an  inch  below  the  ear,  just  in  front  of  the  sterno-mastoid.  A 
traumatic  aneurysm,  believed'  to  be  of  the  vertebral,  slowly  developed.  Digital 
pressure  over  the  carotid  tubercle  was  made  use  of,  and  in  three  hours  the  tumour 
was  cured. 

If  pressure  fails,  and  if  a  vertebral  aneurysm  increases  in  size,  the 
surgeon  must  decide  to  face  the  risks  of  opening  the  swelling  and  effi- 
ciently plugging  it.  The  gauze  should  be  carried  into  the  aneurysm,  the 
wound  being  opened  sufficiently  freely  to  allow  the  surgeon  to  see  what  he 
is  about,  and  the  head  should  afterwards  be  kept  rigidly  still. ^ 

(3)  The  vertebral  has  been  tied  on  several  occasions  in  ligature  of  the 
innominate  artery,  either  at  the  same  time,  to  prevent  secondary  haemor- 
rhage, or  later  on,  to  arrest  this  when  it  has  occurred  at  the  seat  of  ligature 
owing  to  the  reflux  of  blood  from  the  subclavian  (p.  719).  More  than  once 
the  vertebral  has  been  wounded  during  ligature  of  the  first  part  of  thp 
subclavian. 

Relations.  The  vertebral  artery,  the  largest  and  usually  the  first 
branch  of  the  subclavian,  arises  from  the  upper  and  back  part  of  the 
artery,  and  ascends  at  first  a  little  outwards  and  backwards  to  reach 
the  foramen  in  the  transverse  process  of  the  sixth  (sometimes  the  fifth  or 
the  seventh)  cervical  vertebra.  Traversing  these  foramina,  it  passes 
through  that  of  the  axis  ;  it  then  bends  outwards  and  upwards  to  reach 
that  of  the  atlas,  and,  passing  backwards,  lies  in  a  deep  groove  on  the 
posterior  arch  of  the  atlas  behind  the  articular  process,  beneath  the 
suboccipital  nerve.  In  this  position  it  lies  in  the  suboccipital  triangle. 
Finally,  it  pierces  the  posterior  occipito-atloid  ligament  and  dura  mater, 
and,  running  upwards  and  forwards  through  the  foramen  magnum,  winds 
round  to  the  front  of  the  medulla  to  join  its  fellow  and  form  the  basilar  at 
the  lower  border  of  the  pons  Varolii . 

Behind 

Cervical  nerves  (in  vertebral  canal). 
Sympathetic  plexus. 

1  Nciv  York  Archives  of  Medicine,  1884. 

^  In  one  case  related  by  Kocher  the  nerves  lying  behind  the  artery  were  injured, 
and  in  another  dangerous  inflammation  of  the  spinal  meninges  took  place. 


LIGATURE  OF  THE  SUBCLAVIAN  099 

Outside  O  Inside 

Scalenus  anticus  and      Vertebral  artery,  Longus  colli, 

phrenic  nerve. 

In  front 
Internal  jugular. 
Inferior  thyroid. 

Thoracic  duct  (loft  side)  crossing  from  within  outwards. 
Vertebral  vein  (often  plexiform). 
Sympathetic  plexus. 

Operation.  The  head  having  been  suitably  raised  and  turned  slightly 
over  to  the  opposite  side,  an  incision,  three  inches  long,  is  made  along 
the  outer  border  of  the  sterno-niastoid,  extending  to  the  clavicle.  In 
deepening  this  incision  the  external  jugular  must  be  looked  out  for,  running 
parallel  here  with  the  outer  border  of  the  muscle.  When  the  deep  fascia 
is  divided,  the  sterno-mastoid,  together  with  the  vein,  is  to  be  drawni 
inwards,  the  incision  being  prolonged  along  the  clavicle,  and  some  of 
the  clavicular  fibres  detached  from  the  bone  if  needful.  The  surgeon 
then,  working  with  the  narrow  point  of  a  steel  director,  carefully  opens  up 
the  deep  connective  tissue,  and  endeavours  to  define  the  interval  between 
the  scalenus  anticus  and  the  longus  colli  muscles.  As  the  outer  border  of 
the  former  muscle  corresponds  with  that  of  the  sterno-mastoid,  this  muscle 
nmst  be  well  retracted  inwards.  In  defining  the  vertebral  artery  as  it 
lies  between  the  scalenus  and  longus  colli  the  presence  of  the  phrenic 
nerve  lying  on  the  scalenus,  the  pleura  internally,  the  internal  jugular, 
inferior  thyroid,  and  the  vertebral  veins  over  the  vessel,  with  the  thoracic 
duct  crossing  it,  on  the  left  side,  from  within  outwards,  must  all  be  borne 
in  mind,  these  structures  being  drawn  to  either  side,  as  is  convenient,  with 
small  retractors.  The  depth  of  the  wound  and  venous  haemorrhage  are 
difficulties  at  this  stage.  The  needle  is  then  passed  from  \N-ithout  inwards. 
Owing  to  the  deep  position  of  the  artery,  a  good  light  is  essential,  and  the 
head  must  be  manipulated  so  as  to  relax  the  deep  parts  as  required.  The 
anterior  transverse  tubercle  on  the  sixth  cervical  vertebra  is  a  good  guide 
in  cases  of  difficulty  ;  below  it,  the  pulsation  of  the  artery  should  be  felt. 
In  cleaning  the  artery  previous  to  passing  the  hgature  the  fibres  of  the 
sympathetic  must  be  disturbed  as  little  as  possible. 

Temporary  paralysis  from  interference  with  these  fibres  is  almost 
certain,  and  immediate  contraction  of  the  corresponding  pupil  is  of  very 
frequent  occurrence,  and  may  be  regarded  as  a  pretty  certain  indication 
that  the  vessel  has  been  secured.  If  the  vertebral  vein  is  womided  and 
cannot  be  secured  separately,  ligatures  should  be  placed  on  artery  and 
vein  together,  above  and  below  the  wound  in  the  latter. 

LIGATURE   OF  THE  SUBCLAVIAN  IN  ITS  SECOND   AND  THIRD 
PARTS  (Figs.  290,  291) 

Line.  From  the  curved  and  short  course  of  this  vessel  no  defuiite 
line  can  be  given. 

Guide.  The  chief  point  to  remember  is  the  outer  margin  of  the  sterno- 
mastoid,  as  this  corresponds  to  the  outer  border  of  the  scalenus  anticus, 
which  has  to  be  defined  and  then  traced  down  to  the  scalene  tubercle  on 


700 


OPERATIONS  ON  THE  HEAD  AND  NECK 


the  first  rib,  the  part  of  the  artery  to  be  tied  lying  on  the  upper  surface 
of  this  bone,  outside  and  behind  the  muscle  and  tubercle. 

Relations  (third  part)  : 

In  Front 

Skin  ;  fasciae  ;  platysma  ;  branches  of  cervical  plexus. 

Venous  plexus,  viz.   external  jugular  ;   suprascapular  ;  posterior 
scapular  ;  transverse  cervical ;   branch  from  cephalic. 

Transverse  cervical  and  suprascapular  arteries. 

Cellular  tissue  and  fat. 

Nerve  to  subclavian. 

Subclavian  vein  (below). 


Above 
Omo-hvoid, 
Cords  of  brachial  plexus. 

Relations  (second  part) : 


Above 
Cords  of  brachial  plexus. 


Subclavian  artery 
(third  part). 

In  Front 
Skin  ;  fasciae  ;   platysma. 
Sterno-mastoid. 
Scalenus  anticus. 
Phrenic  nerve. 

o 

SubckAaan  artery 
(second  part). 


Behind 

First  rib. 


Below 
Pleura 


Collateral 

Second  Part. 


Behind 
Scalenus  medius. 

Circulation.     When  a  ligature  is  applied  to  the   Third  or 
Three  main  sets  of  vessels  are  here  employed,  viz  : 


Above 
The  suprascapular, 
The  posterior  scapular. 


Below 

with  The  acromio-thoracic,  the  infra- 
scapular,  subscapular,  and  dor- 
salis  scapulae. 

with  The  long  thoracic  and  the  scapular 
arteries. 


Branches  of  the  axillary. 


The  superior  intercostal, 
The  aortic  intercostals, 
The  internal  mammary, 
Numerous  plexiform  vessels   ^^^th 

passing  through  the  axilla 

from  branches  of  the  sub- 

cla\'ian. 

When  a  ligature  is  applied  to  the  First  Part.  The  collateral  circu- 
lation may  be  carried  on  by  the  superior  anastomosing  with  the  inferior 
thyroid,  one  vertebral  with  its  fellow,  the  internal  mammary  and  superior 
intercostal  with  the  long  thoracic  and  the  scapular  arteries,  and  the 
princeps  cervicis  with  the  profunda  cer^^cis.^ 

Indications,  (i)  In  some  cases  of  axillary  aneurysm,^  i.e.  those  in 
which,  owing  to  the  pain,  the  irritability  of  the  patient,  the  depth  of  the 
artery,  or  the  rapid  increase  of  the  aneurysm,  pressure  is  not  available. 

^  Smith  and  Walsham,  p.  38. 

2  Some  of  these  cases  -will  be  suitable  for  Matas's  operatiou  (see  p.  53). 


LIGATURE  OF  TPIE  SUBCLAVIAN 


701 


The  high  mortahty  met  with  in  past  days  is  due  chiefly  to  three  causes, 
viz.  (1)  Inflammatory  changes  within  the  chest;  (2)  suppuration  of 
the  sac  ;    (3)  hemorrhage. 

(ii)  Cases  of  subclavian  and  subclavio-axillary  aneurysm  not  amenable 
to  other  treatment  ;  or  where  the  aneurysm,  especially  if  subclavio- 
axillary,  is  small  in  size  (not  larger  than  a  hen's  egg),  with  a  history  of  a 
few  months'  duration,  and  distinctly  traumatic  in  origin. 


BRACHIAL   PLEXUS 


inl-  -  S  TERN  0  -HAS  TCID. 

EXTERNAL   JUGULAR 

-SCALENUS  ANTICUS 
-SCALENUS    MEDIUS 
-V-OMO-HrOJD 

iM--TRAtiS^^£RSE    CERYiCAl    A. 
]^\--  SUPRA -SCAPUL/^R.  A. 

-SUBCLAyiAH    U 
SUBCLAyiAN  A. 


Fig.  290.     Surgical  anatomy  of  third^part  of  the  subclavian  artery. 

]\Ir.  Poland, 1  in  his  report  on  subclavian  aneurysm,  gives  nine  cases  of  recovery 
and  twelve  cases  ending  fatally  after  ligature  of  the  second  or  third  portions  of  the 
subclavian  for  subclavian  or  subclavio-axillary  aneurysm.  With  regard  to  the 
nine  successful  cases.  Mr.  Poland  raises  a  very  important  question  :  Was  the 
aneurysm  developed  in  a  healthy  artery  ?  If  so,  the  success  is  explained.  In 
three  the  aneurysm  was  entirely  local,  independent  of  general  arterial  disease  ; 
in  two  this  was  doubtful  ;  in  four  the  origin  was  spontaneous.  Whether  general 
atheroma  existed  here  must  remain  uncertain,  as  the  patients  recovered,  and  the 
artery,  where  tied,  was  healthy.  "  We  can  only  saj'  this  :  that  subclavian  aneurj'sm 
in  its  early  stage,  occurring  in  persons  of  the  early  or  middle  period  of  life,  without 
any  indication  of  disease  of  the  heart  or  large  vessels,  may  and  does  recover,  and 
that  a  cure  may  be  effected  by  means  of  a  ligature  of  the  third  or  second  portion 
of  the  artery  notwithstanding  the  disease  is  one  of  spontaneous  origin,  and  therefore 
presumed  to  be  indicative  of  arterial  cUsease." 

Dr.  Taylor,  of  Dubhn,  has  related  ^  a  very  instructive  case  of  traumatic 
aneurysm  of  the  left  subcla\'ian,  due  to  fracture  of  the  clavicle,  most 
successfully  treated  under  circumstances  of  great  difficulty. 


1  Guy's  Hospital  Reports,  1871. 


..-Ik?!,  of  Surg.,  November  1903. 


702  OPERATIONS  ON  THE  HEAD  AND  NECK 

The  man,  set.  62,  had  fractured  his  clavicle  in  the  usual  way,  and  tried  to  work 
the  day  after.  There  was  much  swelling  from  the  first,  and  the  X-rays  showed  a 
spicule  of  bone  passing  down  towards  the  vessel.  Two  weeks  after  the  injury  a 
large  swelling,  with  all  the  evidence  of  an  aneurysm,  was  present.  A  fortnight 
later  an  attempt  was  made  to  tie  the  first  part  of  the  subclavian  after  removal  of 
the  inner  third  of  the  clavicle.  Owing  to  the  difficulties  met  with  which  led  to 
injury  of  the  vertebral  artery,  it  was  determined  to  remove  the  centre  of  the  clavicle, 
expose  and  control  the  artery,  empty  the  sac,  and  apply  double  ligatures.  The 
subclavian  being  controlled  by  pressure  and  the  sac  emptied,  an  opening  was  found 
in  it  of  the  size  of  a  knitting-needle.  Forceps  were  now  placed  on  the  proxijual 
and  distal  sides  of  the  sac,  and  allowed  to  remain  on  for  twelve  days,  a  plug  of 
gauze  being  introduced  between  them.  The  wound  granulated  satisfactorily 
and  the  patient  made  a  good  recovery,  though  the  return  of  power  in  the  limb  was 
very  slow. 

(iii)  As  a  distal  operation,  together  with  Hgatiire  of  the  common 
carotid  for  some  cases  of  aneurysm  of  the  innominate  and  aorta 
{see  p  723). 

(iv)  Preparatory  to  such  operations  as  interscapulo-thoracic  amputa- 
tion (p.  235). 

(v)  For  wounds  of  the  subcla\'ian  itself,  e.g.  stabs.  This  is  very 
rarely  called  for. 

Operation  for  Ligature  of  the  Third  or  Second  Portion  of  the  Subclavian 
(Fig.  291).  These  two  wall  be  considered  together,  as  one  operation  is 
but  an  extension  of  the  other. 

The  patient  having  been  turned  over  on  to  the  sound  side,  propped  up 
with  pillows  at  the  edge  of  the  table,  the  head  drawn  over  to  the  opposite 
side,  the  shoulder  on  the  side  of  the  aneurysm  is  depressed  as  strongly  as 
possible,  so  as  to  open  out  the  posterior  triangle.  The  surgeon  then, 
standing  in  front  of  the  shoulder,  draws  the  skin  down  over  the  clavicle 
with  his  left  hand,  and  makes  an  incision,  three  inches  long,  over  this 
bone,  between  the  sterno-mastoid  and  trapezius,  dividing  skin,  fascise,  and 
platysma. 

The  soft  parts  being  now  allowed  to  ghde  up,  the  incision  should  lie 
half  an  inch  above  the  clavicle,  the  external  jugular  vein  thus  escaping 
injury  ;  for,  as  this  vein  perforates  the  deep  fascia  just  above  the  clavicle, 
it  cannot  be  drawn  down  with  the  skin,  superficial  fascia,  and  platysma. 
If  more  room  be  required  owing  to  the  elevation  of  the  clavicle  or  the 
presence  of  an  aneurysm,  the  above  muscles  must  be  divided,  and  a  longi- 
tudinal incision  made  upwards,  at  right  angles  to  the  inner  end  of  the 
first,  and  a  triangular  flap  raised  outwards  and  upwards. 

When  the  superficial  parts  have  been  sufficiently  incised,  the  deep 
fascia  is  carefully  opened  at  the  inner  end  of  the  incision  and  laid  open  on 
a  director,  and  the  areolar  tissue  beneath,  which  varies  much  in  density 
and  in  the  amomit  of  fat  it  contains,  divided  cautiously  in  a  direction 
aiming  for  the  outer  edge  of  the  scalenus  anticus,  which  corresponds  to 
the  outer  margin  of  the  clavicular  part  of  the  sterno-mastoid.  As  soon  as 
the  deep  fascia  is  divided,  the  presence  of  the  following  compUcations  must 
be  remembered  and  provided  for.  The  soft  tissues  may  be  much  matted, 
oedematous,  and  altered  owing  to  previous  use  of  pressure,  or  inflamma- 
tion set  up  around  a  rapidly  growing  aneurysm.  The  venous  plexus  formed 
by  the  external  jugular  receiving  the  suprascapular  and  transverse 
cervical  veins,  and,  often,  the  posterior  scapular  and  a  branch  over  the 
clavicle  from  the  cephalic  as  well,  may  be  much  engorged.  Any  one 
or  more  of  these  veins  which  are  in  the  way  should  be  dra^vn  aside  or 
divided  between  fine  catgut  ligatures.     It  cannot  be  insisted  upon  too 


LIGATURE  OF  THK  SUBCLAVIAN 


703 


strongly  that  a  bloodless  wound  will  best  enable  the  surgeon  to  reach 
this  often  most  difficult  artery,  and  a  bloodless  wound  is  best  secured 
by  tying  beforehand  every  vein  which  cannot  be  drawn  out  of  the  way, 
and  by  using  a  fine-pointed  steel  director  as  much  as  possible  after  the 
deep  fascia  is  opened. 

As  a  rule,  the  transverse  cervical  artery  is  above  the  incision,  and  the 
suprascapular  below  it,  under  the  clavicle,  but  occasionally  one  or  both 
of  these  may  be  found  lying  across  the  field  of  operation,  and  must  then 
be  drawn  aside.     While  the  veins  may  be  ligatured  without  hesitation, 


CERVICAL  A. 
MASTOID 


SUPR/I'SCAPUL/IR  ^ 

CLA^l/lCLE       I       .       SUBCLAI^IAN   V. 
JUBCLAV/AH  ^. 


SCALENUS  ANT. 
^SUPRA-SCAPUL  AR  A. 


Fio.  291.     Ligature  of  the  third  part  of  the  subclavian  artery. 

the  arteries  must  be  preserved  intact,  that  the  collateral  circulation  may 
not  be  interfered  with  (p.  700). 

The  omo-hyoid  varies  in  position,  and  may  be  neglected. 

By  dissecting  through  the  cellular  tissue  the  scalene  tubercle  on  the 
first  rib,  immediately  above  and  behind  which  landmark  lies  the  artery, 
can  be  felt.  One  of  the  lowest  cords  of  the  brachial  plexus  will  now  come 
into  view,  and  is  another  good  guide  to  the  artery. 

George  Wright,  of  Manchester,  ^  emphasises  the  value  of  the  lowest  nerve  cord 
as  a  guide  in  preference  to  the  scalenus  anticus  and  the  scalene  tubercle.  In  his 
case  the  muscle  was  not  a  very  good  guide,  as  "  the  tense  fascia  reaching  from  its 
posterior  border  to  the  sheath  of  the  artery  obscured  the  line  of  the  muscle,"  and 
as  the  artery  rose  fairly  high  in  the  neck,  the  tubercle  was  not  of  much  value  either. 

This  cord  must  not  be  mistaken  for  the  artery,  a  contingency  other- 
wise not  unUkely  to  happen,  as  the  lowest  cord  is  in  close  contact  with 
the  artery  and  may  receive  pulsation  from  it.  A  Uttle  cleaning  will  show 
the  fasciculation  of  the  nerve,  while  the  artery  is  closer  to  the  rib,  and  is 
flat,  not  rounded,  when  rolled  under  the  finger.^  By  compressing  the 
artery  between  the  needle  passed  beneath  it  and  his  forefinger,  and  noting 

1  "  Case  of  Ligature  of  Subclavian  Artery  for  Axillary  Aneurysm,"  Ann.  of  Surg., 
1888,  p.  3G2. 

"  Another  difficulty  about  the  pulsation  is  its  variableness.  Sometimes  it  is  violent 
and  excited  ;  at  others,  as  in  the  case  of  a  dilated  and  diseased  artery,  or  one  much 
handled  in  the  operation,  it  is  almost  imperceptible  (p.  174). 


704  OPERATIONS  ON  THE  HEAD  AND  NECK 

the  result  of  this  pressure  on  the  aneurysm  and  the  pulse  below,  the  surgeon 
will  clear  up  any  doubts  as  to  whether  he  has  the  artery  or  not.^ 

The  position  of  the  artery  being  made  sure  of,  the  sheath  ^  is  opened 
with  the  point  of  the  knife,  the  artery  cleaned,  and  the  needle  passed  from 
above  downwards  and  from  behind  forwards.  This  best  avoids  the 
worst  risk,  i.e.  of  including  a  nerve  cord.  The  needle  should  be  kept 
most  carefully  close  to  the  vessel,  and  not  dipped  suddenly  or  used  with 
any  force  ;  otherwise  the  pleura  or  subclavian  vein  may  be  injured.^ 
The  artery,  before  the  ligature  is  tightened,  will  be  inspected  with  some 
anxiety  as  to  its  condition — whether  normal  in  size  and  structure,  or 
dilated,  thickened  or  thinned.^  If  much  alteration  be  found,  the  surgeon 
should  carefully  divide  the  outer  half  of  the  scalenus  anticus  on  a  director 
with  a  blunt-pointed  scissors,  keeping  the  wound  absolutely  dry  so  as  to 
watch  for  the  phrenic  nerve,  which,  if  seen,  should  be  drawn  inwards. 

If  the  artery  be  found  diseased  here  also,  the  surgeon  should  use  one  of 
the  ligatures  described  at  pp.  713,  715,  and  endeavour  so  to  adjust 
the  tightening  of  the  ligature  as  not  to  divide  both  the  internal  and 
middle  coats. 

In  cases  where  the  wound  is  a  very  deep  one,  care  must  be  taken,  while 
making  the  second  knot,  that  the  first  does  not  slip.  The  ligature  having 
been  tightened  and  cut  short,  drainage  is  provided,  if  needful,  and  the 
wound  carefully  closed  and  dressed.  The  limb  is  then  bandaged  with 
cotton-wool  and  kept  somewhat  supported,  and  the  temperature  main- 
tained with  hot  bottles  if  needful. 

The  Chief  Points  in  the  After-treatment  are  :  (i)  keeping  the  wound 
rigidly  aseptic,  (ii)  arresting  haemorrhage,  (iii)  meeting  suppuration  of 
the  sac,  (iv)  combating  the  stiffness  and  weakness  of  the  limb  which 
sometimes  follow  on  ligature  of  the  main  trunk. 

(i)  This  need  not  be  further  alluded  to  in  a  work  like  this,  but  it 
cannot  be  too  strongly  insisted  upon  that,  if  the  high  mortality  (pp.  701, 
707)  which  has  hitherto  attended  this  operation  is  to  be  reduced,  it  is 
mainly  to  keeping  the  wound  aseptic  throughout,  and  thus  to  early 
primary  union,  that  we  must  look. 

(ii)  The  risk  of  haemorrhage  is  so  great  that  the  surgeon  should  always 
endeavour  to  prevent  it  by  trying  to  obtain  early  and  firm  closure  of  the 
wound,  as  just  indicated,  and  by  keeping  the  patient  absolutely  quiet 
till  all  is  somidly  healed.  When  once  haemorrhage  occurs,  the  outlook  is 
very  grave.  The  treatment  must  vary  according  to  the  size  of  the  wound 
which  remains.     If  there  be  only  a  sinus,  firm  pressure  must  be  made  over 

1  In  the  dead  subject  the  artery  may  be  distinguished  from  the  nerve  trunk  by  the 
fact  that  the  former  flattens  when  pressed  between  the  aneurysm  needle  and  the  finger, 
while  the  latter  feels  like  a  solid  rounded  cord. 

^  A  process  of  deep  cervical  fascia  which  the  vessel  brings  out  from  between  the 
scaleni,  and  one  which  varies  much  in  density. 

^  The  surgeon  should  be  j)rovided  with  needles  of  different  curves  and  a  silver  probe 
with  a  large  eye.  As  pointed  out  by  8ir  W.  Fergusson  [Surgery,  p.  GOT),  with  his  attention 
to  details  in  operations,  the  eye  of  the  needle  should  always  be  close  to  the  point,  that 
the  ligature  may  be  at  once  seized  with  forceps  as  soon  as  it  apjiears  under  the  vessel, 
the  difficulties  at  this  stage  of  the  operation  being  not  only  the  surrounding  parts  of 
importance,  but  also  the  fact  that  in  this  case  the  handle  cannot  be  depressed  so  freely 
as  in  operation  on  most  other  arteries,  and  thus  it  is  difficult  to  make  the  point  rise 
above  the  vessel. 

*  In  a  case  of  Liston's  the  vessel  was  dilated,  thick,  and  soft,  "  aptly  enough  com- 
pared to  the  finger  of  a  buckskin  glove."  The  patient,  aged  43,  died  of  htemorrhage  on 
the  fourteenth  day.  In  a  patient  of  M.  Jobert's  (Poland,  loc.  supra  cit..,  p.  110)  "the 
vessel  was  found  enormously  large,  equal  to  the  size  of  an  aorta  ;  pulsation  being  very 
marked." 


LIGATURE  OF  THE  SUBCLAVIAN  705 

the  dressings  by  well-adjusted  bandaging,  aided  by  a  heavy  bag  of  shot,^ 
and  most  absolute  quiet.  If  the  wound  be  larger,  and  perhaps  septic 
and  sloughy,  an  anaesthetic  should  be  given,  and,  any  clots  having  been 
removed,  it  must  be  rendered  aseptic,  and  plugged  with  strips  of  sterilised 
gauze,  the  part  placed  within  the  wound  having  been  wrung  out  of 
solution  of  formalin  (1  in  500  or  750),  or  turpentine,  and  pressure  appUed 
as  above.  The  patient  should  be  kept  as  quiet  as  possible  with  morphia  ; 
the  diet  should  be  restricted  and  given  at  regular  intervals,  and  without 
stimulants  unless  absolutely  required. 

The  cases  collected  by  Mr.  Poland  ^  show  that  while  haemorrhage  may 
occur  as  early  as  the  eighth  day  it  may  be  deferred  till  the  twentieth  day 
in  either  case.  In  neither  of  these  two  latter  cases  had  the  wound  healed  ; 
in  the  first  the  patient  had  been  allowed  to  get  up  ;  in  the  second  pyaemia 
was  present. 

The  above  and  the  following  remarks  apply  chiefly,  of  course,  to  the 
days  when  ligature  of  arteries  for  aneurysm  was  much  more  common, 
before  the  period  of  aseptic  surgery  and  the  employment  of  sterile 
ligatures. 

The  same  wi'iter '  thus  sums  up  the  sources  of  haemorrhage  : 

(a)  From  the  sac,  either  primary  from  puncture  during  the  operation,  or 
secondary  from  ulceration  or  rupture  at  an  early  period,  or  later  after  inflammation 
and  suppuration  and  giving  way  of  the  sac. 

(b)  From  the  ligatured  part,  in  consequence  of  non-obliteration  of  the  artery 
when  the  ligature  is  becoming  detached,  the  hannorrhage  being  generally  from 
the  peripheral  end  of  the  artery  tied.  It  may  be  due  also  to  an  unsound  state 
of  the  coats  of  the  artery,  such  as  dilated,  thinned  coats  or  atheromatous 
degeneration. 

It  is  worth  remembering  that  this  hemorrhage  is,  in  exceptional  cases,  recovered 
from. 

(iii)  Suppuration  of  the  sac.  The  frequency  of  this  untoward  accident 
has  been  already  alluded  to  (p.  701).  It  is  due  to  the  close  proximity  of 
the  ligature  to  the  sac,  without  any  intervening  branch,  whereby  the  neces- 
sary coagulum  is  but  ill  formed  and  loose,  acting  as  a  foreign  body,  and 
liable  to  set  up  irritation,  inflammation,  and  its  consequences. 

Every  endeavour  should  be  made  to  prevent  its  occurrence  by  forbid- 
ding all  handling  of  the  aneurysm. 

If  evidence  of  it  occur,  and  the  swelling,  which  has  at  first  diminished 
in  size,  again  about  the  second  or  third  week  steadily  increasing  in  size, 
become  tense  and  painful,  but  without  pulsation,  it  must  be  opened  by  a 
sufficiently  free  incision,  carefully  emptied  of  pus  and  clots,  drained,  and 
well-adjusted  pressure  appUed.  If  the  wound  be  not  healed,  and 
particularly  if  it  is  infected,  haemorrhage  is  extremely  likely  to  occur 
after  opening  the  sac — an  ominous  complication,  which  can  only  be  met 
by  plugging  with  aseptic  gauze  and  using  firm  pressure  {vide  swpra). 

(iv)  Atrophy,  stiffness,  and  weakness  of  the  limb.  These  must  be 
met  by  warmth,  use  of  electricity,  and  above  all,  by  perseveringly  used 
massage. 

The  condition  which  is  so  common  in  the  lower  extremity  after  an 
analogous  operation  {see  Ligature  of  External  Iliac),  in  which  the  limb 
long  remains  in  a  state  not  far  removed  from  gangrene,  is  much  less 
common  in  the  upper  extremity. 

^  In  a  large  hospital,  where  relays  of  assistants  are  available,  digital  pressure  may  be 
made  use  of. 

?  Loc.  supra  cit.,  pp.  11^,117,  ?  Loc.  svpra  cit.,  p.  125. 

SURQERY  I  '45 


706  OPERATIONS  ON  THE  HEAD  AND  NECK 

Difficulties  and  Accidents  which  may  be  met  with,  and  Points  to  avoid, 
during  the  Operation. 

(1)  Sterno-mastoid  and  trapezius  almost  meeting. 

(2)  A  full  short  neck  with  much  fat  above  and  beneath  the  deep 
fascia. 

(3)  Clavicle  much  pushed  up.  This  may  be  due  to  the  patient  having 
carried  his  shoulder  raised  to  relieve  the  painful  pressure  on  the  nerves, 
or  to  the  presence  of  an  aneurysm. 

(4)  The  artery  may  be  displaced. 

This  deviation  from  its  usual  course  may  be  acquired,  as  in  a  case  of  Warren's  ^ 
where  the  left  subclavian  was  raised  and  displaced  by  a  curvature  of  the  spine  in 
a  woman,  aged  30,  the  subject  of  an  anexirysm  (attributed  to  strain)  about  the  size 
of  a  pigeon's  egg,  just  above  the  scayjular  end  of  the  clavicle.  Ligature  was  per- 
formed by  an  incision  made  obliquely  from  the  outer  edge  of  the  stemo-mastoid 
towards  the  acromio-clavicular  joint,  the  pulsation  of  the  artery  being  the  guide.  C!on- 
genital  deviations  which  have  been  met  with  are  the  artery  perforating  the  scalenas 
anticus,  or  lying  in  front  of  it,  or,  as  usual,  behind  this  muscle,  but  now  closely 
accompanied  by  its  veins. 

(5)  The  soft  parts  infiltrated,  or  oedematous,  or  matted  together  owing 
to  the  presence  and  irritation  of  an  aneurysm,  aided,  perhaps,  by  previous 
attempts  at  cure  by  pressure. 

(6)  Great  engorgement  of  the  veins  met  with  here,  due  to  the  presence 
of  an  aneurysm,  and  increased  by  the  anaesthetic. 

(7)  An  aneurysmal  sac  very  prominent  and  liable  to  be  punctured  in 
the  operation. 

(8)  Wound  of  the  suprascapular  artery  necessitating  ligature  of 
this  branch.  As  a  rule  this  artery  lies  too  low  down  to  be  injured— a 
complication  to  be  extremely  deprecated,  as  it  is  one  of  the  chief  channels 
by  which  the  collateral  circulation  is  estabhshed  (p.  700).  In  about  one 
out  of  every  three  cases  the  posterior  scapular  will  be  found  to  arise  from 
the  third  part  of  the  subclavian  as  a  separate  branch.  Erichsen  ^  adxdsed, 
if  this  condition  were  met  with,  that  the  ligature  should  be  applied,  as  far 
as  possible,  "  to  the  proximal  side  of  the  branch.  If  necessity  obliges  the 
ligature  to  be  applied  close  to  the  branch,  it  is  perhaps  safer  to  tie  this  also, 
as  the  anastomosis  of  vessels  in  this  region  is  so  abundant  that  the  risk 
of  gangrene  from  the  obliteration  of  a  single  branch  would  be  very  small." 

Any  artery  crossing  the  subclavian  should  be,  normally,  the  trans- 
verse cervical.  This  or  any  other  vessel  which  may  be  an  artery  should 
be  drawn  aside. 

(9)  Pulsation  in  the  artery  weak  or  deficient,  or,  on  the  other  hand, 
excited  and  tumultuous  (p.  70.3). 

(10)  Including  a  cord  of  the  brachial  plexus  (p.  703). 

(11)  Injuring  the  pleura.  This  has  happened  on  several  occasions 
during  the  passage  of  the  needle  round  the  artery,  owing  to  the  close 
proximity  of  the  serous  membrane  to  the  vessel,  and  the  difficulty  in 
passing  the  needle,  especially  when  the  clavicle  is  much  raised,  rendering 
it  impossible  to  pass  the  needle  from  below,  and  thus  away  from  the 
pleura. 

Erichsen  ^  considered  the  inflammation  of  the  contents  of  the  thorax 
to  be  the  most  frequent  cause  of  death,  proving  fatal  in  one  out  of  every 
2-5  cases.  This  is  not  pysemic,  but  arises  from  causes  essentially  con- 
nected either  with  the  operation  or  \nth  the  aneurysm  itself. 

'  Poland,  Joe.  swpra  cit.,  p.  77.  ^  Surgery,  vol.  ii,  p.  208. 

'  Loc.  supra  cit.,  vol.  ii,  p.  212. 


LICxATURE  OF  THE  SUBCLAVIAN  707 

"  These  are  referable  to  three  heads.  (1)  Septic  inflammation  of  the 
deep  areolar  tissue  at  the  root  of  the  neck  may  extend  to  the  anterior 
mediastinum,  the  pleura,  and  pericardium.  ...  (2)  The  sac  may,  by 
its  pressure  inwards,  encroach  upon,  and  give  rise  to  inflammation  of, 
that  portion  of  the  pleura  which  corresponds  to  its  posterior  aspect. 
(3)  Division  of  the  phrenic  nerve  would  necessarily,  by  interfering  with 
the  respiratory  movements,  induce  a  tendency  to  congestion  and  inflam- 
mation of  the  lungs  ;  and  although  such  an  accident  must  be  a  very  rare 
one  in  cases  of  ligature  of  the  subclavian  for  axillary  aneurysm,  yet  it 
undoubtedly  has  occurred,  as  I  have  myself  witnepsedin  one  case." 

(12)  Injuring  the  nerve  to  the  subclavius,  or  including  it  in  the  liga- 
ture. This  nerve,  derived  from  the  junction  of  the  fifth  and  sixth  cervical, 
usually  gives  a  filament  to  the  phrenic.  If,  as  occasionally  happens,  this 
filament  is  replaced  by  a  nerve  constituting  an  important  part  of  the 
origin  of  the  phrenic,  injury  to  it  will  be  followed  by  urgent  and  possibly 
fatal  dyspnosa. 

(13)  Injury  to  the  subclavian  vein.  This  is  rare,  as  the  vein  lies  below 
and  well  away  from  the  artery.  But  if  ligature  were  called  for  in  a  case 
in  which  the  vein  accompanied  the  artery  between  the  scaleni,  this  devi- 
ation would  prove  embarrassing. 

Mention  has  been  made  at  p.  704  of  division  of  the  scalenus  anticus 
if  the  surgeon  does  not  find  the  part  of  the  artery  beyond  this  muscle 
healthy.  It  is  not  needful  to  speak  at  length  and  separately  of  this  step, 
as  it  is  a  mere  extension  of  the  operation  for  ligature  of  the  third  part,  the 
muscle  also  being  only  divided  in  part.  Mr.  Poland  ^  points  out  that,  of 
eight  cases  in  which  the  scalenus  was  partially  divided,  five  recovered, 
and  that  of  these  five  recoveries  the  operation  was  on  the  left  side.  These 
cases  thus  fully  prove  that  a  ligature  may  be  placed  on  the  second  part  of 
the  artery  without  fear  of  want  of  thrombus  formation  or  of  injury  to 
important  parts.^ 


LIGATURE  OF  THE  FIRST  PART  OF  THE  SUBCLAVIAN  ^ 

As  this  operation  has  been  performed  by  surgeons  of  the  highest 
eminence,  and  as  it  affords  good  practice  on  the  dead  subject,  it  will  be 
given  here.  How  far  the  improvements  of  modern  surgery,  aided  by 
recently  introduced  ligatures  and  removal  of  the  inner  part  of  the  clavicle, 
will  ever  render  this  a  successful  operation,  and  meet  that  secondary 
haemorrhage  which  has  proved  so  fatal  from,  the  distal  side  of  the  ligature, 
owing  to  the  facility  with  which  the  numerous  collaterals  bring  in  blood  to 
this  spot,  remains  to  be  seen. 

Relations.  These,  owing  to  the  great  depth  of  the  artery  on  the  left 
side,  must  be  given  separately. 

^  Loc.  supra  cit..  p.  128. 

2  As  shown  by  Mr.  Poland,  the  remarks  of  Porter  on  the  numerous  and  great  perils 
of  this  operation  are  scarcely  borne  out,  viz.  the  phrenic  on  the  scalenus  anticus  ;  the 
thoracic  duct  Ipng.  on  the  left  side,  at  the  inner  edge  of  the  muscle  ;  the  three  large 
branches  usvially  given  off  by  the  subclavian  while  between  the  scaleni ;  and  the  close 
proximity  of  the  first  dorsal  nerve  behind  the  artery. 

*  These  remarks  refer  chiefly  to  the  right  subclavian.  A  ligature  has  certainly  once 
been  placed  on  the  first  part  of  the  vessel  on  the  left  side.  Dr.  Rodgers,  of  New  York, 
being  the  operator,  and  losing  his  patient  from  hsemorrhage  on  the  fourteenth  day.  Sir 
J.  E.  Erichsen  {loc.  supra  cit.)  states  that  Sir  A.  Cooper  failed  in  an  attempt  to  secure 
the  vessel,  and  that  he  is  said  to  have  wounded  the  thoracic  duct. 


708  OPERATIONS  OX  THE  HEAD  AND  NECK 

In  Front 
Skin  ;  fasciae. 

Steruo-mastoid  ;   sterno-liyoid  ;   sterno-thyroid. 
Internal  jugular  and  (often)  vertebral  vein. 
Vagus  ;  phrenic  ;   cardiac  nerves. 
O 
Right  subclavian  (first  part). 

Bell  ind 

Recurrent  laryngeal ;   sympathetic. 
Longus  colli ;  pleura  (and  beneath). 

In  Front 

Sterno-mastoid  ;  sterno-hyoid  ;  sterno-thyroid. 
Pleura  ;  lung. 

Vagus  ;  phrenic  ;  cardiac  nerves. 
Internal  jugular  ;  innominate  veins. 
Common  carotid. 
Outside  O  •  hiside 

Pleura.  Left  subclavian  (fii'st  part).     Trachea. 

(Esophagus ;  thoracic 
duct. 
Beh  ind 

Sympathetic. 

(Esophagus  ;   thoracic  duct. 

Longus  colli. 

Operation.  This  resembles  ligature  of  the  innominate.  The  follow- 
ing account  is  taken  from  Mr.  Barwell  ^ : 

A  triangular  flap  having  been  turned  upwards  and  outwards,  and  both  heads  of 
the  sterno-mastoid  divided,  the  anterior  and.  if  needful,  the  external  jugular  veins 
are  secured  with  double  chromic-gut  ligatures  and  divided.  The  fascia  over  the 
sterno-hyoid  being  exposed.  "  the  director,  after  a  little  opening  in  the  aponem-osis 
has  been  made,  can  be  insinuated  beliind  that  muscle,  which  also  must  be  severed. 
It  is  well  now  to  look  and  feel  for  the  carotid  artery  before  going  on  to  divide  the 
sterno-tlnToid.  whose  outer  edge  covers  that  vessel,  and  never,  as  far  as  my  experi- 
ence of  the  dead  subject  goes,  conceals  the  subclavian. "  -  The  finger  of  the  operator, 
after  division  of  the  sterno-hyoid.  readily  detects  the  longitudinal  course  and 
pulsation  of  the  carotid,  and  may  with  ease  push  the  edge  of  the  sterno-thyroid 
from  off  its  sheath  inward,  in  which  position  the  muscle  should  be  held  with  a  bhmt 
hook.  When  the  sheath  of  the  vessel  is  thus  brought  into  view,  the  operator 
should  look  for  the  large  veins  that  always,  but  more  especially  if  there  have  been 
dyspnoea,  overlie  it.  Choosing  a  vacant  spot,  he  merely  nicks'^  the  loose  structure 
in  which  they  lie.  and  then  pushes  them  up  and  down,  tearing  the  cellular  tissue  a 
little,  till  the  dense  fibrous  sheath  is  bared  sufficiently  first  to  have  a  small  opening 
made  in  it,  and  then  to  be  slit  up.  This  should  be  done  on  the  front  and  iimer 
aspect.  Now,  at  this  part,  the  vein  diverges  a  little  from  the  artery,  so  as  to  leave 
a  triangular  interval,  through  which  the  vagus  rmis.     A  blunt  hook  is  placed  over 

^  Intern.  Encycl.  Surg.,  vol.  iii,  p.  513. 

'  '■  The  mere  division  of  the  muscle  is  in  itself  unimportant,  but  there  lies  behind  it 
a  plexus  of  large  veins,  passing  from  the  thjToid  body  to  the  internal  jugular,  generalliy 
distended  by  the  dyspnoea,  accompanying  anenrj-sm  at  the  root  of  the  neck.  Their 
division  causes  profuse  bleeding,  and  subsequent  difficulty  in  recognising  the  deeper 
parts." 


LIGATURE  OF  THE  SUBCLAVIAN  709 

this,  and  it  is  to  be  drawai  with  the  jugular  vein  gently  outward.  The  next  point 
is  to  tind  the  subelavian.  'J'o  do  this  the  0])enitor  must  renieuiber  that  the  usual 
deserij)tion  and  delineation  of  the  innominate  bifunietion  is  ineorrect.  It  is 
generally  depicted  as  if  the  two  branches  rose  sitle  by  side  and  almost  at  right 
angles  to  each  other.  In  reality,  the  suljclavian  springs  behind  the  carotid,  and 
the  angle  between  the  two  vessels  is  very  acute.  Therefore,  to  detect  the  sub- 
elavian, tile  operator  nuist  place  his  finger  at  the  back  and  outer  jiart  of  the  carotid 
when,  passing  it  down,  he  comes,  generally  a  few  lines  above  the  clavicle,  to  the 
slightly  divergent  pulsating  line  of  the  subclavian,  whicli  lies  deeper  than  the 
carotid  by  the  whole  diameter  of  that  vessel. 

In  selecting  the  spot  for  placing  the  ligature,  it  is  well  not  to  put  it  quite  close 
to  the  bifurcation,  but  also  not  too  near  the  scalcni,  lest  the  recurrent  laryngeal 
or  the  phrenic  should  be  injured.  The  vagus  and  the  jugular  vein  should  be  kept, 
not  too  forcibly,  outwards,  and  the  needle  should  be  passed  from  below,  while  with  his 
left  forefinger  the  surgeon  gently  presses  the  pleura  downwards  and  outwards. 
Some  obstruction  behind  the  artery  will  very  likely  be  encountered,  but  it  is  better 
gently  and  patiently  to  overcome  this,  and  never  on  any  account  to  attempt  to 
pass  the  needle  the  other  way  ;  for  if  this  be  attemi)ted  the  instrument  is  certain 
to  penetrate  the  pleura.  Having  now  passed  and  tied  the  ligature,  the  surgeon 
should  consider  the  advisability  of  also  securing  the  vertebral.  It  lies  in  the  groove 
between  the  longus  colli  and  scalenus,  so  that  the  jugular  vein  must  now  be  held 
inwards  ;  the  dissection  already  made  will  have  so  nearly  exposed  the  artery  that 
a  few  touches  with  a  director  will  lay  it  sufficiently  bare  to  allow  the  passage  of 
the  needle.  The  position  of  the  phrenic  nerve  on  the  anterior  scalene,  outside 
and  a  good  deal  in  front  of  the  vessel,  guards  it  against  much  risk  of  injury,  but 
still  it  must  be  carefully  avoided.  The  operator  must  not  mistake  the  inferior 
thyroid  (which  is,  however,  much  smaller,  and  usually  at  this  part  external)  for 
the  vertebral^  itself. 

As  Mr.  Stonham's  case  of  ligature  of  the  first  part  of  the  left  sub- 
clavian for  aneurysm  of  the  fii'st  and  second  parts  of  this  vessel  ^  is  one 
of  the  few  cases  in  which  this  operation  has  been  completed  and  ended 
successfully,  the  following  details  are  given.  They  emphasise  in  the 
strongest  way  the  need  of  removing  the  inner  part  of  the  clavicle  in  these 
cases  (p.  717).  The  patient  being  in  the  usual  position,  with  shoulders 
raised,  "  a  vertical  incision  about  six  inches  long  was  made  parallel  to  the 
sternal  head  of  the  sterno-raastoid,  the  centre  being  over  the  sterno- 
clavicular joint.  In  its  lower  half  the  incision  was  carried  right  down 
to  the  sternum  ;  a  second  incision  was  then  made  along  the  inner  half  of 
the  clavicle,  the  knife  being  here  also  carried  down  to  the  bone.  The 
inner  part  of  the  clavicle,  for  about  an  inch  and  a  half  isolated  subperi- 
osteally  while  the  deeper  parts  were  protected,  was  removed.  The  floor 
of  the  wound  was  now  seen  to  consist  of  a  portion  of  the  clavicular  peri- 
osteum, a  layer  of  the  deep  cervical  fascia,  and  muscular  tissue.  By 
means  of  two  pairs  of  dissecting-forceps  the  outer  edge  of  the  muscular 
layer  was  clearly  defined,  the  muscles  being  the  sterno-hyoid  and  sterno- 
thyroid ;  these  were  drawn  inwards.  Further  blunt  dissection  revealed 
the  carotid  running  vertically  upwards  along  the  inner  border  of  the 
wound,  which  was  now  becoming  very  deep.  On  the  outer  side  and 
below  was  the  dome  of  the  pleura,  covered  by  the  jimction  of  the  sub- 
clavian and  internal  jugidar  and  a  short  piece  of  the  left  innominate  vein. 
These  veins  were  drawn  carefully  do\^^l wards  and  outwards,  when,  deeply 
behind  them,  about  two-thirds  of  an  inch  of  the  subclavian  artery  was 
revealed,  surrounded  by  a  little  loose  fat.  The  thoracic  duct  was  not  seen, 
nor  any  veins  or  nerves  other  than  those  mentioned."  The  artery  was 
now  tied  with  little  difficulty  by  means  of  a  ligature  of  salicylic-acid  floss 

^  In  certain  eases  the  aneurysmal  sac  overlying  the  vertebral  artery  renders  it  in- 
accessible. 

-  Lancet,  August  2,  1902. 


710  OPERATIONS  ON  THE  HEAD  AND  NECK 

silk  passed  from  within  outwards  by  means  of  an  ordinary  aneurysm- 
needle.  The  hgatuxe  was  tied  with  a  surgeon's  knot,  only  sufficient  force 
being  used  to  occlude  the  vessel. 

Within  two  months  of  this  skilfully  performed  operation  the  aneurysm 
was  again  enlarging  and  pulsating.  By  means  of  an  incision  similar  and 
a  little  external  to  the  first,  a  triangular  flap  was  turned  outwards  and 
upwards.  "The  remains  of  the  clavicular  head  of  the  sterno-mastoid 
were  drawn  outwards  and  the  internal  jugular  vein  exposed.  Blunt 
dissection  external  to  the  vein  exposed  the  anterior  scalenus  and  phrenic 
nerve.  The  jugular  vein  was  drawTi  inwards,  and  the  muscles  our-wards. 
The  transverse  process  of  the  sixth  cer\'ical  vertebra  was  exposed.  A 
vsssel  of  no  great  size  was  now  defined  in  the  position  of  the  vertebral 
artery,  and  was  ligatured  \Aath  silk  ;  the  ligature  unfortunately  broke, 
chviding  the  vessel,  which  was  secured  with  cUfficulty,  and  tied  at  both 
ends.  No  other  vessel  could  be  fomid  in  this  situation,  though  the  fora- 
men through  the  transverse  process  could  be  clearly  defined.  A  second 
vessel,  the  inferior  thyroid  artery,  was  also  tied."  As  ligature  of  these 
two  vessels  did  not  arrest,  though  it  materially  diminished,  the  pulsation 
in  the  sac,  a  distal  hgature  was  applied  to  the  third  part  of  the  axilJaiy 
just  above  the  subscapular  branch.  Complete  arrest  of  pulsation  followed. 
The  aneurysm  was  eventually  completely  cured.  Mr.  Stonham  saw 
his  patient  nearly  three  years  later,  when  he  continued  quite  well,  and 
was  doing  light  work  as  a  carpenter. 

Ligature  of  the  Internal  Mammary  Artery.  The  internal  mammary  artery, 
a  branch  of  thetirst  part  of  the  subcla^aan,runs  dowTiwards  a  short  distance  to  the 
outer  side  of  the  external  border  of  the  sternum.  Behind  it  rests  upon  the  pleura, 
while  in  front  of  it  are  the  cartilages  of  the  upjier  six  ribs,  the  intercostal  muscles, 
and  below,  the  triangularis  sterni.  It  thus  crosses  the  anterior  ends  of  the  inter- 
costal spaces  about  half  an  inch  from  the  sternum.  This  vessel  may  have  to  be 
secm-ed  for  haemorrhage  after  a  stab,  or  it  may  be  injured  during  an  osteoplastic 
resection  of  the  sternum  or  ribs.  It  is  occasionally  set  as  an  operative  surgery  test. 
A  transverse  incision  is  made,  about  two  inches  in  length,  with  the  centre  just 
external  to  the  margin  of  the  sternum,  in  the  line  of  the  selected  intercostal  space. 
The  anterior  intercostal  membrane,  the  internal  intercostal  muscle,  and  the  layer 
of  fascia  on  the  deep  aspect  of  this  are  divided,  and  the  vessel  accompanied  by  its 
companion  veins  \rill  then  be  found  resting  upon  the  pleura.  Care  must  be  taken 
not  to  damage  the  latter  structure. 


LIGATURE  OF  THE  INNOMINATE 

There  have  certainly  been  over  twenty  cases,  and  in  only  about  five 
have  the  patients  survived. 

One  of  these  is  the  well-known  case  of  Dr.  Smyth's,  of  New  Orleans,^ 
which  occurred  before  the  days  of  antiseptic  surgery.  The  second,  under 
the  care  of  Sir  W.  Mitchell  Banks,  has  never  been  pubUshed.  A  third 
successful  case  of  ligature  of  the  innominate  has  been  pubhshed  by 
Dr.  Lewtas,  of  the  Indian  Medical  Service. ^  The  subclavian  aneurysm 
here  was  a  traumatic  one  of  only  a  month's  duration,  the  artery  was 
healthy,  and  the  patient  only  20. 

A  month  before  his  admission  a  jiiece  of  the  breech  of  a  bursting  gun  had  lodged 
above  the  right  clavicle.  A  swelling  about  the  size  of  a  fcetal  head  occupied  the 
lower  part  of  the  posterior  triangle,  hard  to  the  touch  and  not  pulsating.  From 
a  partially  healed  wound  brownish  blood  had  been  oozing  for  three  days.     As  the 

1  St/fL  Hoc.  Bien.  Betr.,  1865-6,  p.  .346. 
^  Bril.  Med.  Journ.,  1889,  vol.  ii.  p.  .'512. 


LIGATURE  OF  THE  INNOMINATE  711 

man  was  anxious  for  removal  of  the  foreign  body,  and  as  the  case  seemed  to  be 
one  of  deep  cervical  suppuration,  the  opening  was  enlarged  sufficiently  to  admit 
the  little  Hnger,  and  a  fragment  of  steel,  weighing  three  drachms,  removed  with 
dressing-forceps.  This  was  followed  by  an  alarming  rush  of  blood,  so  ])rofuse  as 
to  render  im})ossible  discovery  of  the  bleeding-point.  Fortunately  the  finger 
detected  the  opening  in  the  subclavian  behind  the  scalene,  and  by  pressure  an 
assistant  thus  arrested  the  haemorrhage.  The  man's  condition  being  desperate, 
it  was  decided  to  tie  the  innominate  and  carotid.  This  was  done  by  an  incision 
along  the  inner  border  of  the  sterno-mastoid  and  notching  the  sterno-hyoid  and 
sterno-thyroid.  The  two  vessels  were  secured  with  catgut  ligatures.  A  drainage- 
tube  was  inserted  into  the  extensive  cavity  of  the  original  wound,  some  of  the 
coagula  which  filled  this  being  removed.     The  patient  made  a  good  recovery. 

Mr.  Coppiuger  ^  briefly  mentions  a  case  in  which  he  successfully  tied 
the  innominate  for  a  large  subclavian  aneurysm.  A  vertical  incision  was 
employed,  and  silk  was  used  for  the  hgatiu'e.  The  patient  was  seen  at 
St.  Bartholomew's  Hospital  two  and  a  half  years  afterwards,  and  was  quite 
free  from  any  trace  of  his  aneurysm  (Sheen). 

Another  brilHantly  successful  case,  and  one  most  encouraging  to  the 
surgeon,  was  under  the  care  of  Mr.  C.  J.  Symonds,  who  supplied  the 
folio ^\dng  notes. 

G.  McCaim,  aged  53,  was  admitted  October  1894  for  a  subclavio-axillary 
aneurysm.  The  most  prominent  part  of  the  sac  was  just  below  the  clavicle.  The 
whole  of  the  supraclavicular  space  was  filled,  and  the  pulsating  swelling  extended 
backwards  under  the  trapezius  to  the  scapula.  It  was  just  possible  to  limit  the 
swelling  at  the  border  of  the  sterno-mastoid.  Fearing  that  the  artery  would  be 
unhealthy^  in  its  second  part,  it  was  decided  to  attempt  to  ligature  the  first  part 
of  the  subclavian,  and  if  this  proved  difficult  or  impossible,  to  secm-e  the  imiominate. 
On  November  5  a  vertical  incision  was  made  between  the  two  heads  of  the  sterno- 
mastoid  muscle,  and  without  much  trouble  the  first  part  of  the  subclavian  was 
identified.  On  attempting  to  pass  the  needle,  a  short  sharp  gush  of  blood  occurred, 
which  stopped  on  withch-awing  the  needle.  A  fui'ther  dissection  of  the  artery  was 
made,  but  again,  on  passing  the  needle,  the  haemorrhage  was  repeated  with  greater 
force.  Pressure  of  the  finger  stopped  it  at  once,  and,  though  the  pressm-e  was 
removed,  the  haBmorrhage  was  not  repeated.  As  apparently  some  large  branch  of 
the  thyroid  axis  was  injured,  it  was  decided  to  Ugatm'e  the  innominate.  The  sternal 
head  of  the  sterno-mastoid  was,  therefore  divided,  and  an  incision  made  in  the 
median  line.  Thus,  there  were  two  vertical  incisioixs  joined  by  a  transverse  one 
along  the  inner  third  of  the  clavicle.  The  sterno-hyoid  and  thyroid  were  divided, 
and  subsequently  sutui-ed  with  catgut.  The  common  carotid  was  easily  reached, 
and  surrounded  with  a  silk  ligature.  Slight  traction  was  then  nuide  upon  this  : 
the  begimiing  of  the  subclavian  was  identified,  and  then  the  imiominate  brought 
into  view.  This  was  secured  by  a  silk  ligature  and  the  wound  closed.  The  muscles 
were  sutui-ed  with  chromic  gut.  The  ligature  was  of  stout  floss  silk.  After  a  few 
daj's  two  openings  appeared,  one  over  the  imier  end  of  the  clavicle  and  one  in  the 
first  vertical  incision.  Through  both  of  these  several  pieces  of  catgut  came  away, 
and  one  piece  of  silk.  The  man  made  otherwse  an  uninterrupted  recovery, 
the  pain  gradually  disappeared,  and  the  aneurysm  became  quite  Jiard.  When 
seen  in  June  1895  the  usefulness  of  the  hand  and  arm  was  gradually  retm-uing  ; 
the  aneurysmal  sac  was  hard,  but  still  obvious.  There  was  no  pulsation  in  the 
brachial  or  i-adial.     Pulsation  could  be  felt  in  the  carotid  above  the  ligatm'e. 

Dr.  H.  L.  Burrell  published  ^  a  carefully  reported  case  of  Ugatm'e  of 
the  innominate  for  a  fusiform  aneurysm  of  the  right  subclavian  and  in- 
nominate. As  in  this  case  death  occurred  from  carcUac  collapse  (the 
heart  being  dilated  and  hypertrophicd)  three  months  after  the  operation, 
the  wound  having  healed  in  seventeen  days,  it  must  be  considered  a 
successful  one. 

1  Lancel,  1893,  p.  243. 

*  Boston  Med.  and  Surg.  Journ.,  August  8,  1895. 


712  OPERATIONS  OX  THE  HEAD  AND  NECK 

The  following  points  are  of  much  interest  :  (1)  The  inner  end  of  the  clavicle, 
the  sterno-clavicular  joint,  and  the  right  half  of  the  notch  of  the  sternum  for  about 
an  inch,  were  removed  (p.  717).  (2)  The  fasiform  aneurysm  of  the  subclavian  and 
carotid  extended  on  to  the  innominate  itself,  sufficient  space  being  left  to  place  a 
ligature  between  this  fasiform  extension  and  the  aorta.  Two  ligatines  of  flat- 
braided  silk  were  used.^  The  first  was  placed  three-quarters  of  an  inch  from  the 
aorta.  Both  were  tied  in  "  square  knots."  Fully  three  minutes  were  taken  in 
tying  the  first  ligature,  this  being  gradually  tightened  until  the  circulation  was 
completely  cut  off.  The  second  ligature  was  placed,  in  the  same  manner,  half  an 
inch  higher  uji.  As  each  ligature  was  tightened  the  coats  were  felt  to  give  way. 
At  the  necropsy  the  innominate  showed  an  extreme  degree  of  endarteritis.  The 
artery  was  occluded  by  the  upper  ligature  ;  by  the  lower  one  it  was  severed,  con- 
secutive healing  along  the  line  of  severance  having  taken  place.  Continuity  of  the 
lumen  of  the  artery  had  followed  here,  and  the  ligature  was  found  within  the  vessel, 
probably  covered  by  a  thin  layer  of  the  intima.  While  the  fusiform  aneurysm 
had  shrunk,  very  little  clot  had  formed  at  the  site  of  the  ligatiue.  For  this  reason 
'Mi.  Bmrell,  in  another  case  of  fusiform  aneurysm  in  this  situation,  would  tie  the 
carotid,  if  possible  the  subclavian  in  its  first  part,  and,  if  practicaWe,  the  vertebral. 
It  is  noteworthy  that  the  operation  took  an  hour  and  a  half,  and  that  though  the 
patient,  with  general  arterio-sclerosis  and  a  dilated  and  enlarged  heart,  was  under 
the  influence  of  ether  all  this  time,  no  ill  effect  followed. 

The  extreme  danger  of  the  operation  is  due  partly  to  difficulties  which 
may  be  met  with  at  the  time  of  its  performance — difficulties  which  have 
driven  most  skilful  surgeons  to  abandon  the  operation^ — but  chiefly  to  the 
frequency  of  secondary  haemorrhage. 

Sir  W.  M.  Banks'  case  terminated  in  death  from  hfemorrhage  on  the 
thirty-seventh  day  after  hgature  of  the  first  part  of  the  subcla\aan,  sub- 
sequent to  ligature  of  the  innominate.  The  patient,  a  man  aged  -50,  had 
a  well-marked  aneurysm  of  the  third  part  of  the  right  subclavian.  The 
common  carotid  was  also  tied.  Mr.  Jacobson's  case,  fatal  on  the  tenth 
day  from  exhaustion  brought  on  by  incessant  restlessness  in  an  alcohohc 
patient,  with  probably  some  infection  of  the  wound,  is  described  at  p.  719. 

Two  more  recent  cases,  each  finally  successful  after  other  operations 
which  emphasise  the  gravity  of   this  condition,   must  be  alluded  to. 

They  are  recorded  by  Mr.  Sheen,  of  Cardiff,^  and  Dr.  B.  F.  Curtis.^ 
Mr.  Sheen's  paper  contains  full  references  to  other  cases. 

ISIr.  Sheens  patient  was  46.  The  aneurysm  affected  the  second  and  third  parts 
of  the  right  subclavian.  The  innominate  was  reached  by  a  five-inch  median 
incision,  without  removal  of  bone,  and  the  vessel  tied  with  stout  floss  silk  (Xo.  2 
pearl  silk)  passed  double  roruid  the  arterj'  and  tied  by  Ballance  and  Edmunds's 
stay-knot.  The  carotid  was  also  tied.  Pulsation  retmning  in  the  anemysm,  an 
unsuccessful  attempt  was  made  about  six  weeks  later  to  again  tie  the  imiominate. 
After  another  interval  of  a  fortnight,  the  second  part  of  the  subclavian  was  ligatm-ed 
with  Xo.  4  Chinese  t^"ist  tied  in  a  surgical  knot.  The  aneurysm  consolidated,  and 
the  patient  was  well  eight  months  after  the  first  operation. 

In  Dr.  Curtis  s  case  a  free  median  incision  was  made,  the  manubrium  sterni 
divided  in  the  middle  line  and  transversely  above  the  right  second  rib.  The  in- 
nominate was  tied  with  a  double  stout  chromic  gut  ligature,  the  inner  coat  not 
being  chvided  ;  a  single  similar  ligature  was  placed  a  quarter  of  an  inch  distally 
to  the  first.  Pulsation  returned  four  days  later.  About  three  months  later  the 
carotid  and  first  part  of  the  subclavian  were  tied  ;  the  imiominate  was  impervious, 
the  pulsation  in  the  sac  being  attributed  to  some  branch  of  the  first  part  of  the 
subclavian.  When  last  seen,  eleven  months  later,  the  patient  was  well  and 
apparently  cined  of  his  aneurysm. 

Whatever  material  he  employs,  the  surgeon  must  have  several 
ligatures  reliably  sterilised,  as  their  breaking  is  still  an  accident  to  be 
prepared  for. 

^  Two  ligatures  are  considered  necessary,  "  one  to  act  as  a  breakwater  by  obstructing 
the  eonstantlv  recurring  waves  of  blood  coming  from  the  aorta." 

2  Ann.  of  Surg.,  July  1905.  ^  Ibid.,  October  1(X)1. 


LIGvVTURE  OF  THE  INNOMINATE  713 

With  jci^Mid  to  the  best  material  lor  /igatiiie  in  these  cases  where  the 
artery  is  perhu^js  diseased,  where  the  blood  will  be  driven  against  it  with 
nuicli  loi-ce,  as  it  was  pointed  out  in  the  last  edition  of  this  book,  Mr. 
Symonds's  and  Mr.  Coppinger's  successful  cases  with  silk  have  gone  far 
to  help  on  this  point.  Mr.  Sheen's  case,  successful  with  a  silk  ligature, 
corroborates  this  view,  and  gives  weight  to  his  remarks:  "  Too  much 
importance  has  been  attached  to  the  question  of  the  best  material  for 


FiiJ.  292.  Artery  ligatured 
with  kangaroo-tendon  (X3) 
without  rujjture  of  its  coats. 
to  show  the  folds  into  which 
the  wall  of  the  artery  is  thrown 
by  a  kangaroo-tendon  ligature 
when  the  coats  are  uninjured. 
Transverse  section  made  im- 
mediately above  the  ligature ; 
there  are  three  main  folds, 
the  middle  or  largest  of  which 
is  under  the  knot. 


Fig.  29.3.  'J'he  same  artery  opened  out  by 
a  longitudinal  incision  passing  through  the 
knot  and  the  artery  wall  beneath  it.  The 
arrow  in  the  left  figure  indicates  the  line 
through  which  this  incision  was  made.  The 
knot  is  seen  cut  in  two,  and  the  folds  of  the 
artery  wall  are  exposed,  the  largest  being 
divided  and  the  halves  turned  aside.  Each 
fold  has  secondary  folds,  indicated  by  the 
longitudinal  lines  on  their  surface. 
(Ballance  and  Edmunds.) 


ligature,  fatal  results  having  been  attributed  to  defects  in  the  ligature, 
when  they  have  really  been  due  to  infection  at  the  site  of  ligature.  Silk, 
as  being  strong  and  certainly  steiihsable,  is  the  best  material.  Whether 
floss-silk  or  Chinese  twist  does  not  matter."  While  success  has  been 
obtained  by  a  few  operators  with  different  ligatures  tied  in  different  ways, 
when  we  turn  to  the  results  of  experiment  we  are  struck  by  the  diametric- 
ally opposite  conclusions  at  w^hich  workers  have  arrived  as  to  the  most 
useful  form  of  ligature  and  the  best  means  of  tying  it. 

This,  shown  by  the  papers  of  IMi-.  Ballance  and  Mr.  Edmunds,  "The  Ligation 
of  the  Larger  Arteries  in  their  Continuity :  an  Experimental  Inquiry  "  ^  ;  "  Ligation 
of  the  Great  Arteries  in  Continuity,  with  Observations  on  the  Natiu-e,  Progress 
and  Treatment  of  Aneurysm"  (1891);  and  ]VIr.  Spencer's  "  Experiments  on 
Ligation  of  the  Innominate  "  ~  The  first-named  wTiters  have  arrived  at  the  following 
conclusions  :  (1)  That  the  operation  of  ligature  of  a  large  artery  in  its  continuity 
should  be  performed  without  danger  to  its  wall.  (2)  That  the  ruptiu-e  of  the  coats  of 
an  artery  during  ligation  in  contmuity  is  a  useless  and  dangerous  proceeding  :  useless, 
because  the  surgeon  can  secure  the  effectual  occlusion  of  the  vessel  by  a  measure 
at  once  safer  and  less  severe  ;  and  dangerous,  on  account  of  the  possible  occurrence 
of  haemorrhage  or  secondary  aneurysm  at  the  seat  of  ligature,  which  could  not 
happen  if  the  wall  of  the  vessel  were  uninjured  by  the  ligature.  (3)  That,  if  the 
artery  be  diseased,  the  advantages  attenchng  ligation  without  ruptui-e  of  the  tunics 
are  much  magnified.  It  sometimes  happens  that  the  surgeon,  on  cutting  down 
upon  a  large  artery,  observes  a  state  of  atheroma  so  extensive  that  he  is  obliged 

1  Med.-Chir.  Trans.,  1886,  p.  443. 

2  Brit.  Med.  Journ.,  1889.  vol.  ii,  p.  73. 


714  OPERATIONS  ON  THE  HEAD  AND  NECK 

to  close  the  wound  and  ligate  a  vessel  nearer  the  heart,  and  thus  expose  his  patient 
to  considerably  increased  risk.  There  is  no  escape  from  such  a  dilemma  under  the 
system  which  declares  that  the  arterial  coats  must  be  divided  ;  but  with  a  non- 
irritating  aseptic  ligatiu-e,  so  applied  as  not  to  lessen  the  power  of  the  arterial  wall, 
but  actually  to  be  a  som-ce  of  adchtional  strength  to  it,  the  question  of  ligation  is 
seen  under  entirely  new  auspices,  and  the  occlusion  of  a  diseased  artery  would  be 
undertaken  -with  an  assurance  of  success  almost  equal  to  that  which  obtains  when 
a  healthy  vessel  is  in  question.  (4)  That,  when  the  coats  of  an  artery  are  uninjm-ed 
by  the  ligature,  the  danger  of  ligation  near  a  large  collateral  branch  is  wholly 
avoided,  because  (a)  no  danger  can  accrue  from  hemorrhage  when  the  wall  of  the 
vessel  is  intact  ;   (b)  the  formation  of  clot,  upon  which  the  safety  of  the  patient  so 


Fig.  294.  Floss-silk  stay-knot  (first 
stage).  Represents  two  'floss-silk  liga- 
tures side  by  side  (X4).  The  fu'st  half  of 
a  reef-knot  is  tied  on  each  in  the  same 
way.  The  two  ends  on  either  side,  being 
treated  as  one,  are  diawn  upon  to 
occlude  the  vessel.  The  hitches  lie  at 
the  bottom  of  a  deep  groove,  and  are 
seen  to  fit  into  one  another. 


Fio.  295.  Floss-silk  stay-knot  (com- 
pleted). Shows  the  knot  comi)leted  by 
using  the  two  ends  on  each  side  as  a 
single  cord,  and  by  tjang  the  second 
hitch  as  if  completing  an  ordinary  reef- 
knot.  The  ligatures  maj'  also  be  tied 
separately. 


(Ballance  and  Edmunds.) 

much  depends  if  the  wall  of  the  vessel  be  damaged,  has  realty  nothing  to  do  with 
the  adhesive  changes  which  take  place  in  a  ligatiu:ed  vessel  ;  (c)  the  plastic  actions 
which  proceed  at  the  place  of  ligation  are  practically  alike,  whether  the  tmiics  be 
rujitiu-ed  or  not.  (5)  It  would  appear  that  a  small  round  antiseptic  ligature  which 
will  not  become  absorbed  in  less  than  three  weeks,  and  which  during  tliat  period 
holds  lirmly  so  as  to  cause  a  constriction  of  the  arterial  wall,  and  complete,  or 
almost  complete,  obstruction  of  the  cavity  of  the  vessel,  will  so  influence  the 
nutrition  of  the  part  that  permanent  occlusion  will  follow.  It  is  pointed  out  that 
by  tlie  use  of  two  ligatures  a  gi-eater  length  of  the  intima  of  opposite  sides  is  brought 
into  contact.  (6)  That  it  is  no  more  necessary  to  use  a  flat  tape-shaped  ligatm-e 
(as  revived  by  Mr.  Barwell  to  prevent  damage  to  the  arterial  coats  during  ligation) 
than  to  rupture  the  coats  of  the  vessel.  The  small  round  ligatm'e  is  the  most  easy 
to  manipulate,  and  it  is  not  difficult  to  learn  to  apply  it  in  the  manner  here  indicated. 
Mr.  Sheen  is  inclined  to  take  the  opposite  view  with  regard  to  the  degree  of  tight- 
ness with  which  the  ligature  shovdd  be  tied.  "  Injury  to  the  imier  coats  becomes 
a  dangerous  factor  only  when,  in  adchtion  to  such  injm-y,  sepsis  is  present."  ]Mr. 
Sheen  places  in  order  of  preference  the  methods  suitable  for  occlusion  of  the  in- 
nominate as  follows  :  (a)  Two  separate  ligatures  tied  with  the  special  object  of 
preventing  the  first  hitch  slipping,  which  is  probably,  to  a  large  extent,  brought 
about  by  the  force  of  the  blood  pumped  from  the  aorta.  Two  strands  are  passed 
beneath  the  vessel  if  possible  half  an  inch  or  more  apart.  The  first  tui'n  of  a  surgical 
or  reef-knot  is  then  made  in  the  proximal  ligature  and  tightened,  pulsation  ceasing 
in  the  vessel  beyond  and  in  the  aneurysm.  This  first  turn  in  the  proximal  ligature 
is  then  held  tight,  and  the  force  of  the  pumping  blood  being  thus  taken  off  the 
part  of  the  vessel  encircled  by  the  distal  ligatm-e.  the  latter  is  completely  tied  by 
a  surgical  or  reef-knot.  Finally  the  second  tmn  is  taken  in  the  proximal  ligature 
and  fixes  it.  (&)  The  "  stay-knot."  (c)  A  single  ligatm-e  tied  in  a  surgical  knot. 
Some  amount  of  damage  to  the  inner  coats  would  be  particular!}-  essential  in  the 
last  method. 


LIGATURE  OF  THE  INNOMINATE  715 

Mr.  Si)encer,  from  his  results  of  ligature  of  the  innominate  in  monkeys,  also 
advises  silk,  concluding  that  the  best  ligature  is  one  of  Chinese  twist  silk  which  has 
been  kept  in  five  ix-r  cent,  carbolic  acid,  and  boiled  in  that  solution  before  being 
used.  A  silk  ligature  can  be  thus  '•  rendered  more  thoroughly  aseptic  than  any 
other  without  injuring  its  strength,  and,  being  aseptic,  it  will  remain  quiet  in 
position  witlioiit  relaxing.  The  ligature  should  be  tied  tight  to  divide  the  internal 
coats.'' 

The  Question  of  using  Drainage.  If  all  oozing  can  be  stopped  and 
the  wound  be  left  dry,  it  should  be  completely  closed.  If  any  oozing  were 
going  on  it  should  be  drained  either  by  a  strip  of  steiile  gauze  or  by  a 
small  drainage-tube. 

As  to  selection  of  cases,^  the  following  words  of  Mr.  Holmes  ^  should  be 
remembered.  The  operation  "  should  never  be  performed,  however, 
unless  the  artery  can  clearly  be  felt  healthy  behind  the  sterno-clavicular 
joint,''  or  the  tumour  is  so  plainly  limited  as  to  afford  a  very  reasonable 
hope  that  it  will  be  found  so.  In  cases  of  tubular  enlargement  of  a  long 
tract  of  artery  in  the  neck,  it  is  more  than  useless  to  expose  an  artery 
wliich  will  probably  be  found  so  diseased  as  either  to  prevent  the  operator 
from  the  attempt  to  tie  it,  or  to  give  way  and  occasion  fatal  bleeding  \s-ithin 
a  few  hours  if  it  be  tied." 

The  following  are  amongst  the  precautions  indicated  : 

(1)  Rigid  aseptic  precautions  persevered  with  till  the  wound  is  soimdly 
closed.  (2)  Use  of  a  reliable  ligature  in  securing  the  innominate,  probably 
diseased — viz.  one  of  sterile  kangaroo-tail  or  silk — ^sith  care,  if  possible, 
that  the  knot  is  not  a  hard  one  and  does  not  press  strongly  on  the  side 
towards  the  artery. 

(3)  Securing  the  carotid  artery  at  the  same  time.  By  this,  in  Mr. 
Spencer's  words,  "  a  thrombus  is  then  formed  in  the  proximal  end  of  the 
carotid,  which  extends  to  the  bifurcation,  and  thus  aids  a  thrombus  in 
forming  in  the  first  part  of  the  subclavian  as  far  as  the  vertebral ;  other- 
wise the  blood-flow  will  pass  from  the  subclavian  to  the  carotid  close  by 
the  distal  side  of  the  ligature  of  the  innominate,  and  so  the  operation  will 
lack  one  of  the  important  characteristics  of  a  Hunterian  ligation.'' 
(4)  Obhterating  the  cavity  and  all  pockets  as  thoroughly  as  possible, 
after  every  care  has  been  taken  to  cheek  all  oozing  and  to  leave  a  dry 
wound,  so  as  to  prevent  formation  and  collection  of  discharges. 

(5)  Keeping  the  patient  absolutely  at  rest  till  the  wound  is  soundly 
healed,  morphia  being  used  subcutaneously,  and  any  tendency  to  cough 
checked  at  once  if  possible. 

Line  and  Guide.  The  vessel,  one  to  two  inches  long,  extends  along 
a  line  drawn  from  the  middle  of  the  junction  of  the  first  with  the  second 
bones  of  the  sternum  to  the  right  sterno-clavicular  joint  (Holden).  Its 
point  of  bifurcation  varies  somewhat. 

Relations : 

In  Front 

Sternum  ;   sterno-hyoid  ;  sterno-thvroid. 

Left  innominate  and  right  inferior  thyroid  vein. 

Inferior  cer\ncal  branch  of  right  vagus. 

1  A  radiographic  examination  will  afford  important  evidence  of  the  extent  of  the 
aneurysm,  especially  as  to  whether  the  innominate  arterj-  and  the  aorta  are  involved. 

-  Syst.  of  Surg.,  vol.  iii.  p.  112. 

^  As  Mr.  Holmes  remarks  in  a  footnote,  "  if  the  shape  of  the  bones  or  joints  is  altered, 
it  is  clear  that  the  aneurjsm  arises  in  the  thorax." 


716  OPERATIONS  ON  THE  HEAD  AND  NECK 

Outside  O  Inside 

Right  innominate  vein.        Innominate  artery.  Left  carotid. 

Right  vagus. 

Pleura. 

Behind 

Trachea. 

Collateral  Circulation.  This  is  thus  given  by  Sir  W.  MacCormac 
(Ligature  of  Arteries,  p.  75)  : 

Cardiac  Side  Distal  Side 

First  aortic  intercostal,         with     Superior  intercostal  of  subclavian. 

Upper  aortic  intercostals,     with     Thoracic   branches   of   axillary   and 

intercostals  of  internal  mammary. 

Phrenic,  with     Musculo-phrenic   of   internal   mam- 

mary. 

Deep  epigastric,  with     Superior  epigastric  of  internal  mam- 

mary. 

Free  communication  of  vertebrals  and  internal  carotids  of  opposite 
sides  inside  the  skull.  Communication  of  branches  of  opposite  external 
carotids  in  the  middle  line  of  the  face  and  neck. 

Operation.  The  patient  having  been  brought  into  as  satisfactory 
a  condition  as  possible  by  preparatory  treatment,  which  must  include 
the  leaving  off  for  some  days  all  lowering  treatment,  such  as  that  of 
Valsalva,  the  whole  area  of  the  operation  having  been  sterihsed  with 
scrupulous  care,  the  head,  body,  and  arm  are  placed  as  in  ligature  of  the 
subclavian  (p.  702).  The  surgeon,  standing  in  front,  makes  an  incision 
along  the  inner  half  of  the  clavicle,  and  another  along  the  anterior  border 
of  the  sterno- mastoid  and  upper  part  of  manubrium,  meeting  the  first 
at  an  acute  angle,  each  incision  being  four  inches  long.  The  flap  thus 
marked  out  having  been  dissected  up,  the  heads  of  the  sterno-mastoid 
and  the  sterno-hyoids  and  sterno-thyroids  are  divided.  This  incision  was 
made  use  of  by  Mott  when  he  tied  the  artery  in  1818.  The  fact  that  it 
had  been  employed  in  successful  cases  indicates  its  adoption  to  begin  with, 
but  the  surgeon  must  always  be  prepared  for  the  need  of  removing  part  of 
the  clavicle  and  manubrium.  The  above  incision  has  the  serious  disad- 
vantage of  dividing  muscles  which  retract  much  and  leave  a  large,  gaping, 
deep  wound,  the  difficulty  of  draining  which  has  already  been  alluded  to. 
Where  the  presence  of  a  large  aneurysm  with  one  or  more  processes  to 
its  sac  increases  enormously  the  difficulties  of  this  operation  and  thus  calls 
for  free  access  to  the  important  parts  dealt  with,  this  division  of  muscles 
will  be  found  needful.  Mr.  Spencer,  from  his  experiments  on  monkeys, 
advises  the  use  of  a  single  median,  vertical  incision,  made  as  if  for  a  low 
tracheotomy,  retracting  the  sterno-mastoid,  sterno-hyoid,  and  sterno- 
thyroid, opening  the  sheath  and  tying  the  carotid,  and  then  following  this 
down  as  a  guide  to  the  innominate.  He  argues  rightly  that  if  the  muscles 
be  retracted  only,  and  not  divided,  when  they  are  released  they  will  come 
together,  so  that  no  cavity  will  be  left  in  the  deeper  parts  of  the  wound. 
Sound  as  this  reasoning  is,  there  is  no  comparison  between  ligature 
of  the  innominate  in  monkeys  and  the  same  operation  under  the  con- 


LIGATURE  OF  THE  INNOMINATE  717 

ditions  wliich  usually  call  for  it  in  man.  Every  atom  of  room  will  be 
required,  not  only  on  account  of  the  importance  of  the  parts  dealt  with, 
the  great  enlaigement  of  the  veins,  the  presence  of  a  dilated  subclavian, 
a  process  of  the  aneurysm  extending  inwards,  or  a  hugely  expanded 
vertebral  as  in  the  case  mentioned  at  p.  702,  but  also  because  the  surgeon 
may  feel  bound  to  give  his  patient  the  benefit  of  a  less  risky  operation, 
and  thus  be  driven  to  divide  the  sterno-mastoid  in  order  to  examine  the 
fitness  for  ligature  of  the  second  part  of  the  subclavian. 

The  muscles  may  be  divided  in  a  case  of  any  real  difficulty,  at  a  point 
an  inch  and  a  half  above  the  clavicle.  If  they  are  divided  just  above 
this  bone  the  ends  retract  behind  it,  rendering  the  introduction  of  sutures 
impossible.  During  these  preliminary  steps  one  or  two  small  arteries 
may  be  divided  and  some  enlarged  veins  connected  with  the  inferior 
thyroids  drawn  aside  or  tied  with  double  ligatures  ;  and,  in  reflecting  the 
above-mentioned  flap,  the  presence  of  the  anterior  jugular  passing  out- 
wards beneath  the  sterno-mastoid  just  above  the  clavicle  must  be 
remembered. 

The  above  muscles,  when  cut,  being  carefully  held  out  of  the  way, 
and  a  layer  of  deep  cervical  fascia  varying  in  strength  divided,  the  pulsa- 
tion of  the  carotid  is  defined,  and  its  sheath  opened  to  the  inner  side  and 
as  low  down  as  possible.  Other  guides  will  be  found,  in  the  trachea  and 
the  subclavian  artery,  to  lead  the  finger  down  to  the  innominate. 

The  carotid  having  been  traced  down,  the  innominate  will  be  found 
bifurcating  into  the  carotid  and  subclavian.  It  is  now  that  the  real 
difficulties  may  be  met  with,  (f )  Owing  to  engorgement  of  the  venous 
circulation,  increased  by  the  ansesthetic,  the  internal  jugular  and  innomin- 
ate vein  may  be  so  much  enlarged  as  to  protrude  into  the  wound.  (2)  An 
aneurysm  may  have  extended  under  the  artery  and  flattened  it  out  so  as 
to  make  it  difficult  of  recognition.  (3)  The  cellular  tissue  round  the 
vessel  and  between  it  and  the  sternum  may  be  so  matted  with  adhesions 
as  to  make  it  difficult  to  define  the  artery  and  its  important  relations  on 
the  right  side,  viz.  vagus,  pleura,  and  right  innominate  vein.  (4)  The 
artery  itself  may  be  greatly  diseased  and  expanded.  (5)  The  bifurcation 
of  the  artery  may  be  quite  an  inch  below  the  joint. 

In  tracing  down  the  innominate  itself,  the  surgeon  must  keep  his 
instruments  most  carefully  on  the  front  of  the  artery.  In  following  the 
vessel  down  behind  the  sternum  in  order  to  fuid  a  site  for  his  ligature, 
he  will  be  aided  by  slightly  flexing  the  head,  and  if  needful  by  an  electric 
headhght.  The  cleaning  of  the  artery  must  be  done  with  the  utmost 
caution,  especially  on  the  outer  side,  owing  to  the  important  structures 
lying  there  ;  of  these  the  innominate  vein  and  the  vagus  may  be  drawn 
outside,  but  it  is  only  by  keeping  the  director  or  needle-point  very  close 
to  the  artery  here  that  injury  to  the  pleura  can  be  avoided. 

If  there  be  doubt  as  to  the  position  of  the  artery,  pressure  with  the 
finger  behind  the  vessel  against  the  sternum  will  arrest  the  pulsation  in 
the  carotid  and  the  aneurysm.  If  the  bifurcation  of  the  artery  lie,  as  in 
the  case  mentioned  at  p.  719,  a  full  inch  below  the  joint,  attempts  should 
be  made,  by  pulling  up  the  carotid  protected  by  a  piece  of  aseptic  gauze, 
to  raise  the  bifurcation  sufficiently  for  the  passing  of  the  ligature.  The 
method  mentioned  at  p.  719  is  preferable  to  dragging  on  the  vessel  by  the 
ends  of  a  ligature  previously  tied  round  the  carotid,  and  left  long.  If  it 
be  impossible  thus  to  raise  the  bifurcation  sufficiently,  the  inner  end  of 
the  clavicle  must  be  removed  by  disarticulating  and  sawing  through  the 


718  OPERATIONS  ON  THE  HEAD  AND  NECK 

bone  ;  as  much  of  the  manubrium  as  is  needful  is  also  removed,  partly  by 
a  vertical  and  a  transverse  cut  just  above  the  second  rib  with  a  saw, 
partly  with  a  chisel.     Dr.  Burrell  (p.  711)  considers  this  step  essential. 

He  quotes  Bardenheuer  ^  as  convinced  that  ligature  of  the  innominate 
can  only  be  intelligently  carried  out  by  resection  of  part  of  the  sternum 
and  sterno-clavicular  joint. 

Mr.  Ballance  ^  spht  the  manubrium,  bisecting  it  vertically  with  a  saw 
and  chisel,  and  at  the  level  of  the  upper  border  of  the  second  costal 
cartilages  added  transverse  incisions.  Pulling  apart  the  two  halves 
did  not  afford  the  desired  access,  so  about  half  an  inch  of  bone  was 
removed  on  either  side  of  the  vertical  incision.  After  this  retraction  was 
very  effective.  Mr.  Ballance  considers  the  above  method  of  sphtting  the 
sternum  ^  inadvisable  in  these  cases. 

The  needle  should  be  passed  from  without  inwards  and  a  little  from 
below  upwards  to  avoid  the  pleura.  In  this  case,  as  in  that  of  the  sub- 
clavian and  other  deeper-seated  arteries,  the  surgeon  will  do  well  to 
provide  himself  with  needles  of  different  curves  (of  these  the  late  Mr. 
Durham's  needle,  in  which  the  curve  is  twisted  laterally  at  a  right  angle 
to  the  shaft,  is  a  very  helpful  one),  or  with  a  silver  probe  sufficiently  flexible 
to  take  any  curve,  and  with  a  large  eye  close  to  the  point. 

The  needle  should  be  loaded  with  thoroughly  sterilised  silk,  or,  if 
preferred,  after  the  needle  has  been  passed,  flat  hgatures  of  reliable  and 
sterihsed  kangaroo-tail  should  be  secured,  and  then  pulled  beneath  the 
vessel.  The  material  and  mode  of  securing  the  ligatures,  the  latter  still 
an  especially  moot  point,  have  been  alluded  to  at  p.  713.  Care  should 
be  taken  to  keep  the  ligature  flat  around  the  artery  while  tying  it,  and  the 
knot  as  little  projecting  (especially  towards  the  vessel)  as  possible. 

In  addition  to  the  amount  of  force  used,  the  surgeon  will,  by  watching 
the  aneurysm — all  pulsation  in  which  should  have  ceased — derive  some 
information  as  to  the  extent  to  which  he  has  constricted  the  vessel. 
No  doubt  severing  the  vessel  between  two  ligatures  would  ensure  more 
rest  of  the  parts  which  have  to  heal,  but  the  size  of  the  vessel,  its  probable 
condition,  the  doubtfulness  as  to  whether  its  lumen  is  completely  closed, 
and  the  difficulty  of  placing  the  ligatures  sufficiently  far  apart,  forbid  the 
adoption  of  this  step.  The  ligatures  having  been  tied  and  cut  short,  the 
common  carotid  should  be  tied  also,  about  half  an  inch  above  its  origin. 
If  the  thyroidea  ima  arise  from  a  point  at  which  it  is  hkely  to  bring  in 
a  reflux  current  which  will  dangerously  disturb  the  clot,  on  which  so  much 
depends,  this  vessel  should  be  tied  also.* 

The  wound  is  now  carefully  cleaned  and  dried,  the  severed  muscles 
vmited  with  chromic-gut  buried  sutures,,  haemorrhage  most  scrupulously 
stopped,  drainage  employed,  if  needful,  and  the  wound  carefully  closed. 
The  limb,  previously  wi-apped  in  cotton- wool,  should  be  secured  to  the 
side  and  chest,  and  every  attempt  made,  by  elastic  bandaging,  to 
keep  the  dressings  firmly  in  place,  and  thus  promote,  from  the  first, 
steady  adjustment  of  the  parts  and  sound  healing.  Morphia  should 
be  used  as  freely  as  is  safe,  to  diminish,  as  far  as  possible,  the  sensi- 
bihty  of  the  patient  to  the  irksomeness  of  his  position.  The  slightest 
tendency  to  cough  should  be  treated  at  once.     The  absolute  need  of  rest 

^  Mittheilungen  aus  dem  Kolncr  Burgcr-Hosj)itnl,  Estes  Heft,  1886. 
-  Lancet,  November  1,  1902. 
3  Milton,  Lancet,  March  27,  1897. 

*  This  was  the  case  in  Lizars'  patient  {Lancet,  1837,  vol.  ii,  pp.  445,  602  ;  Spencer, 
loc.  supra  cit.). 


LIGATURE  OF  THE  INNOMINATE  719 

and  quiet  should  be  enforced  upon  the  patient  until  the  wound  is  soundly 
healed.  The  folloAving  case  of  ligature  of  the  innominate  which  was 
under  Mr.  Jacobson's  care  will  illustrate  some  of  the  difficulties  which  may 
be  expected  : 

A.  H.  was  sent-  to  Mr.  Jacobson  by  Dr.  Lockhart  Ste])lions,  of  Emswortli, 
February  1890,  with  a  large  subclavio-axillary  aneurysm.  The  man  gave  his  age 
as  48  ;  he  looked  ten  years  older,  and  was  stout  and  flabby,  with  chronic  bronchitis 
and  emphysema.  Occupying  all  the  lower  part  of  the  posterior  triangle,  and  to 
be  felt  in  the  axilla  and  between  the  heads  of  the  sterno-mastoid,  was  a  large 
an(>urysm,  six  inches  by  four  inches.  There  was  no  evidence  that  the  innominate 
itself  was  involved.  Patient  had  first  noticed  the  swelling  a  year  before,  when  it 
was  about  the  size  of  a  walnut.  He  had  been  doing  his  work  as  a  gamekeeper, 
till  two  weeks  before  his  admission,  February  10.  Chloroform  having  been  given 
and  the  parts  cleansed,  an  incision  three  inches  and  a  half  long  was  made  alonir 
the  anterior  margin  of  the  sterno-mastoid,  and  another  transversely  outward-s 
just  above  the  clavicle,  over  both  heads  of  the  sterno-mastoid  to  a  point  over  the 
imier  part  of  the  aneurysm.  The  skin  and  both  heads  of  the  sterno-mastoid  were 
divided  together,  with  the  hope  of  keeping  the  skin  down  better  when  the  wound 
was  closed,  thus  better  obliterating  the  large  wound  and  ensuring  earlier  healing. 
The  sterno-hyoid  and  sterno-thyroid  being  divided,  two  very  large  inferior  thyroid 
veins  sectu-cd,  and  the  internal  jugular  drawn  outwards,  the  inner  part  of  the  carotid 
sheath  was  opened  and  this  artery  traced  down  to  the  innominate.  The  chief 
difficulty  at  this  stage  was  due  to  what  was  thought  to  be  a  pulsating  process  of 
the  aneurysm,  which  extended  inwards  under  the  jugular  and  carotid,  but  was 
really  a  hugely  dilated  vertebral.  The  carotid  being  traced  down,  it  was  found 
impossible  to  pass  a  ligatiu-e  below  the  bifurcation,  which  lay  a  full  inch  lower  than 
the  joint.  In  spite  of  the  assistance  given  by  the  late  IVIr.  J.  N.  Davies-Colley. 
who  di-ew  up  the  carotid,  protecting  the  vessel  with  a  bit  of  gauze  wrung  out  of 
carbolic  lotion,  it  was  impossible  to  get  a  finger  or  a  director  sufficiently  deep 
behind  the  clavicle  to  make  sure  of  being  below  the  bifm-cation.  The  inner  extremity 
of  the  clavicle  was  accordingly  removed.  It  was  now  possible  to  bring  just  the  top 
of  the  bifm-cation  into  view.  More  than  this  was  impossible,  and  the  aneiu-ysm- 
needle  was  passed  by  touch  rovmd  the  innominate  from  without  inwards.  It  was 
previously  loaded  with  silk,  to  which  a  piece  of  ox-aorta  ligature,  kindly  provided 
by  Mr.  Barwell.  was  Icnotted.  In  tying  the  vessel  Mr-.  Jacobson  used  force  sufficient 
to  close  it,  but  not  to  injm-e  its  coats.  Judging  from  the  outside,  the  walls  were 
well  puckered  together.  Pulsation  in  the  aneurysm  ceased  at  once,  and  never 
returned.  The  carotid  was  then  tied,  with  a  similar  ligature,  about  an  inch  above 
its  origin,  not  only  to  prevent  any  efflux  of  blood  through  it,  but  also  because  the 
vessel  was  probably  weakened  by  much  handling.  By  the  third  day  the  aneurysm 
began  to  shrink  markedly,  but  the  following  night  the  patient  began  to  be  restless 
and  delirious,  and  this  increased  and  persisted.  It  was  most  difficult  to  keep  his 
right  arm  still,  and  before  long  it  was  needful  to  secure  him  with  straps.  Morphia, 
sulphonal,  chloral,  chloralamide.  hydriodate  of  hyoscyamin,  were  all  tried,  with 
very  little  result.  There  was  also  evidence  of  broncho-pneumonia  at  both  bases. 
The  restlessness  and  chattering  delirium  continued,  and,  in  spite  of  the  abundance 
of  food  taken,  the  strength  became  exhausted,  and  the  patient  sank  on  the  tenth 
day.  At  the  necropsy  the  wound  was  found  to  be  perfectly  sweet,  without  a  trace 
of  pus.  and  levelling  up  well.  A  large  sacculated  anemysm  occupied  the  second 
and  third  parts  of  the  subclavian  and  the  first  and  second  parts  of  the  axillary. 
In  addition  to  the  main  sac,  which  occupied  the  posterior  triangle,  a  hemispherical 
dilatation  projected  into  the  upper  part  of  the  right  pleura.  Encircling  the  in- 
nominate, just  below  the  bifurcation,  which  was  on  a  level  with  the  first  costo- 
sternal  articulation,  were  the  remains  of  a  ligature,  but  no  knot  could  be  found, 
and  the  ligature  was  movable  with  the  point  of  a  director.  Siu-rounding  the 
bifurcation  of  the  innominate  was  a  small  cavity,  from  which  could  be  squeezed 
not  more  than  a  drachm,  if  so  much,  of  quite  sweet  pus-like  fluid.  The  carotid 
had  been  tied  about  a  quarter  of  an  inch  above  the  top  of  the  sternum,  and  here, 
too.  the  wall  of  the  vessel  was  very  soft,  so  that  in  dissecting  it  a  hole  was  made 
in  the  vessel  above  the  ligature.  The  Ivnot,  however,  had  held  well  in  position. 
Running'^behind  the  carotid  sheath,  and  given  off  from  the  subclavian  immediately 
after  its  origin,  was  a  long  fusiform  dilatation,  which  was  probably  the  vertebral 
nmch  dilated,  as  large  as  the  forefinger.  A  small  window  being  cut  in  the  aneurysm 
showed  that  this  was  filled  with  a  greenish-tinted  jelly-ljke  coagulum,  not  blood- 


720  OPERATIONS  ON  THE  HEAD  AND  NECK 

stained,  and  traversed  in  every  direction  by  isinglass-like  threads.  The  only 
remnant  of  a  cavity  was  quite  at  the  back  part,  where  a  space  into  which  the  tip 
of  the  finger  could  be  introduced  contained  a  little  fluid  blood.  The  inner  aspect 
of  the  sawn  clavicle  was  smooth,  with  granulations  save  jast  at  its  upper  part. 
Both  bases  were  the  seat  of  broncho-pneumonia.  It  is  quite  possible  that  this 
was  infective,  as  no  bacteriological  examination  was  made  of  the  very  small  amount 
of  fluid  in  the  wound,  but  if  so  the  degree  of  infection  was  slight,  as  the  first  three 
days  passed  without  unfavourable  symptoms,  and  the  patient  survived  till  the 
tenth  day.  It  should  be  noted  that  the  man  had  chronic  bronchitis  before  the 
operation.  The  mediastinal  connective  tissue  was  extensively  occupied  with  air  ; 
this  had  not  penetrated  beneath  the  pulmonary  pleura,  nor  produced  interstitial 
emphysema.  The  aortic  and  mitral  valves,  the  latter  especially,  were  diseased  ; 
the  aortic  arch  was  the  seat  of  atheroma,  dilated  uniformly,  irregular  on  the  surface 
and  rough  internally,  but  not  calcareous.  The  kidneys  showed  early  interstitial 
nephritis.  There  was  a  small  hard  mass  of  clot  in  the  innomniate,  below  the  ligature, 
little  in  the  carotid.     The  brain  was  normal. 

Causes  of  Death  after  the  Operation.  It  may  be  expected  that  most 
of  these  will,  with  septic  precautions,  disappear,  viz.  : 

(1)  Infective  celliihtis  and  mediastinitis. 

(2)  Lmig  trouble,  e.g.  bronchitis,  pleuro-pneumonia. 

(3)  Cerebral  softening. 

(4)  Pericarditis. 

There  still  remains  the  terrible  complication  of  secondary  haemorrhage 
which  has  occurred,  as  yet,  in  almost  every  instance. 

Secondary  haemorrhage  may  occur  up  to  the  sixtieth  day.  It  has 
already  been  discussed  how  far  modern  surgery  is  likely  to  prevent  this, 
and  certain  precautions  have  been  enumerated  at  p.  713.  The  treatment, 
as  shown,  is  mainly  preventive.  When  once  bleeding  has  occurred,  little 
can  be  done  beyond  tying  the  vertebral  and  common  carotid,  if  this  has 
not  already  been  performed,  plugging  the  wound  -with  gauze  and  putting 
on  pressure. 

The  treatment  of  recurrent  pulsation  in  the  aneurysm  by  ligature 
of  such  vessels  as  the  carotid  and  subclavian  has  been  illustrated  by  the 
cases  already  given. 

SURGICAL  INTERFERENCE  IN  ANEURYSMS  OF  THE  INNOMINATE 

AND  AORTA 

While  the  distressing  nature  of  the  cases  justifies  a  resort  to  surgery 
when  medicine  fails,  it  may  be  pointed  out  :  (1)  That  the  surgeon  is 
often  called  in  too  late  in  large  thoracic  aneiuysms  where  treatment  of 
any  kind  is  certain  to  be  unsatisfactory.  (2)  The  fact  has  been  too  much 
lost  sight  of,  that  large  thoracic  aneurysms,  with  their  size,  varying  degree 
of  sacculation,  restricted  power  of  collapse,  and  important  surroundings, 
are  on  quite  a  different  footing,  for  operative  interference,  from  aneurysms 
of  the  extremities.  Further,  the  disease  here  is  much  less  often  a  local 
one.  (3)  That,  with  regard  to  the  amount  of  relief  which  surgery  can 
fairly  be  expected  to  give,  when  the  large  number  of  cases,  pubhshed  and 
unpublished,  which  have  been  treated  surgically  in  the  last  few  years  are 
duly  weighed,  when  the  difficulties  of  diagnosis  and  the  risks  of  operation 
have  been  considered,  it  is  clear  that  permanent  cures  are  extremely 
few  ;  and  that  Avhile  in  some  cases  decided  rehef  is  given,  in  many  pub- 
lished at  the  time  as  successes,  were  the  sequel  followed  up,  it  would  be 
found  that  very  Uttle  real  relief  had  followed,  while  in  not  a  few,  what 
with  the  risk  of  the  anaDsthetic,  the  excited  circulation,  the  partial  cure 
of  the  aneurysm  fn  one  direction,  and  the  tendency  set  up  to  spread 


INTERFERENCE  IN  THORACIC  ANEURYSMS      721 

at  another  spot,  possibly  less  able  to  bear  the  strain  ^  and  perhaps  with 
more  important  surroundings,  suigery  has  not  only  failed  to  check  but 
has  actually  hastened  the  progress  of  the  aneurysm. 

The  advisability  of  resorting  to  surgical  means  will  be  considered 
under  the  heads  of :  A.  Diagnosis  ;   B.  Treatment,  the  latter  including  : 

(1)  Ligature,  (2)  Introduction  of  Foreign  Bodies,  (3)  Galvano-puncture. 
A.  Diagnosis  between  Innominate  and  Aortic  Aneurysms.     While  a 

precise  diagnosis  is  usually  im])()ssil)le,  no  pains  should  be  spared  in  goiiig 
into  those  points  which  may  help  in  deciding  how  far  the  aneurysm  is 
probably  limited  to  the  innominate  or  to  the  aorta,  and,  in  the  case  of 
this  vessel,  which  part  of  the  arch  is  chiefly  encroached  upon,  for  it  is  only 
by  paying  attention  to  the  above  points  that  answers  can  be  given  to  the 
two   questions  which  arise,  viz.  (1)  Is  any  operation  justifiable  at  all  ? 

(2)  If  an  operation  is  justifiable,  what  is  it  to  he  ? 

Chief  Points  to  pay  Attention  to  in  Diagnosis.  ( 1 )  The  Position  of  the 
Aneurysm.  This  is  obviously  only  of  value  in  a  few  cases,  when  the 
patient  is  seen  early,  or  when  he  can  be  rehed  upon  for  an  intelligent  history 
of  his  case.  Mr.  Wardrop's  rrde  was,  that  innominate  aneurysm  first 
presents  itself  to  the  inner  side  of  the  right  sterno-mastoid,  carotid  aneu- 
rysm in  the  interval  between  the  two  heads,  and  a  subclavian  one  to  the 
outer  side  of  the  muscle.  Mr.  Barwell  ^  writes  of  the  first  of  the  above 
thus  :  "  The  tumour  of  an  innominate  aneurysm  generally  occupies 
the  episternal  notch,  but  chiefly  on  the  right  side,  and,  even  though 
it  may  not  rise  high,  takes  up  the  whole  breadth  of  this  space.  On  gently 
pressing  the  finger  backward  and  downward,  the  rounded  margin  of  the 
sac  can  be  felt.  After  a  little  time  the  sternal  end  of  the  clavicle  protrudes 
abnormally,  and  partakes  in  the  pulsation  (communicated),  while  the 
sternal  and,  afterwards,  the  clavicular  portions  of  the  sterno-mastoid 
are  also  pushed  forward.  Not  unfrequently  the  first  costal  cartilage, 
outside  where  it  joins  the  sternum,  is  also  abnormally  prominent,  and 
throbs  with  the  beat  of  the  tumour." 

(2)  The  Pulse.  If  a  decided  diminution  be  found  in  the  right  radial 
and  carotid,  the  aneurysm  is  probably  of  the  innominate  ;  but  an  aortic 
aneurysm  near  the  root  of  the  innominate  will  bring  about  the  same  result. 

(3)  Pressure  Symptoms.  These  will  vary  with  the  position  as  well 
as  the  size  of  each  form  of  aneurysm.  Thus,  in  innominate  aneurysm 
pressure  symptoms  will  vary  according  as  the  sac  is  high  up  or  low  down, 
and  pressing  inwards  or  outwards.  As  to  oedema,  the  value  of  this, 
remains  undecided  while  surgeons  hold  such  opposite  views. 

(4)  A  careful  X-ray  examination  will  throw  much  light  on  the  position 
size,  and  extent  of  the  aneurysm. 

The  other  pressure  symptoms,  viz.  laryngeal  or  tracheal  dyspnoea  and 
irregularity  of  the  pupil,  are  not  really  distinctive  between  innominate 
and  aortic  aneurysm. 

(5)  Displacement  of  the  Heart  downwards.  The  more  marked  this  is 
the  greater  is  the  probability  that  the  aneurysm  is  aortic. 

Difficulties  and  Fallacies  in  the  Diagnosis.  (1)  The  proximity  of  the 
heart.     "  Where  there  is  a  bruit,  it  is  extremely  difficult  to  distinguish 

^  The  rapid  exteiLsion  of  the  aneurysm  in  another  direction  after  its  original  growth 
has  been  checked  by  operative  interference  is  well  shown  by  a  case  of  Dr.  Churton's 
(Clin.  Soc.  Trans.,  vol.  xix,  p.  261),  in  which,  subsequently  to  galvano-puncture,  the 
blood-pressure  found  other  weak  spots  in  addition  to  the  original  aneurysm,  thus  bringing 
about  other  saccular  projections  and  fatal  rupture  into  the  bronchus. 
^  Intern.  Encycl.  Surg.,  vol.  iii,  p.  507. 
SURGERY   I  '  6 


722  OPERATIONS  ON  THE  HEAD  AND  NECK 

whether  it  is  hmited  to  the  tumour,  or  is.  propagated  into  it  from  the 
cardiac  valves."  (2)  "  The  growth  of  the  aneurysms  in  the  celhilar  tissue 
of  the  mediastinum  and  root  of  the  neck  is  so  free  that  instances  have 
been  observed  of  aneurysms  of  the  arch  of  the  aorta  causing  compression 
of  the  subclavian  and  carotid,  without  any  disease  of  those  vessels  ;  while, 
on  the  other  hand,  if  the  aneurysm  approaches  the  tubular  shape,  the 
pulse  may  be  unaffected  in  the  branches,  though  the  trunk  is  extensively 
diseased  "  (Holmes). 

(3)  The  distribution  of  the  branches  of  the  aorta  may  be  anomalous.-^ 

B.  Treatment.     (1)  Ligature.^ 

Aids  in  selecting  Cases  fitted  for  Operation.  Mr.  Barwell,^  writing  on 
innominate  aneurysms,  has  formulated  the  following  aphorisms  : 

(i)  An  aneurysm  commencing  suddenly,  especially  if  traceable  to  some  over- 
exertion, is  more  likely  to  be  bcnetited  by  operation  than  one  arising  gradually  and 
without  mechanical  causes,  (ii)  Distinct  sacculation  is  a  most  desirable  condition  ; 
fusiform  dilatation  of  the  iiuiominate  indicates  almost  certainly  a  similar  condition 
of  the  aorta  and  widesjjread  arterial  cUsease.  (iii)  If  symptoms  show  the  aortic 
arch  to  be  also  affected,  the  disease  should  be  limited,  that  is.  should  not  extend 
along  the  transverse  portion.  It  should  be  of  the  sacculated  variety,  not  a  general 
dilatation  of  the  whole  calibre.  Absence  of  any  other  aneiu-ysm.  especialh^  of  the 
rest  of  the  aorta,  must  be  ascertained,  (iv)  Absence  of  rasp-sound  along  the  aorta 
or  any  other  indication  of  extensive  atheroma  should  be  verified,  (v)  Aortic  in- 
competence, tmless  very  slight,  is  a  decided  objection,  as  is  also  mitral  disease,  or 
considerable  hypertrophy  of  the  heart,  (vi)  The  patency  of  the  vessels  leading  to 
the  brain  should  be  investigated  by  making  a  few  seconds'  pressure  on  the  carotids 
alternately  and  then  simultaneously,  (vii)  Absence  of  visceral  disease  must  be 
ascertained. 

Contraindications  to  Operative  Interference.  Mr.  Barwell  *  lays  down  the 
following:  (1)  \\'lKn  luiiiour  symptoms  reach  widely  on  both  sides  of  the  middle 
line  ;  (2)  when,  with  jjaralysis  of  the  left  vocal  cord,  there  is  obstruction  of  the 
right  bronchus  ;  (3)  when  there  is  evidence  of  coiLsiderable  aortic  incompetence  ; 
(4)  when  there  is  mitral  disease  or  considerable  cardiac  hypertrophy  ;  (5)  when 
there  is,  in  the  course  of  the  aorta,  the  rasping  sound  of  calcification  or  advanced 
atheroma,  the  more  particularly  if  the  superficial  vessels  are  rough  and  rigid  ; 
(6)  when  there  is  pain  about  the  spine  and  intercostal  nerves  ;  (7)  when  there  is 
obstruction  of  the  left  bronchus  only  ;  (8)  when  there  is  pressui'e  on  the  left  apex, 
and  ^expectoration  of  frothy  blood. 

Choice  of  Vessels.  Question  of  Simultaneous  or  Consecutive  Ligature. 
On  this  subject  the  following  remarks  of  Mr.  Holmes  may  be  quoted  : 

(1)  "  One  thing,  I  think,  has  been  fully  proved,  viz.  that  the  dis- 
tinction which  was  so  much  insisted  on  between  aortic  and  innominate 
anemysm  is  of  less  importance  in  regard  to  the  distal  operation  than  used 
to  be  taught,  and  that  a  case  of  innominate  aneurysm  which  otherwise 
seems  appropriate  for  operation  need  not  be  rejected  because  it  is  sus- 
pected or  known  that  the  aorta  is  also  involved.  It  has  also  been  satis- 
factorily proved  that  aneurysms  purely  aortic  have  been  much  benefited 
by  distal  operations.  It  remains  to  inquire  what  cases  should  be  selected, 
and  what  arteries  should  be  tied  in  each  case." 

(2)  "To  my  mind  the  clearest  e\adence  of  benefit  has  been  in  the 
case  of  hgatuie  of  the  left  carotid  in  the  treatment  of  aneurysm  affecting 

^  Mr.  Holmes  quotes  the  following  instructive  case  :  In  a  patient  in  whom,  from 
other  sjanptoins,  there  was  no  difficulty  to  account  for,  viz.  that  while  the  pulse  in 
the  right  carotid  was  unaffected,  that  in  the  right  wrist  was  imperceptible.  After  death 
the  right  subclavian  was  found  to  be  the  last  branch  of  the  aorta.  .  Passing  between 
the  aneurysm  and  the  spine,  it  had  been  compressed,  while  the  carotid  was  unaffected. 

^  Many  of  the  remarks  below  apply  also  to  the  two  other  methods  of  surgical  inter- 
ference^— introduction  of  foreign  bodies  into  the  sac  and  galvano-punctiire. 

'  Loc.  supra  cit.,  p.  520.  *  Lo".  supra  n't.,  p.  528. 


INTERFERENCE  IN  THORACIC  ANEURYSMS      723 

the  transverse  part  of  tlio  arch.''  In  a  case  of  this  kind  it  was  the  evident 
extension  of  tlie  tumour  up  the  nock  and  towards  the  tracliea  whicli  made 
Mr.  Holmes  tliink  that  the  ligature  would  prove  beneficial ;  and  the  result 
even  surpassed  his  expectations,  the  patient  being  alive  and  in  tolerable 
health  five,  and  probably  seven,  years  after  the  operation. 

(3)  With  regard  to  operations  on  the  right  side  in  cases  of  innominate 
or  mixed  innominate  and  aortic  aneurysms,  opinions  vary  as  to  whether 
the  carotid  or  subclavian  should  be  tied  sinudtaneously,  or  whether  the 
carotid  should  be  tied  first.  Mr.  Holmes,  who  holds  this  latter  view, 
evidently  thinks  that  ligature  of  this  vessel  may  be  sufficient  without  any 
consecutive  hgature  of  the  subclavian,  unless  indications  arise,  e.g.  the 
manifest  growth  of  the  subclavian  portion  of  the  sac,  or  the  effect  of 
compression  of  the  subcla\'ian  in  diminishing  the  size  or  the  pulsation  of 
the  tumour. 

Mr.  Holmes'  chief  reasons  for  preferring  ligature  of  the  carotid  alone 
as  a  first  step  are  :  (a)  that  while  the  number  of  cases  of  simultaneous 
ligature  is  much  larger,  the  most  striking  instances  of  success  have  followed 
ligature  of  the  right  carotid  alone ;  (6)  in  some  cases,  where  hgature 
of  the  subclavian  has  been  also  resorted  to  later,  the  aneurysm  was 
already  diminishing  and  becoming  firmer  after  ligature  of  the  carotid  ; 
(c)  the  simultaneous  ligature  of  two  such  vessels  as  the  carotid  and  the 
subclavian  may  be  a  very  formidable  undertaking  from  the  prolonged 
dissection  and  difficulties  with  the  angesthetic  ;  .{d)  as  ligature  of  the  left 
carotid  has  proved  sufficient  in  aortic  aneurysm,  a  similar  step  should 
be  tried  on  the  right  side  in  innominate  aneurysm. 

Facts  which  show  that  the  resort  to  Ligature  has  been  justifiable. 
(1)  Solidification  and  diminution  in  the  size  of  the  swelling.  (2)  Diminution 
of  pulsation.  In  one  case  of  Mr.  Barwell's,^  a  month  after  simultaneous 
ligature  of  both  arteries  for  innominate  aneurysm,  the  swelhng  again  began 
to  increase,  and  the  solidifying  tumour  to  soften,  pulsation  also  recurring  ; 
this  went  on  for  about  two  weeks,  when  the  swelling  again  solidified  and 
decreased,  recovery  ultimately  taking  place.  (3)  Improvement  in 
dyspnoea,  dysphonia,  and  dysphagia,  (i)  Regain  of  power  over  a  limb. 
(5)  Expectoration  of  mucopm-ulent  discharge,  which  has  been  accumu- 
lating in  the  lungs  owing  to  interference  with  expiration  from  pressure 
on  the  trachea. 

One  of  the  most  recent  reviews  of  the  subject  of  the  treatment  of 
innominate  aneurysm  by  distal  ligature  of  the  right  subclavian  and  carotid 
is  a  critical  one  by  Jacobsthal.-  After  investigating  the  results  obtained 
by  distal  hgature  and  comparing  them  with  other  methods,  he  shows  that 
the  results  of  this  operation  do  not  warrant  its  performance.  The  im- 
mediate mortality  is  55-7  per  cent.  In  Poivet's  collection  of  94  cases,  the 
cures  were  put  down  as  7-1  per  cent.  Jacobsthal  has  collected  28  more 
recent  cases  in  which  there  were  no  cures,  though  improvement  was 
found  thirteen  times. 

(2)  Introduction  of  Foreign  Bodies  into  the  Sac. ^  A.  Wire,  Horsehair, 
&c.  This  method  was  originally  brought  before  the  profession  by 
Mr.  Moore,'*  who  introduced  twenty-six  yards  of  fine  iron  wire  into  an 

1  Med.-Chir.  Trans.,  vol.  Ixviii,  p.  130.  ^  Zeil.f.  Chir.,  August  23.  1902. 

^  See  a  paper  by  Dr.  Wm.  C.  Lusk  (Ann.  of  Surg.,  1913,  vol.  Ivii,  p.  285),  on  Wiring 
of  Thoracic  Aneurysms.  Also  a  discussion  on  the  Surgical  Treatment  of  Aneurysm 
before  the  Surgical  Section,  Roy.  Soc.  Med.  (Pro:.  Roy.  So".  Med..  Surg.  Sec,  June  1912, 

p.  1  •;<.). 

*  Med.-Chir.  Trans.,  vol.  xlra,  p.  129. 


724    OPERATIONS  ON  THE  HEAD  AND  NECK 

aortic  aneurysm.  No  relief  followed,  inflammation  of  the  sac  set  in,  and 
the  patient  died  five  days  later.  Used  by  itself,  this  method  should  be 
considered  obsolete.  The  theoretical  advantages  have  not  been  borne 
out  in  practice.  The  chief  causes  of  failure  have  been  the  difficulties  in 
introducing  a  sufficient  amount  of  the  fihform  material ;  in  the  case  of 
wire  irritation  has  often  followed,  leading  in  some  instances  to  early  rup- 
ture of  the  sac  ;  in  that  of  horsehair  and  catgut,  owing  to  the  readiness 
with  which  they  bend  in  the  cannula,  it  is  far  from  easy  to  get  enough  into 
the  sac.  And  even  if  this  were  rendered  feasible,  it  is  probable  that  the 
large  amount  of  foreign  material  present  would  interfere  mth  the  due 
contraction  of  the  clot,  so  essential  for  the  cure  of  the  aneurysm.  In 
some  cases,  where  partial  consolidation  has  been  secured,  extension  has 
followed  in  another  direction,  causing,  e.g.  urgent  tracheal  dyspnoea. 
Further,  this  method  is  not  without  its  special  risks  ;  the  foreign  material 
may  pass  beyond  the  aneurysm  and  form  emboli. 

B.  Needles.  While,  for  reasons  already  given,  none  of  the  surgical 
methods  employed  in  thoracic  aneurysms  can  be  considered  satisfactory, 
this  one,  is,  perhaps,  more  deserving  of  trial. 

Sir.  W.  Mace  wen,  who  used  this  method  as  long  ago  as  1875,  has  pub- 
lished ^  a  most  interesting  paper  on  the  use  of  pins  to  secure  the  formation 
of  thrombi,  and  so  the  cure  of  the  aneurysm. 

"  The  instrument  employed  is  a  pin  of  sufficient  length  to  completely  transfix  the 
aneurysm  and  so  to  permit  of  manipulation  within  it.  Its  calibre  ought  to  be  as 
fine  as  possible,  the  strength  being  only  sufficient  to  penetrate  the  coats  of  the 
aneurysm  and  the  intervening  tissues.  The  cylindrical  pin  tapers  to  a  jioint,  like 
an  ordinary  sewing  needle,  and  has  on  its  opi:)Osite  extremity  a  somewhat  rounded 
head.  As  the  coats  of  anemysmal  sacs  vary  in  thickness,  these  pins  must  be  made 
of  various  calibres.  They  ought  to  be  finely  polished,  not  only  to  facilitate  their 
introduction,  but  to  help  render  them  aseptic.  The  sterilised  pin  ought  then  to 
penetrate  the  sac  and  pass  through  its  cavity  until  it  comes  into  contact  with  the 
opposite  side.  It  ought  to  touch  this  and  no  more.  Then  one  of  two  methods  may 
be  employed  :  either  to  move  the  pin  over  the  surface  of  the  inner  wall  so  as  to 
irritate  its  surface,  or  to  allow  the  influence  of  the  blood-current  playing  on  the 
very  thin  pin  to  effect  the  same  object.  If  the  walls  penetrated  by  the  pin  be  dense 
the  former  method  will  be  preferable,  as  the  force  of  the  blood-current  produces 
such  a  feeble  action  on  the  thin  pin  as  to  be  unable  to  move  it  to  and  fro  while  it 
is  firmly  grasped  by  the  dense  wall.  After  acting  thus  for  ten  minutes  at  one  part, 
the  point  of  the  pin,  without  being  removed  from  the  sac,  ought  to  be  shifted  to 
another  spot,  and  so  on  until  the  gi'eater  portion  of  the  internal  smiace  opposite  to 
the  point  of  entrance  has  been  touched  ;  this  ought  to  be  done  in  a  methodical 
manner.  A  single  insertion  of  the  pin  through  the  sac  into  its  interior  may  be 
sufficient  to  enable  the  point  of  the  instrument  to  come  in  contact  with  the  greater 
part  of  its  internal  siu-face  ;  but,  in  some  cases,  puncture  from  various  sides  of  the 
external  wall  may  be  necessary,  so  as  to  reach  portions  of  the  tumour  which  caiuiot 
be  attacked  from  the  first  puncture.  While  the  pin  is  in  the  aneurysm,  it  is  sur- 
rounded with  sterile  gauze.  ^Vhen  it  is  withdxawn  from  the  aneurysm,  the  part 
should  be  covered  with  an  antiseptic  di'essing  for  some  days.  The  period  a  pin  may 
remain  in  an  anemysmal  sac  without  doing  damage  is  perhajos  dependent  on  the 
individual,  and  the  state  of  the  aneurysm,  but  it  ought  never  to  exceed  forty-eight 
hours.  It  is  questionable  w'hether  all  the  necessary  advantages  derivable  from 
irritation  of  the  wall  of  the  aneiu-ysm  could  not  be  produced  within  a  few  hours. 
If  the  aneurysm  be  very  large,  several  pins  may  be  introduced  from  several  points, 
always  allowing  a  considerable  interval  to  exist  between  each,  otherwise  there 
might  be  too  much  damage  to  the  vessel  wall  at  one  spot.  When  the  pin  has  been 
withdrawn,  though  there  may  be  a  little  thickemng  of  the  tissues  in  the  neighbour- 
hood, there  will  probably  be  little  or  no  diminution  of  the  eccentric  impulse. 
Occasionally  it  may  be  weeks  before  any  distinct  or  tangible  thickening  of  the 
coats  can  be  made  out.      In  other  instances  this  may  be  discernible  at  a  much 

1  Lancet,  1890,  vol.  ii,  p.  1086. 


INTERFERENCE  IN  THORACIC  ANEURYSMS      725 

earlier  period.     But,  as  a  rule,  a  distinct  thickening  of  the  wall  can  bo  made  out 
at  an  early  period." 

It  will  be  seen  that  the  aim  in  Sir  W.  Macewen's  use  of  acupuncture 
differs  somewhat  from  that  of  other  surgeons  in  that  his  object  is  to 
irritate  the  wall  of  the  aneurysm,  the  irritation  being  carried  just  so  far 
as  to  set  up  reparative  exudation  in  the  parietes,  infiltration  of  these  with 
leucocytes,  and  then  a.  further  separation  of  these  from  the  blood.  The 
irritation  is  set  up  at  as  many  points  as  possible,  so  as  to  produce  numerous 
white  thrombi,  and  so  complete  occlusion  as  soon  as  possible. 

The  following  of  Sir  W,  Macewen's  cases  is  of  great  interest. 

The  aneurysm  was  here  in  the  thoracic  area,  probably  of  the  left  subclavian, 
and  accompanied  by  great  pain,  numbness,  and  loss  of  power  in  the  left  arm.  Pins 
were  introduced  on  February  27,  March  3,  17,  and  24,  a  gradual  thickening  o£  the 
walls  ensuing,  as  made  evident  by  the  greater  difficulty  experienced  in  penetrating 
the  walls,  a  pin  of  very  fine  calibre  being  used  at  first,  some  much  stouter  and  more 
rigid  being  required  later  on.  During  the  next  four  months  there  was  much  diminu- 
tion in  the  swelling  and  jiain.  Pins  were  again  used  on  five  subsequent  occasions, 
but  as  in  two  of  them  it  was  doubtful  if  any  cavity  was  entered,  their  use 
was  discontinued.  During  the  following  months  there  was  slow  but  continuous 
decrease  in  the  swelling,  and  the  a?dema  and  pain  gradually  disappeared  entirely, 
the  patient  being  finally  able  to  resume  all  her  ordinary  duties. 

Writing  in  1895  Sir  W.  Macewen  said  : 

"  I  have  had  three  cases  of  aneurysm  treated  since  I  wi-ote  my  paper.  One  at 
root  of  neck,  subclavian,  but  involving  aorta  ;  cure  absolute.  One  aortic,  trans- 
verse arch  ;  greatly  thickened  and  improved  ;  patient  can  go  freely  about  and 
follow  his  usual  avocation,  from  which  he  was  debarred  prior  to  operation.  One,  a 
very  large  popliteal,  in  which  consolidation  took  place  rapidly,  but  owing  to  the 
great  pressure  exercised  by  the  anemysm  on  the  surrounding  parts,  which  was 
apparently  inci'eased  by  the  consolidation,  incision  had  to  be  made  into  the  sac. 
Firm,  laminated  white  thrombi  were  found  inside  the  sac,  part  of  which  was  turned 
out  to  relieve  the  pressure  and  to  preserve  the  vitality  of  the  limb.  The  patient 
made  a  rapid  recovery,  and  is  now  quite  well,  the  remainder  of  the  white  thrombus 
becoming  converted  into  dense  fibrous  tissue,  which  subsequently  has  undergone 
great  shrinking." 

(3)  Galvano-Puncture.  This  method  has  for  its  object  the  production 
of  clotting  without  the  risks  and  difficulties  connected  with  the  intro- 
duction of  foreign  bodies,  e.g.  wire.  Galvano-puncture,  the  introduction 
of  filiform  material,  and  the  merits  of  these  compared  with  the  combined 
use  of  electrolysis  and  introduced  wire,  are  discussed  in  a  paper  by  Dr. 
Stewart,  of  Philadelphia.^ 

Points  to  Pay  Attention  to.  (1 )  To  avoid  production  of  heat,  pain,  and  sloughing 
of  the  skin,  the  current  used  should  be  a  comparatively  weak  one.  As  an  anaesthetic 
is  not  usually  required,  the  time  occupied  may  be  considerable.  (2)  The  needles 
should  be  of  steel,  as  fine  as  is  consistent  with  perforating  the  tissues,  in  order  to 
diminish  pain,  hajmorrhage,  and  risk  of  sloughing.  (3)  To  avoid  the  same  risks, 
the  needles  should  be  insulated  within  about  half  an  inch  of  their  points  by  two 
layers  of  spirit  varnish.  (4)  As  it  has  been  proved  that  the  eft'ect  of  electrolysis  on 
blood  at  the  positive  pole  is  a  fairly  firm  and  tenacious  dark  clot,  while  the  negative 
rather  produces  a  pinkish  frothy  substance,  it  seems  wiser  to  connect  the  needle  or 
needles  introduced  into  the  sac  with  the  positive  pole,  while  a  large  sponge,  wrung 
out  of  warm  salt  water,  is  connected  with  the  negative  pole  and  applied  to  the 
chest  wall  near  the  swelling.  (5)  A  sitting  should  not  be  prolonged  over  thirty 
or  forty  minutes.  The  punctures  had  best  be  closed  by  collodion.  (6)  The  opera- 
tion should  not  be  repeated  too  soon  ;  time  should  be  allowed  for  all  local  reaction 
to  cease,  and  for  consolidation  of  the  coagulum  to  occur,  which  often  takes  some 
time. 

Drawbacks  and  Dangers.  (1)  As  pointed  out  by  Mr.  Holmes,  it  is  a  radical 
^  Anier.  Jonrn.  Med.  Set.,  October  1892,  vide  infra. 


726  OPERATIONS  ON  THE  HEAD  AND  NECK 

defect  of  this  method  that  it  acts  by  inducing  "  passive  "  coagulation  of  blood  in 
the  sac.  Hence  it  is  inherently  uncertain,  liable  to  cause  relapse  by  the  melting 
of  the  coagiilum,  or  inflammation  by  its  too  sudden  deposition.  Again,  it  is  very 
liable  to  set  up  inflammation  in  the  walls  and  contents  of  the  sac.  Then,  too,  the 
needles  sometimes  produce  eschars  at  the  points  of  their  insertion,  and  thus  give 
rise  to  consecutive  haemorrhage.  In  fact,  the  cases  are  few  in  which  a  perfectly 
happy  result  has  been  obtained,  but  some  of  these  are  worthy  of  particular  attention. 

Use  of  Galvanism  through  Introduced  Coiled  Wire.^  Dr.  Stewart,  of 
Philadelphia  ^  has  employed  this  method  and  considers  it  superior  to  the 
introduction  of  wire  alone  or  galvano-puncture  alone. 

Owing  to  the  conditions  present  in  large  aneurysms,  the  most  that 
operative  interference  can  usually  promise  is  some  prolongation  of  life 
and  alleviation  of  symptoms. 

Attention  may  be  again  dra^^^l  to  the  remarks  at  p.  721  (a  point  to 
which  attention  has  not  been  sufficiently  directed),  that  surgical  inter- 
ference may,  in  some  cases  of  large  aneurysms,  do  more  harm  than  good 
by  diverting  the  blood  current  from  the  original  aneurysm  into  some 
outlying  and  unsuspected  secondary  sac,  and  thus  cause  dangerous  and, 
it  may  be,  fatal  pressure  on  important  parts  which  have  hitherto  escaped. 
Besides  this  danger,  three  other  chief  ones  have  to  be  remembered  when 
wire  is  introduced.  (1)  Embolism.  (2)  Suppuration  of  the  sac.  Both 
these  have  been  made  much  rarer  by  carefully  rendering  the  wire  aseptic. 
Any  inflammation  of  the  sac  should  at  once  be  treated  by  ice-bags. 
(3)  Introduction  of  the  wire,  &c.,  beyond  the  aneurysm,  and  consequent 
especial  risks. 

1  Further  information  as  to  the  indications  for.  and  technique  of.  this  and  allied 
methods  of  treating  thoracic  aneurysms,  will  be  found  in  the  following  papers  :  Dr.  Hare, 
"  Twenty-two  Cases  of  Thoracic  Aneurysm  treated  by  \\'iring  and  Electroylsis  "  (Journ. 
Amer.  Med.  Assoc,  1912,  vol.  i,  p.  1088)  ;  Dr.  Finney,  "  Twenty-three  cases  of  Thoracic 
Aneurysm  treated  by  Wiring  and  Electrolysis  "  ;  Dr.  W.  C.  Lusk,  "  Thoracic  Aneurysm 
treated  with  Gold  Wire  and  Galvanism"  {Ann.  Surg.,  1912,  vol.  Iv,  p.  789). 

2  Amer.  Journ.  Med.  Sci.,  October  1892,  and  Philadelphia  Med.  Journ.,  November  12, 
1898. 


1*AKT    111 

oPKirv  I  IONS  OX  Tin:  i  iioijax 

CHAPTER  XXXIV 
REMOVAL  OF  THE  BREAST  (Figs.  2G9-307) 

Indications.  The  following  remarks  must  be  considered  to  refer  to  that 
most  common  and  important  of  diseases — carcinoma.  Removal  of  the 
breast  is  an  operation  which  deserves  most  careful  attention,  on  the 
following  gromids,  viz.  the  frequency  and  the  distressing  results  of 
malignant  disease  here,  and  the  fact  that,  while  there  is  reason  to  hope 
that  the  operation  is  becoming  more  successful,  much  still  remains  to  be 
done.  Women  will  always  be  unwilhng  to  make  known  their  fears  here, 
on  account  of  a  natural  delicacy ;  but  another  reason  leads  them  to 
conceal  the  earlier  stages  of  a  growth  (in  which  alone  it  can  be  thoroughly 
dealt  with),  and  that  is  the  well-known  want  of  permanent  success  which 
too  often  follows  operation.  Precious  time  is  also  still  too  often  lost  by 
the  medical  attendant  when  he  is  consulted,  in  some  cases  from  a  mistaken 
kindness  and  desire  to  make  light  of  fears,  in  others  from  a  disbehef  in 
the  value  of  the  operation. 

Here,  as  in  all  cases  of  malignant  disease,  early  and  thorough  operation 
is  needed.  With  regard  to  the  latter,  the  limits  of  wide  and  thorough  opera- 
ting have  probably  been  reached,  but  can  it  be  said  that  the  patients  are 
submitted  to  operation  as  early  as  might  be  the  case  ?  Is  it  not  rather  the 
truth  that  in  the  majority  of  cases  the  operating  surgeon  does  not  get  his 
chance  mitil  the  disease  has  had  time  to  pass  beyond  its  first  stage,  and  to 
spread  to  parts  outside  the  breast  itself,  as  e\nnced  by  the  adhesion  to  the 
skin  and  by  the  glands  found  when  the  axilla  is  opened  ?  ^  While  in 
mahgnant  diseases  of  the  sexual  organs  we  shall  always  have  to  deal  vnth 
a  larger  proportion  of  late  cases  then  elsewhere,  there  is  no  doubt  that  we 
should  diminish  the  number  of  these  late  cases  if  both  the  patients  and 
the  general  practitioners  who  are  first  consulted  realised  more  clearly, 
and  if  the  latter  impressed  more  strongly  on  their  patients;  (1)  that 
there  are,  every  year,  an  increasing  number  of  patients  who  are  living 
in  good  health  several  years  after  the  operation  ;  (2)  that  the  operation, 
while  serious,  is  not  a  dangerous  one ;  (3)  that  if  the  disease  does  recur  after 
the  improved  operation  of  the  present  day  the  recurrence  will  be  delayed ; 
(-4)  that  the  operation  of  the  present  day  promises  much  better  results, 
but  that  these  results  will  only  be  secured  by  the  operation  being  an  early 
one,  i.e.  while  the  disease  is  in  its  first  stage  ;  (5)  that  in  this  first 
stage,  in  which  operation  is  so   essential,  there  is  an  entire  absence 

1  Dr.  L.  S.  Pilcher,  whose  opinion  is  always  valuable  from  his  thoughtfulness,  mature 
experience,  and  candour,  thus  expresses  himself  {Ann.  of  Surg.,  September  1903)  :  "  It 
cannot  be  too  strongly  emphasised  that  practically  every  case  of  carcinoma  of  the  breast, 
when  it  has  reached  that  degree  of  development  by  which  a  palpable  tumour  is  formed,  is 
already  in  such  an  advanced  stage  that,  as  a  rule,  metastatic  deposits  have  already 
begun  to  be  formed." 

727 


728  OPERATIONS  ON  THE  THORAX 

of  pain,  or  of  much  or  anything  to  see  :  thus,  a  "  lump  "  must  not  be 
neglected  because  it  is  painless,  as  is  so  often  the  case  ;  (6)  that  when  in 
doubt  as  to  whether  a  persisting  "  lump  "  which  he  is  examining  is 
carcinoma  in  its  first  and  quiescent  stage,  or  induration,  or  a  deeply-lying 
cyst  with  thick  walls,  the  general  practitioner  sliould  consider  it  his  duty 
to  have  the  "  lump  "  excised  at  once  {vide  infra),  and  the  breast  dealt 
with  as  may  prove  necessary. 

Results  and  Dangers  of  the  Improved  Operation  for  Removal 
of  Malignant  Disease  of  the  Breast  :  (1)  Mortality  of  the  Operation. 
(2)  Results  of  the  Operation. 

(1)  Mortality  of  the  Operation.  Recent  statistics  clearly  show  that 
though  the  severity  of  the  operation  has  been  much  increased,  its  mortality 
is,  under  the  best  conditions  {vide  infra),  very  low.  Thus,  Sir  W.  M. 
Banks  ^  gave  a  series  of  sixty  operations  without  one  death.  Dr.  Halsted  ^ 
states  that  fifty  of  what  he  terms  "  complete  "  operations  had  been  per- 
formed at  the  John  Hopkins  Hospital,  Baltimore,  and  not  a  death  had 
resulted  from  these  operations.  Sir  Watson  Cheyne^  had  only  one 
death  in  sixty-one  cases,  and  thought  that  "  the  ether  had  probably  as 
much  to  do  with  this  death  as  the  operation." 

With  regard  to  this  very  low  mortality,  it  must  be  remembered  that 
such  results  are  the  work  of  men  of  special  experience  ;  that  cases  in 
private  as  well  as  in  hospital  practice  are  included  ;  and,  lastly,  in  Dr. 
Halsted's  case,  the  operator  was  working  with  very  highly  trained  assist- 
ants. 

When  due  attention  and  weight  are  given  to  such  conditions  as  shock 
in  an  obese  patient  with  poor  cardiac  fibre,  lung  trouble  in  a  patient  with 
chronic  bronchitis,  unavoidable  infection  as  from  an  ulcerated  *  growth, 
the  readiness  with  which  this  operation  is  undertaken,  and  the  personal 
equation  of  the  skill  of  the  operators,  it  will  be  admitted  that  if  all  fatal 
cases  were  published,  the  death-rate  would  not  be  so  low  as  that  given 
above.  It  has,  however,  proved  what  can  be  done  under  the  hest  jjossible 
conditions.  There  are  causes  of  death  which,  even  when  foreseen,  no 
amount  of  care  and  caution  will  always  prevent  when  an  urgent  operation 
is  performed.  For  example,  bronchitis  after  an  anaesthetic,  when  the 
chest  is  hampered  by  bandages,  and  the  patient,  scarcely  answerable  for 
her  actions,  persistently  slips  down  in  bed  ;  to  the  failing  strength  and 
vitahty  with  which  the  flickering  light  of  the  hfe  of  a  patient  with  a  fatty 
heart  or  albuminuria  is  snuffed  out,  it  may  be  two  or  three  weeks  after  the 
operation.  The  severity  itself  of  operations  rarely  brings  about  a  fatal 
result,  unless  the  patient  prove  unamenable,  another  condition  against 
which  it  is  extremely  difficult  to  guard. 

(2)  Results  of  the  Operation.  It  is  clear,  from  the  statistics  which 
have  been  furnished  {vide  infra),  that  a  considerable  proportion  of  patients 
submitted  to  the  improved  operation  will  be  alive  and  apparently  well 
three  years  and  more  after  the  operation.  By  many  surgeons,  some  of 
them  of  eminence,  this  is  looked  upon  and  spoken  of  as  tantamount  to  a 

1  Brif.  Med.  Journ.,  1900.  vol.  i..  p.  823. 

2  Ann  of  Surg.,  November  1894,  p,  512.  • 
^  Letlsominn  Ltxtnres.  1896,  "  The  Objects  and  Limits  of  Operations  for  Cancer,"  p.  34. 
*  Mr.  Lockwood  has  drawn  attention  {Trcmmatic  Injection,  p.  51)  to  the  grave  im- 
portance of  an  ulcerating  carcinoma  as  a  dangerous  source  of  sci^tictpmia  during  the 
operation  for  removal  of  the  breast.  In  his  opinion  (loc.  supra  cit..  p.  63)  swabbing  over 
the  surface  of  the  ulcer  with  pure  carbohc  acid  is  not  always  reliable,  and  he  would  advise 
destroying  the  entire  surface  of  the  ulcer  with  the  actual  cautery. 


REMOVAL  OF  THE  BREAST  729 

cure  {vide  infra).  Dr.  Halsted  ^  had  operated  on  133  cases  by  his  im- 
proved metliod  between  June  1889  and  April  1898.  Of  these  133,  70 
had  been  operated  on  more  than  three  years.  Of  these  76  operated  on 
more  than  three  years,  31  (41  per  cent.)  were  Uving  at  the  time  of  pubUca- 
tion  of  the  above  article,  without  local  recurrence  or  signs  of  metastasis. 
Sir  W.  Cheyne,2  from  his  private  cases  which  he  was  able  to  trace,  con- 
cludes that  "  from  50  to  55  per  cent  of  the  cases  are  alive  and  well  after 
periods  varying  from  six  to  thirteen  years." 

Sir.  H.  Butlin,^'  from  a  collection  of  47  cases  operated  on  by  Dr.  Halsted 
himself.  Sir  W.  Cheyne,  and  Rotter,  gives  a  percentage  of  over  50  cases 
"  cured,"  i.e.  alive  and  well  three  years  or  more  after  the  operation. 

Sir  W.  Mitchell  Banks  ^  tabulates  213  cases,  "of  which  175  are 
available  for  statistical  comparison.  Of  these  175,  108  have  remained 
free  from  local  recurrence.  Of  these  108,  73  lived  over  three  years  as 
follows  : 

Cases  tliat  have  lived  between  3  and  6  years  after  operation  .     40 

„       7    „    14     „  „  .     28 

,,  ,,  ,,     16  or  more  ,,  ,,  .5 

With  regard  to  the  results  of  operation,  it  is  necessary  to  exercise 
the  greatest  caution  with  regard  to  the  use  of  the  word  "  cure."  There 
has  been  a  tendency  for  surgeons,  both  English  and  American,  to  adopt 
the  view  originally  brought  forward  by  Volkmann,  that  if  three  years  have 
elapsed  after  an  o])eration  for  malignant  disease  without  recurrence,  to 
look  upon  the  patient  as  cured,  and  to  speak  of  these  cases  as  "  cures." 
Such  surgeons  make  Kght  of  any  inaccuracy  which  it  is  admitted  may  be 
present  in  the  above  dictum,  and  they  claim  that,  being  "  optimists,"  such 

1  A7iti.  of  Svrj.,  November  1898,  p.  575.  Dr.  Halsted  in  a  later  review  of  his  results 
of  radical  operations  for  the  cure  of  carcinoma  of  the  breast  {Ann.  of  Surg.,  1907,  vol.  xliv, 
p.  1)  divides  his  cases  into  three  groups  :  (1)  cases  in  which  on  one  occasion  the  complete 
pectoral  and  neck  operation  was  performed  ;  (2)  cases  in  which  at  fii-st  the  complete 
pectoral  operation  was  performed,  and  later  the  complete  neck  operation ;  (3)  cases  in 
which  the  complete  pectoral  operation  was  performed,  the  neck  being  unexplored.  He 
gives  the  following  interesting  statistics  of  each  group,  a  patient  who  was  alive  and  well 
at  the  end  of  five  years  being  regarded  as  "  cured."  Group  1  :  There  were  96  cases,  of 
which  88  could  be  traced  ;  of  these  13  were  cured  and  alive,  6  were  cured  but  died  from 
other  causes.  5  developed  metastases  after  five  years.  Group  2  :  This  contained  16 
cases,  of  which  3  were  cured  and  alive,  1  was  cured  but  died  from  other  causes,  and 
1  developed  metastases  after  five  years.  Group  3  :  Here  there  were  92  cases,  of  which 
87  could  be  traced.  Of  these  23  were  cured  and  living,  3  after  living  for  five  years  or 
over  died  from  other  causes,  yhile  4  developed  metastases  after  the  five  years  limit. 
Dr.  Halsted's  cases  are  very  carefully  tabulated  and  analysed,  and  his  results  are  certainly 
most  encouraging.  At  the  same  time,  after  reading  his  paper  one  cannot  help  feeling 
how  difficult  it  is  to  use  the  word  "  cure." 

Dr.  Greenough,  Dr.  Channing  Simmons,  and  Dr.  Dallinger  Barney  investigated  the 
end  results  of  376  primary  operations  for  carcinoma  of  the  breast  at  the  Massachusetts 
General  Hospital  between  1894  and  1904  (AnJi.  of  Surg.,  1907,  vol.  xlvi,  p.  20).  Of  a 
total  of  416  cases,  376  were  traced  to  a  conclusive  end  result  at  an  average  period  of  eight 
years  after  operation.  Sixty-four  patients  were  alive  and  well,  and  7  died  without  recurrence 
three  or  more  years  from  the  time  of  the  operation.  Counting  the  operation  mortality 
there  were  320  cases,  of  which  67,  or  20-9  per  cent.,  were  successful.  It  is  interesting  to 
note  that  no  case  of  carcinoma  of  both  breasts,  or  where  there  were  palpable  enlarged 
glands  above  the  clavicle,  was  successful.  17  out  of  88  cases  who  passed  the  three 
years  limit  without  recurrence  developed  metastases  later,  and  in  four  a  recurrence  took 
place  more  than  six  years  after  the  operation. 

Interesting  papers  on  the  end  results  of  this  operation  by  Dr.  Ochsner,  of  Chicago, 
who  gives  an  analysis  of  164  cases,  by  Dr.  Nathan  Jacobson,  and  by  Dr.  John  Chadwick 
Oliver,  will  also  be  found  in  the  Ann.  of  Surg.,  vol.  xlvi. 

2  Lancet.  1904.  vol.  i.  p.  701. 

3  Operative  Surgery  of  Malignant  Disease,  2nd  ed..  p.  404. 

*  Lettsomian  Lectures,  "  Practical  Observations  on  Cancer  of  the  Breast,"  i?rfi.  Med. 
Journ.,  1900,  vol.  i,  p.  823. 


730  OPERATIONS  ON  THE  THORAX 

a  dictum  is  quite  good  enough  for  them,  and  that  any  other  surgeons  who 
hold  a  different  view  are  to  be  looked  upon  as  "  pessimists."  Now,  there 
is  one  thing  which  is  above  optimism  and  pessimism,  and  that  is  the 
truth.  What  is  the  truth  in  this  matter  ?  It  turns  on  what  we  under- 
stand by  the  word  "  cure,"  and — a  matter  of  even  greater  importance— 
what  our  patients  understand  by  it.  On  this  point  Mr.  Shield's  remarks 
may  be  quoted  :  "  As  regards  the  prospect  of  a  definite  cure,  as  the  term 
is  understood  by  the  public,  i.e.  definite  eradication  of  the  disease,  leaving 
the  organism  in  a  healthy  state,  it  is  the  duty  of  a  conscientious  surgeon 
to  be  exceedingly  cautious  in  pronouncing  such  definite  opinions  as  have 
emanated  from  the  German  schools."  And  again  at  p.  437  :  "  Fresh 
manifestations  of  the  disease  locally,  or  in  the  bones  or  viscera,  may  occur 
at  any  period  up  to  ten  or  fifteen  years  after  the  original  operation.  These 
may  be  termed  fresh  outbreaks  of  the  disease,  or  what  name  any  patholo- 
gist fancies,  but  the  fact  remains  that  the  word  '  cure  '  wall  be  used 
with  great  caution  by  any  one  who  views  the  matter  from  the  light  of 
plain  common  sense,  and  a  desire  to  act  truthfully  and  conscientiously 
towards  patients."  It  has  been  estimated  that  20  per  cent,  of  patients 
who  survive  three  years  die  eventually  of  recurrences.  With  regard  to  the 
prognosis  Mr.  Sampson  Handley  says,  "  Halsted's  results  show  that  when 
the  modern  complete  operation  is  performed  before  the  axillary  glands 
have  become  involved  two  out  of  three  patients  are  permanently  cured, 
while  when  the  axillary  glands  are  already  infected  at  the  time  of  operation 
three  out  of  four  ultimately  die  of  the  disease." 

Local  Recurrence,  when  it  occurs,  is  delayed  by  more  Extensive 
Operations.  While  we  cannot  honestly  hold,  without  watching  longer 
and  publishing  later  the  results  of  recent  operations,  that  patients  can 
count  on  a  cure  of  the  disease,  there  is  no  doubt  that  local  recurrence  is 
less  frequent,  and  when  it  does  take  place  it  is  delayed,  especially  when 
X-ray  treatment  is  called  in  to  our  aid.  To  ensure  such  improved  results 
the  following  conditions  are  essential  : 

A.  To  operate  widely  and  thoroughly,  and  thus  to  endeavour  to 
remove  every  atom  of  tissue  which  recent  researches  have  shown  may 
be  the  seat  of  disease. 

This  will  include  (i)  removal  of  the  whole  breast,  which  the  facts 
given  below  will  show  to  be  far  from  as  easy  as  it  is  often  thought  to  be  ; 
(ii)  removal  of  the  costo-sternal  portion  of  the  pectoralis  major,  and,  if 
advisable,  the  pectoraHs  minor  also  ;  (iii)  clearing  out  the  axilla  ;  and 
(iv)  this  is  as  important  as  any — the  breast,  the  pectoralis  major,  axillary 
fat  and  glands,  should  be  removed  in  one  continuous  mass. 

Mr.  Sampson  Handley  *  gives  the  following  principles  of  the  operation 
for  cancer  of  the  breast,  (i)  The  area  of  the  operation  must  be  concentric 
with  the  growth.  Only  when  the  growth  itself  is  in  the  centre  must  the 
nipple  be  taken  as  the  central  point  of  the  area  of  skin  and  subjacent 
tissue  to  be  removed. 

(ii)  The  area  of  tissue  to  be  removed  must  approximate  to  a  circle  in 
shape,  in  view  of  the  centrifugal  spread  of  permeation. 

(iii)  Since  permeation  spreads  primarily  by  way  of  the  deep  fascial 
lymphatic  plexus,  the  ablation  of  tissue  must  be  most  extensive  in  the 
plane  of  the  deep  fascia,  and  the  area  of  fascia  removed  must  be  approxi- 
mately a  circle. 

(iv)  Smaller  circular  areas  of  skin  and  of  muscle  also  require  removal, 
^  System  of  Surgery,  vol.  ii,  p.  87. 


REMOVAL  OF  THE  JiHEAST  731 

on  account  of  the  secondary  invasion  of  these  layers  from  the  permeated 
fascial  plexus. 

(v)  The  skin  incision  subject  to  the  preceding  conditions  should  afford 
convenient  access,  and  should  not  be  so  placed  that  the  scar  will  lie  along 
the  anterior  axillary  fold,  since  in  this  situation  it  will  tend  to  bind  the  arm 
to  the  side. 

H.  To  exercise  as  far  as  possible  a  careful  and  judicious  selection  of 
cases. 

(".  To  keep  patients  under  supervision  for  a  long  time,  and,  at  first, 
to  see  them  at  short  intervals. 

A.  The  operation  to  be  wide  and  thorough,  in  order  to  remove  every 
atom  of  tissue  which  may  be  diseased. 

(i)  Removal  of  the  Whole  Breast.  The  importance  of  an  extensive 
radical  operation,  even  in  early  cases,  has  already  been  insisted  upon. 
The  following  points,  bearing  on  the  way  in  wliich  carcinoma  attacks  the 
breast,  explain  the  necessity  for  \\ade  removal,  {a)  The  breast  is,  in 
reality,  a  much  more  extensive  organ  than  is  usually  believed.  In 
addition  to  the  well-known  prominence,  there  is  often  a  ring  of  outlying 
gland-masses  of  varying  size  and  extent.  Mr.  H.  J.  Stiles  ^  thus  alludes 
to  the  latter  point  :  "  The  breast  tissue  is  not  encapsulated  into  a  compact 
body,  but  is  so  broken  up  and  branched  at  its  periphery  that  the  stronia 
becomes  directly  continuous  with  the  superficial  fascia.  There  is, 
therefore,  no  capsule  in  the  ordinary  sense  of  the  term."  (6)  The  liga- 
menta  suspensoria  may  contain  breast  tissue  and  lymphatics.  Both 
these  facts  make  clear  the  futility  and  risk  of  niggardly  skin  incisions, 
(c)  There  are  often  lobules  of  breast  tissue  intimately  connected  with 
the  pectoralis  fascia. ^  These  are  certainly  left  behind  if  the  breast  is 
merely  separated  from  the  pectoral  fascia,  as  used  to  be  done,  (d)  A 
deep  lymphatic  plexus  or  lymph  path  runs  in  this  fascia  from  the  breast 
towards  the  axilla.  Volkmann  was  the  first  to  teach  prominently  that  it 
was  right  to  remove  entirely  the  pectoral  fascia.  Prof.  Halsted  thus 
quotes  from  Volkmann's  Beitrage  zur  Chirurgie  :  "  I  was  led  to  adopt 
this  procedure  because,  on  microscopical  examination,  I  repeatedly  found, 
where  I  had  not  expected  it,  that  the  fascia  w^as  already  carcinomatous, 
whereas  the  muscle  was  certainly  not  involved.  In  such  cases  a  thick 
layer  of  apparently  healthy  fat  separated  the  carcinoma  from  the  pectoral 
muscle,  and  yet  the  cancerous  growth,  in  places  demonstrable  only  with  the 
microscope,  had  shot  its  roots  along  the  fibrous  septa  down  between  the 
fat  lobules,  and  had  reached  and  spread  itself  out  in  fiat  islands  in  the 
fascia.  It  seems  to  me,  therefore,  that  the  fascia  serves,  for  a  time,  as  a 
barrier,  and  is  able  to  bring  to  a  halt  the  spreading  growth  of  the 
carcinoma." 

Mr.  Stiles  ^  beheves  that  "  local  recurrence  of  carcinoma  after  removal 
of  the  breast  is  usually  due,  not  to  the  rest  of  the  breast  being  in  a  pre- 
cancerous state,  but  to  the  non-removal  of  small  and  often  microscopic 
foci  of  cancer,  more  or  less  remote  from  the  main  tumour,  and  depending  for 
their  origin  upon  the  arrest  and  growth  of  cancerous  emboli  disseminated 

1  Edin.  Mrd.  Joiirn..  June  and  July  1892. 

-  As  will  be  shown  later  (p.  740)  Mr.  Handley  is  of  opinion  that  "  the  use  of  the  ex- 
pression >  removal  of  the  pectoral  fascia '  instead  of '  removal  of  as  wide  an  area  as  possible 
of  the  deep  fascia  '  and  the  exclusive  attention  paid  to  the  axillary  glands  as  the  channels 
of  dissemination  have  led  to  neglect  in  the  excision  of  the  deep  fascia  oVer  the  lower  part 
of  the  thorax  and  the  ujiper  part  of  the  abdomen." 

^  Loc.  supra  cit. 


732  OPERATIONS  ON  THE  THORAX 

more  or  less  directly  from  the  primary  tumour  along  the  lymphatics.^ 
The  importance  of  removing  all  the  retromammary  tissue,  pectoral 
and  axillary  fascia,  the  axillary  fat  and  glands,  along  with  the  breast, 
in  all  cases  of  carcinoma,  cannot  be  too  thoroughly  insisted  upon  or  too 
often  repeated.  The  anastomosis  and  intersection  of  the  lymphatics  are 
so  free  that  it  is  impossible  to  say  towards  which  set  of  glands  the  lymph 
from  any  given  point  in  the  breast  will  be  conveyed.  I  have  seen  can- 
cerous lymphatic  emboli  at  the  axillary  border  of  the  mamma  when  the 
tumour  was  situated  in  the  inner  hemisphere,  and  vice  versa." 

The  following  case  from  an  important  paper  by  Mr.  Raymond  Johnson, 
.  read  before  the  Pathological  Society, ^  illustrates  how  unsafe  it  is  to  leave 
any  portion,  however  small,  of  a  breast  the  seat  of  malignant  disease,  not 
only,  as  shown  by  Mr.  Stiles,  on  accomit  of  the  frequent  presence  of  minute 
foci  of  carcinoma,  remote  from  the  main  growth,  but  also  because  changes 
of  a  "  pre-cancerous  "  nature  may  be  going  on  in  parts  of  the  breast  not 
yet  actually  attacked  by  carcinoma. 

In  a  case  of  infiltrating  carcinoma  in  a  woman,  aged  27,  microscopical  examination 
of  parts  of  the  breast,  which  appeared  normal  to  the  naked  eye,  revealed  masses  of 
carcinomatous  cells  a])parently  lying  in  lymphatic  spaces.  In  another  si^ccimen 
of  the  infiltrating  variety  the  microscopical  appearances  strongly  suggested  that 
widesjjread  carcinomatous  change  was  involving  the  whole  organ,  sections  showing 
the  new  growth  arranging  itself  arovuid  the  small  ducts,  which  were  themselves 
normal.  In  the  case  of  a  woman,  aged  34,  a  small  nodular  carcinoma  was  situated 
at  the  axillary  border  of  the  left  breast.  After  removal  two  small  nodules  were  found 
at  the  sternal  end  of  the  gland,  each  having  the  tyjjical  structure  of  glandular 
carcinoma,  whilst  microscopical  examination  of  the  central  part  of  the  breast  showed 
marked  proliferative  changes  in  the  epithelium  of  the  acini,  these  changes  probably 
standing  in  the  same  relation  to  carcinoma  of  the  breast  as  chronic  suiierficial 
glossitis  does  to  epithelioma  of  the  tongue,  namely,  a  possible  "  pre-cancerous  " 
condition. 

Heidenhain,  in  a  most  valuable  paper,^  teaches  that  in  carcinoma  of 
the  breast  there  are  proliferative  changes  in  the  lobules  throughout  the 
whole  gland,  which  must  be  looked  upon  as  the  direct  forerunner  of 
carcinoma  ("  das  mittelbare  Vorstadium  der  Krebsentwickellmig  ")  and 
which  sooner  or  later  pass  into  this  disease. 

On  this  account,  believing  that,  whether  the  whole  breast  is,  in  the 
great  majority  of  cases,  in  a  condition  to  become  carcinomatous  or  not, 
partial  operations  are  liable  (especially  when  the  coarse  fat,  which  is  often 
so  abundant,  and  the  hemorrhage  in  the  operations  are  remembered) 

^  Mr.  Sampson  HancHcy  (Cancer  of  the  BreaM  and  itn  Operative  Treatment,  cliap.  iii., 
pp.  47  and  49)  says,  "  The  lymphatics  of  the  skin  originate  in  the  papillae,  and  communicate 
in  the  superficial  layer  of  the  dermis  to  form  the  subpayjillary  plexus.  From  this  plexus 
vessels  arise,  which  pierce  the  dermis  at  right  angles  to  the  surface,  and  pass  along  the 
fibrous  septa  of  the  subcutaneous  fat  to  empty  themselves  into  the  main  parietal  lym- 
phatic plexus,  which  lies  upon  or  just  over  the  deep  fascia. 

"  The  lymphatic  plexus  of  the  pectoi-al  fascia  is  often  spoken  of  as  if  it  were  an  ana- 
tomical entity.  It  is  in  reality  merely  a  conventional  subdivision  of  the  deep  fascial 
lymphatic  jalexus,  whose  network  of  intercommunicating  channels  invests  the  entire  body. 
This  great  plexus  is  divisible  by  the  median  plane  of  the  ))0(ly,  and  by  two  horizontal 
planes  passing  through  the  clavicles  and  through  the  umbilicus  respectively,  into  six 
areas,  three  on  either  side,  draining  as  the  case  may  be  into  the  cervical,  the 
axillary,  or  the  inguinal  glands.  AVithin  each  area  a  special  set  of  trunk  lymphatics 
arises  from  the  plexus  and  converges  on  the  corresponcUng  set  of  glands.  The  line,  or 
rather  zone,  separating  any  two  adjacent  areas,  may  be  called  the  lymphatic  water-parting, 
and  is  anatomically  a  zone  of  narrow  tortuous  channels  nowhere  traversed  by  trunk  lym- 
phatics, a  region  consequently  where  the  lymph  stream  is  at  its  feeblest,  and  where  even 
very  fine  particles  are  liable  to  be  arrested." 

'^  Brit.  Med.  Journ.,  1892,  vol.  i,  p.  70. 

'  "  Uebcr  die  Ursachen  der  localen  Krebsrecidive  nach  amputatio  Mammae,"  Ver- 
handiungen  der  Deutschen  Gcscllschaftfur  Chirurgie.  Berlin,  1889. 


REMOVAL  OF  THE  BREAST  733 

to  leave  behind  potential  foci  of  disease,  the  more  wholesale  operations  are, 
in  these  days  of  niodeni  surgery,  absolutely  essential. 

(ii)  Removal  of  the  Costo-sternal  Part  of  the  Pectoralis  Major  and  the 
Pectoralis  Minor.     It  is  now  generally  admitted  that  the  sterno-costal 
portion  of  the  pectoralis  major  should  be  completely  removed.     The 
necessity  for  this  step  in  every  case  was  first  urged  by  Halsted.     His 
reasons  are   as   follows  :     (a)  It   has  been   microscopically   proved  by 
Volkmann  and  Heidenham  that  repeatedly  a  carcinoma  of  the  breast, 
though  freely  movable  on  the  subjacent  parts  and  separated  from  the 
nmscle  by  a  layer  of  fat  apparently  healthy,  has  reached  and  spread  out 
in  the  fascia  over  the  pectoralis  major.     Removal  of  the  costo-sternal  part 
of  the  pectoralis  major  is  the  surest  method  of  getting  quickly  rid  of  this 
lascia.     (b)  It  facilitates  the  removal  of  the  diseases  in  one  piece,  which 
is  so  essential  {vide  infra,  pp.  734,  752  and  Fig.  :308).     (c)  This  step  does 
not  increase  the  danger  of  the  operation  ;   that  this  is  so  in  Dr.  Halsted's 
hands  is  shown  by  the  very  low  mortality  in  his  paper  {vide  swpra), 
pubHshed  in  1894,  viz.  seventy-six  cases  without  one  death,     {d)  The 
impairment  of  usefulness  of  the  upper  extremity,  due  to  the  operation,  is 
but  little  increased  by  the  above  step.     Indeed,  it  is  most  surprising  that 
one,  or  even  both,  pectorals  can  be  completely  removed,  with  little  or  no 
impairment  of  the  function  or  movements  of  the  arm.     In  most  cases 
the  arm  of  the  side  operated  upon  has  been  quite  as  useful  as  before  the 
operation.     Some  of  the  patients,  when  questioned,  complain  that  they 
cannot  dress  their  back  hair.     This  disabihty  is  due  to  the  loss  of  the  skin, 
and  not  to  the  loss  of  muscle.     The  above  small  impairment  of  usefulness 
Dr.  Halsted  attributes  to  his  securing  primary  union  of  the  axillary  end 
of  the  wound,  and  thus  an  absence  of  fixation  of  the  arm  to  the  side,  by 
his  flap  (Fig.  306).     With  regard  to  those  cases  in  which  there  is  some 
impairment  of  usefulness,  all  wall  agree  with  his  remark  :   "  After  all,  dis- 
ability, ever  so  great,  is  a  matter  of  very  little  importance  as  compared 
with  the  life  of  the  patient." 

As  regards  the  desirability  of  removing  the  pectorahs  minor  opinions 
still  differ.  Its  division  gives  very  free  access  to  the  axilla,  and  it  must 
be  remembered  that  there  is  usually  a  lymphatic  gland  between  the 
pectoralis  major  and  minor  which  is  frequently  diseased.  It  is  probably 
best  to  remove,  or  at  any  rate  to  divide,  the  pectoralis  minor  in  every  case. 

Sir  Watson  Cheyne  ^  considers  it  advisable  to  take  away  practically  the  whole 
of  the  sternal  portion  of  the  pectoralis  major.  As  to  removal  of  the  pectoralis 
minor,  he  removes  this  muscle  where  there  is  much  glandular  infection,  as  the  nerve- 
supply  is  almost  certain  to  be  injured.  Where  the  axillary  glands  are  not  much 
affected,  and  where  the  nerve -suj^ply  can  be  preserved,  he  generally  leaves  the 
pectoralis  minor,  as  the  axilla  can  be  quite  well  cleared  without  taking  it  away. 

"  For  myself,  knowing  that  in  the  majority  of  cases  carcinoma  of  the 
breast  is  not  brought  to  the  operator  mitil  it  is  no  longer  limited  to  the 
breast  itself,  feeling  also  that  the  growth  may  have  invaded  the  sheath 
though  the  fat  over  this  appears  healthy  (p.  731),  that  it  may  also  have 
invaded  the  muscle  itself  though  invisible  to  the  miaided  eye,  having 
found  that  for  myself  a  free  removal  of  the  muscle  facihtates  clearing  out 
of  the  top  of  the  axilla,  and  feeling  that  though  this  free  operating  leads 
to  a  thicker,  wider  scar,  and  therefore  in  some  cases  to  impaired  abduction 
and  elevation  of  the  arm,  this  must  not  weigh  against  any  step  that  may 

1   Lancet,  March  12,  1904,  vol.  i,  p.  700. 


734  OPERATIONS  ON  THE  THORAX 

help  in  extirpation  of  the  disease,  I  advocate  entire  removal  of  the  costo- 
sternal  portion  of  tlie  pectoralis  major  in  all  cases.  And  I  would  add  here 
that  the  fascia  over  the  serratus  magnus  should  be  removed  as  well, 
especially  in  those  cases  where  the  chief  disease  is  situated  over  the  lower 
and  outer  part  of  the  pectoralis  major,  w^here  the  coverings  of  the  chest 
wall  are  becoming  thinner.  When  the  patient  is  feeble,  or  has  chronic 
bronchitis  and  a  weak  heart,  the  decision  as  to  removal  of  the  costo-sternal 
part  of  the  muscle  will  depend  upon  the  way  in  which  the  anaesthetic  is 
taken,  the  condition  of  the  pulse,  and  the  amount  of  skilled  help  that  is  to 
hand.  For  free  removal  of  the  above  part  of  the  muscle  leads  to  additional 
haemorrhage  and  to  some  increase  of  the  shock." 

"  As  to  removal  of  the  pectoralis  minor,  I  agree  that  when  this  muscle 
is  but  little  developed,  as  is  usually  the  case,  the  axilla  can  be  cleared  out, 
by  efficient  use  of  retractors,  without  division  of  the  muscle.  But  the 
fatty  cellular  tissue  over  and  under  it  is  so  delicate,  and,  on  Dr.  Halsted's 
authority,  is  so  liable  to  be  infiltrated,  that  removal  of  the  muscle  certainly 
facilitates  clearing  this  tissue  away  thoroughly.  Removal  of  this  muscle 
will  not  increase  the  impaired  mobility  of  the  arm,  but  it  does  leave  a 
deeper,  more  irregular  floor  to  the  wound,  in  which  discharges  may  collect 
if  it  be  not  left  dry.  For  the  same  reason  immediate  grafting  is  rendered 
less  easy — a  matter  of  minor  importance,  as  it  is  wiser  to  defer  this  step 
if  it  be  found  needful  (p.  754)." 

(iii)  The  Need  of  Clearing  out  the  Axilla  in  every  Case.  The  need  for 
this  step  in  every  case  is  now  universally  recognised.  It  is  acknowledged 
that  the  axillary  glands  may  be  extensively  involved  without  any  external 
evidence  ;  nay,  more,  the  microscope  has  shown  that  axillary  contents, 
apparently  normal  to  the  unaided  eye,  have  been  the  seat  of  extensive 
carcinomatous  deposit.  We  know  now  that  opening  and  clearing  out  the 
axilla  does  not  add  to  the  risks  of  the  operation  as  long  as  due  precautions 
against  infection  are  taken.  Cases  are  still  occasionally  quoted  in  which 
though  the  axilla  was  never  opened,  the  disease  has  not  appeared  there  for 
many  years,  as  long  as  the  patient  was  kept  under  observation.  The 
answer  to  this,  as  an  argument  against  a  routine  practice  of  clearing  out 
the  axilla,  is  very  simple.  We  must  admit  that  such  cases  exist,  but  they 
are  extremely  few.  Possibly,  in  one  hundred  cases  in  which  the  axilla 
has  been  cleared  out  as  part  of  the  thorough  operating  of  the  present 
day,  in  four  or  five  this  step  might  be  superfluous,  as  the  disease  had  not 
reached  the  glands.  But  which  of  the  hundred  were  these  four  or  five  ? 
Does  any  one  pretend  for  a  moment  that  our  knowledge  of  carcinoma  of 
the  breast  enables  us  to  select  them  before  operation  ? 

(iv)  The  Whole  of  the  Disease  should  be"  Removed  in  one  Continuous 
Piece  (Fig.  308).  The  following  are  Dr.  Halsted's  words  ^  on  this  point, 
and  it  will  be  seen  that  to  achieve  this  object  is  one  of  his  chief  reasons 
for  removing  the  pectoralis  major  :  "  The  pectoralis  major,  entire,  or  all 
except  its  clavicular  portion,  should  be  excised  in  every  case  of  cancer 
of  the  breast,  because  the  operator  is  enabled  thereby  to  remove  in  one 
piece  all  of  the  suspected  tissues.  The  suspected  tissues  should  be 
removed  in  one  piece  (1)-  lest  the  wound  become  infected  by  the  division 
of  tissues  invaded  by  the  disease,  or  of  lymphatic  vessels  containing 
cancer  cells,  and  (2)  because  shreds  of  pieces  of  cancerous  tissue  might 
readily  be  overlooked  in  a  piecemeal  extirpation."  And  again,  at  p.  510  ; 
"  All  that  is  removed  in  one  piece  (Figs.  307  and  308)  ;  there  are  no  small 

1  Ann.  nj  Surg.,  November  1894,  p.  507. 


REMOVAL  OF  THE  BREAST  735 

pieces  of  sliicJs  or  tissue.  .  .  .     The  division  of  one  lymphatic  vessel 
and  th(>  liberation  of  on(<  cell  luii.y  be  en()n<fli  to  start  a  new  cancer."  ^ 

13.  A  Careful  and  Judicious  Selection  of  Cases. 

(i)  Cases  in  ivhicJi  an  Operalion  is  Indicated  or  in  which  the  circum- 
stances are  favourable.  (J)  Cases  somewhat  advanced  in  hfe ;  for  the 
younger  the  patient  the  more  active  is  the  cancer.  (2)  Especially  if 
patients  who  arc  on  in  years  are  thin,  dry  and  tough,  clear-voiced  and 
bright-eyed,  with  good  pulses  and  digestion,  and  no  cough  or  wheezing. 
{'.))  8niall  breasts  and  little  fat.  (4)  Where  the  growth  is  circumscribed, 
with  a  distinct  outline.  The  least  defined  tiiniours  are  the  worst  for 
recurrence.  (5)  Where  the  growth  is  very  hard.  The  "  stoniest " 
growths  are  usually  the  slowest.  (6)  8kin  not  involved.  (7)  Absence  of 
fixity.  (8)  Either  no  axillary  glands  palpable,  or  but  very  few  involved. 
(9)  Rate  of  progress  slow,  and  family  history  good. 

(ii)  Cases  to  which  an  Operation  is  altogether  unsuited,  or  especially 
Doubtful  and  {in  many)  Dangerous.  (1)  The  aged,  e.g.  after  seventy; 
not  only  are  the  aged  less  healthy,  but  they  are  usually  less  troubled  by ' 
the  disease  and  more  resigned.  (2)  The  unhealthy,  fat  and  plethoric. 
(3)  Habitual  over-eaters.  (4)  Tipplers  on  the  sly.  (5)  The  subjects 
of  a  confirmed  bronchitis  and  weak  heart.  (6)  Subjects  of  decided  albu- 
minuria, cirrhosis,  or  diabetes.  The  first  two  of  these  often  should  pro- 
hibit operation.  Where  glycosuria  is  present  the  prognosis  will  depend 
on  how  far  the  amount  of  sugar  is  affected  by  treatment.  Where  treat- 
ment has  no  effect,  and  where  the  operation  must  be  an  extensive  one,  it 
must  be  clearly  put  before  the  patient  and  her  friends  that  the  risks  are 
much  increased.  (7)  Extensive  disease  of  the  skin,  accompanied  by 
scattered  tubercles,  or  oedema,  or  a  condition  of  erythema  (this  is  the 
"  cancer-erythema  "  to  which  Sir  J.  Hutchinson  has  drawn  attention), 
and  worst  of  all,  a  brawny,  leather-like,  greasy  condition  of  the  skin, 
with  firm  oedema  and  open  sebaceous  glands,  approaching  the  condition 
of  cancer  en  cuirasse.  (8)  Quick  growth  with  rapidly  increasing  fixity. 
(9)  Enlargement  of  the  supraclavicular  glands.  When  this  condition  is 
present  the  general  opinion  of  surgeons  has  been  that  the  disease  has 
taken  too  extensive  a  hold,  and  that  operation  is  useless.  Dr.  Halsted's 
rule  ^  would  be  to  operate  on  the  neck  in  every  case.^  This  operation 
is  not  postponed,  as  it  can  never  be  done  so  well  as  at  the  first  opportunity 
when  the  axilla  is  opened,  the  subclavian  vein  fully  exposed,  and  the 
clavicle  free.  This  bone  is  not  now  divided  as  in  former  years,  "  for 
simple  division  of  the  clavicle  does  not  facilitate  the  dissection  much,  if 
any,  and  the  removal  of  a  piece  of  the  collar-bone  is  a  procedure  which 
maims  without  sufficient  compensation."  This  dissection  is  begun  at  the 
junction  of  the  internal  jugular  and  subclavian  veins,  and  the  supra- 
clavicular fat  and  lymphatics  cleared  away  by  working  from  within 
outwards  and  from  below  upwards.  The  great  majority  of  surgeons  are 
against  this  step. 

Sir  H.  Butlin's  opinion  *  is  as  follows  :  "I  have  not  been  in  the  habit  of  removing 
the  supraclavicular  glands,  certainly  not  as  a  routine  j)art  of  the  operation  for  cancer 

1  Though  there  is  no  definite  evidence  that  this  is  so,  yet  the  possibility  of  this  happening 
justifies  every  precaution.  Should  a  preUminary  exploratory  incision  be  thought  desir- 
able the  knife  and  other  instruments  used  for  this  purpose  should  be  cleaned  and  boiled 
before  being  again  used. 

2  Ann.  of  Sur(j.,  November  1898,  p.  570. 

*  Later  Halsted  gave  up  this  extreme  step  as  a  routine  measure. 

*  Operative  Treatment  of  Mcdigncmt  Disease,  2nd  ed.,  p.  399. 


736        OPERATIONS  ON  THE  THORAX 

of  the  breaat.  The  operations  which  are  now  performed  are  so  extensive  that  any 
addition  to  them  is  fraught  with  danger.  If  the  glands  above  the  clavicle  are  to  be 
removed  I  think  it  would  be  wiser  to  do  this  when  the  patient  has  recovered  from  the 
larger  operation.  If  they  are  actually  cancerous,  I  believe  that  the  case  is  hopeless  as 
far  as  radical  cure  of  the  disease  is  concerned.  And  that  is  an  opinion  which  is  shared 
by  most  operators  at  the  present  time."  Sir  W.  Cheyne  ^  would  only  clear  out  the 
posterior  triangle  if  he  found  the  fat  which  runs  up  behind  the  axillary  vessels  and 
nerves  in  the  direction  of  the  posterior  triangle  infected  with  enlarged  glands.  If  the 
glands  behind  the  sterno-mastoid  in  the  root  of  the  neck  are  implicated — and  this 
is  much  the  most  common  glandular  infection  in  the  jiosterior  triangle — he  would  not 
interfere,  "as  the  results  do  not  justify  operation."  Writing  a  few  years  later,^  Sir 
W.  ChejTie  would  open  the  posterior  triangle  if  any  enlarged  glands  are  felt  there,  or 
if  in  clearing  the  axilla  infected  glands  are  found  high  up.  Marked  enlargement  of  the 
supraclavicular  glands  in  his  opinion  "  renders  the  case  inoperable  from  the  point 
of  view  of  radical  removal." 

/^  The  question  may  be  summed  up  as  follows  :    If  the  supraclavicular. 
/  glands  are  enlarged  and  hard  but  still  mobile,  they  should  be  removed 
/    as  part  of  the  primary  operation.    If  large,  adherent  and  fixed,  operation  is 
/     contra -indicated. 

L The  only  evidence  of  any  value  which  we  learn  from  Dr.  Halsted's 

statistics  ^  on  this  point  is  that  two  of  the  cases  in  which  the  supra- 
clavicular region  was  cleared  out  were  alive  and  well  three  and  three  and 
a  half  years  respectively  after  the  operation  on  the  neck,  which  was  here 
a  secondary  one. 

There  is  one  point  which  appears  to  negative  success,  and  that  is,  that 
in  dealing  with  disease  here  it  is  impossible  to  follow  the  cardinal  rule  on 
which  Dr.  Halsted  has  himself  laid  so  much  stress,  viz.  to  get  out  the 
disease  in  one  continuous  piece.  AA^here  the  disease  has  reached  only  a  few 
of  the  axillary  glands,  and  these  lower  ones,  carefully  operating  on  wide 
lines  may  succeed  in  extirpating  in  its  continuity.  But  where  it  has 
extended  above  the  clavicle,  it  is  impossible  to  follow  the  above  most 
essential  rule.  There  will  always  be  an  infected  lymphatic  tract  running 
between  the  two  regions  behind  the  clavicle,  and  even  removal  of  this 
bone — itself  no  slight  operation- — ^will  not  enable  us  to  extirpate  the 
above  tract,  considering  what  its  relations  are,  however  carefully  the 
dissection  is  carried  from  below  and  above,  and  however  much  the  shoulder 
is  raised  and  depressed.^ 

Removal  of  the  supraclavicular  glands  may  be  called  for  as  a  second- 
ary operation.  In  this  case  the  condition  oi  the  patient,  her  wish  for 
furthei  treatment,  and  the  absence  of  recurrences  or  secondary  deposits, 
will  guide  the  surgeon  as  to  the  desirabihty  of  clearing  out  the  posterior 
triangle.  The  latter  may  be  a  difficult  and  trying  operation,  and,  if  the 
enlargement  of  the  glands  is  noticed  at  the  time  of  the  primary  operation, 
it  may  often  with  advantage  be  postponed  for  a  week  or  ten  days  after 
the  removal  of  the  breast  and  the  axillary  contents. 

1  Lancet,  1899,  vol.  i,  p.  757.  2  jjj^_^  1904,  ^0!.  i,  p.  700. 

^  The  supraclavicular  fossa  was  cleared  out  in  67  cases,  53  being  primary  and  14 
secondary  operations.  Of  the  53  primary  operations  in  12  the  supraclavicular  glands 
were  involved  ;  of  the  subsequent  history  of  these  we  are  told  nothing.  Cancer  was 
found  in  the  tissues  removed  23  times,  or  in  34  per  cent,  of  these  cases.  In  30  cases  there 
was  no  cancer,  and  in  14  the  result  was  uncertain,  as  the  tissues  removed  had  not,  at 
the  time  of  publication  of  Dr.  Halsted's  paper,  been  submitted  to  the  regular  exhaustive 
examination  which  his  specimens  undergo. 

*  It  is  the  same  with  cancer  of  the  tongue  when  the  glands  in  the  neck  are  invaded. 
Radical  cure  is  here  almost  hopeless,  owin^  to  the  great  difficulty  in  extirpating  the 
lymphatic  tract  which  lies  behind  the  jaw  and  in  the  floor  of  the  mouth.  It  is  noteworthy 
that  Mickuhcz  (Twentieth  Century  Practice  oj Medicine,  vol.  ix,  p.  79),  wrote  on  this  point : 
"  I  regard  the  prospect  of  radical  cure  as  excluded  as  soon  as  the  deep  glands  of  the  nock 
become  invaded." 


REMOVAL  OF  THE  BREAST  737 

(JO)  A  young  patient,  especially  with  a  voluminous  bieast,  a  rapidly 
increasing  growth,  and  a  bad  family  liistory.  (11)  Of  course,  the 
presence  of  carcinoma  elsewhere — c.:/.  uterus — or  secondary  deposits  in 
the  liver,  pleura,  and  bones. 

Tho  prcsi'uce  of  palpable  subcutaneous  nodules  over  or  below  tin;  xiphoid  cartilage 
is  an  luiequivocal  inilication  that  e])igastric  invasion  has  already  taken  place,  and 
that  o[)eration  is  uselc>ss.  It  nnist  never  be  forgotten  that  the  first  sign  of  ei)igastric 
invasion  may  be  found,  not  in  the  epigastric  region,  but  in  the  pelvis,  from  the  gravi- 
tation of  cancerous  particles  into  it.  A  vaginal  and  rectal  examination  should  be  made 
as  a  routine  measure  prior  to  oj)eration.  Pelvic  pain,  enlargement  of  the  ovaries, 
or  induration  in  Douglas's  Pouch,  should  raise  a  grave  suspicion  that  the  case  is 
beyond  the  reach  of  oi^eration. 

Mr.  Sampson  Handley's  advice  ^  should  always  be  remembered  : 

"  In  seeking  for  evidence  of  visceral  deposits,  examination  of  the  spine  for  angular 
curvature  should  not  be  omitted.  Prior  to  operating  on  a  cancer  of  the  breast,  a  care- 
ful examination  of  the  epigastric  parietes  should  always  be  made.  The  px-esence  of 
tenderness  or  pain  in  this  region  should  raise  the  suspicion  that  epigastric  invasion 
has  already  occurred  ;  and  in  such  cases  the  liver  should  be  carefully  palpated  under 
the  anaesthetic,  especially  in  the  ei)igastric  region,  before  the  breast  is  removed.  If 
any  irregular  nodular  enlargement  of  the  organ  is  present  the  operation  should  be 
abandoned  ;  for  it  appears  at  present  ho])eless  to  pm-sue  the  cancer  into  the  peritoneal 
cavity,  and  anything  short  of  this  would  be  futile  in  such  a  case." 

(1 2)  Cases  in  which  the  axillary  vessels  and  nerves  are  clearly  involved 
in  a  mass  of  growth.  (13)  Pregnancy  and  suckling.  When  these  com- 
plications are  present  in  carcinoma  of  the  breast  two  questions  arise. 
One  refers  to  the  diagnosis.  In  these  cases  the  carcinoma  is  likely  to  be 
associated  with  evidence  of  inflammation,  and  to  be  mistaken  for  acute 
mastitis.  The  following  points  should  be  investigated  :  "  The  skin  has  a 
peculiar  erythematous  blush  upon  it  (cancer-erythema,  Hutchinson) 
which  spreads  over  the  skin  of  the  mamma  and  thorax,  gradually  fading 
off  into  the  surrounding  tissues.  There  are  local  heat  and  tenderness  and 
the  temperature  is  raised.  A  close  inspection  of  the  skin  usually  declares 
the  true  nature  of  the  case,  for  it  is  infiltrated  with  carcinoma  over  the 
breast,  and  has  invariably  the  "  peau  d'orange "  ajjpearance.  The 
lymphatics  of  the  integument  may  be  markedly  implicated,  so  that  they 
stand  out  as  white  cords  and  nodules  of  a  yellowish  or  white  and  pearl -like 
aspect."  2  With  regard  to  operation,  the  prognosis^  is  extremely  un- 
favourable when  the  patient  is  either  pregnant  or  suckling.  If  the 
patient  be  comparatively  young,  there  is  much  vascularity  and  activity 
of  the  lymphatic  circulation,  and  hence  a  very  high  degree  of  malignancy. 
However  free  the  removal,  return  in  the  adjacent  area  is  extremely 
probable,  together  with  secondary  deposits.  If  the  patient  survive,  the 
other  breast  may  not  improbably  be  attacked.  The  outlook  should  be 
put  before  the  patient.  If  operation  be  decided  upon  the  risks  of  abortion 
or  premature  labour  must  be  faced. 

(iii)  Cases  in  uhich  cm  Operation  is  Doubtful.  These  lie  intermediate 
between  (i)  and  (ii),  both  as  to  the  general  and  local  points. 

Operation'*  (Figs.  296-309).  The  chief  objects  to  be  borne  in  mind 
throughout  the  operation  have  been  given  at  p.  731.     Owing  to  the 

1  Cancer  of  the  Breast,  p.  189. 

2  Sheild,  Diseases  of  the  Breast,  p.  358. 

'  There  arc  no  worse  cases  for  operation  than  those  in  which  malignant  disease  super- 
venes on  mammary  abscess  and  induration  in  suckling  women.  The  more  vascular  the 
breast  and  the  more  abundant  the  fat,  the  more  difficult  will  it  be  to  make  certain  of 
extirpating  not  only  the  growth,  but  also  every  atom  of  the  breast. 

*  By  some  the  above  operation  is  called  "  the  complete  operation."  Till  the  cases 
submitted  to  it  have  been  watched  for  a  much  longer  period  than  three  years,  the  period 

SURGERY  I  47 


738  OPERATIONS  ON  THE  THORAX 

age  of  many  of  these  patients,  the  after-confinement  to  bed,  and  the 
restricted  position  which  hes  before  them,  especial  care  should  be  paid 
to  the  state  of  the  bowels  and  kidneys,  and  any  bronchitis,  however  slight 
this  appears  to  be,  should  be  treated.  The  parts  having  been  very 
widely  sterilised,  the  patient's  neck  and  abdomen  are  well  protected 
wth  mackintoshes  with  warm  towels  beneath,  while  sterilised  towels 
are  securely  packed  around  the  area  of  the  operation,  and  one  wrapped 
round  the  patient's  hair.  When  the  patient  is  weakly,  the  subject  of  any 
bronchitis,  the  warmth  of  the  trunk  and  lower  limbs  should  be  carefully 
looked  to.  On  a  cold  day  the  room  should  have  a  temperature  of  70°. 
The  operation  should  not  be  performed  on  a  foggy  day.  The  surgeon 
should  be  prepared  at  every  point  by  the  time  that  the  patient  is  anses- 
thetised.  It  will  be  well  to  allude  here  to  a  preliminary  point  of  much 
importance.  Let  it  be  supposed  that  the  case  is  one  of  doubtful  diagnosis, 
whether  one  of  carcinoma,  chronic  mastitis,  or  cyst.  When  chronic 
mastitis,  which  has  resisted  judicious  treatment,  is  present,  the  patient 
being  at  a  carcinomatous  age,  is  rendered  much  safer  by  removal  of 
the  whole  breast  (p.  732),  and  the  same  is  true  of  many  cases  of  cysts, 
where  this  condition  does  not  occur  singly  ;  in  any  of  these  the  operator's 
hands  are  sometimes  tied,  and  he  is  pledged  to  save  the  breast  if  possible. 
In  such  cases — and  here  the  patient  must  take  the  entire  risk — in  making 
any  exploration  to  clear  up  the  case,  it  is  best  not  to  make  an  incision 
into  the  supposed  growth,  but  an  excision  of  it,  with  a  margin  of  appa- 
rently healthy  tissue,  as  the  risk  of  auto-infection  is  not  a  mere  theoretical 
danger.  If  more  requires  to  be  done  the  wound  is  rapidly  sutured,  and 
the  hands  of  the  operator  and  any  instruments  used  are  re- sterilised. 

The  patient  being  brought  to  the  edge  of  the  table,^  and  raised  on 
a  pillow  to  a  height  convenient  to  the  operator  the  arm  is  sufficiently^ 

too  often  considered  sufficient  (p.  729),  it  will  be  wiser  and  more  honest  not  to  write  of 
operations  on  cancer  as  complete.  By  others  the  operation  is  described  by  the  name  of 
some  operator,  e.g.  Dr.  Halsted,  whose  operation  has  been  given  later.  This  has  since 
been  extended  and  modified  as  the  result  of  the  important  researches  of  Mr.  Handley.  Sir 
W.  Cheyne,in  the  discussion  on  Mr.  Sheild's  paper  (Med.-Chir.  Soc.  Tran3.,  February  22, 
1898),  considered  that  as  Heidenhain  and  Stiles  had  described  the  pathology  and  mode 
of  spread  of  breast  cancer,  and  shown  in  full  detail  what  must  be  done  as  regards  operation, 
before  Halsted  wrote,  the  operation  should  be  called  the  Heidenhain-Stiles  operation,  "  after 
the  man  to  whom  the  whole  credit  of  it  is  due."  To  give  to  any  two  operators  the  whole 
credit  of  an  operation  which,  not  a  new  one,  has  been  built  uji  by  the  labours  of  many, 
and  which  owes  its  present  improved  technique  verj^  largely  to  the  advances  of  aseptic 
surgery,  appears  to  involve  injustice  to  others.  The  tendency  nowadaj^s  to  talk  and  write 
as  if  the  origin  of  the  modern  operative  treatment  of  cancer  of  the  breast  dated  to  the 
labours  of  Heidenham,  Stiles,  and  Halsted.  ignores  most  unfairly  the  work  of  others  who 
should  not  be  forgotten.  And  one  name  at  least — that  of  an  English  surgeon — rises 
pre-eminently  as  a  worker  in  this  field.  That  surgeon  is  the  late  Sir  W.  M.  Banks.  For 
twenty-three  years  this  surgeon,  with  unfaiUng  earnestness  and  characteristic  vigour  and 
terseness  of  expression,  in  many  jDlaces  urged  the  need  of  more  extensive  operations  in  this 
disease.  His  papers  are  :  "  A  Plea  for  tlie  more  Free  Removal  of  Cancerous  Growths," 
1877  ;  "  On  Free  Removal  of  Mammary  Cancer,  with  Extirpation  of  the  Axillary  Glands 
as  a  Necessary  Accompaniment,"  1882  ;  "  Extirpation  of  the  Axillary  Glands,  a  Necessary 
Accompaniment  of  the  Removal  of  the  Breast  for  Cancer,"  read  before  the  Harveian 
Societj'  in  1887,  a  paper  which  deserved  a  much  more  comprehensive  title,  as  in  it  several 
points  of  which  we  have  lately  heard  so  much,  viz.  removal  of  the  disease  in  one  con- 
tinuous mass  and  the  need  of  division  of  the  jiectoralis  major,  are  dealt  with.  These 
papers  are  mentioned  in  the  Lettsomian  Lectures  of  Sir  W.  M.  Banks  {Brit.  Med.  Jovrn., 
April  7.  1900),  and  prove  that  if  honour  is  to  be  given  where  it  is  due  a  fair  share  of  it 
must  fall  to  him. 

1  Tills  step,  aided  by  careful  jiacking  of  the  towels,  will  diminish  the  tendency  of  blood 
to  trickle  backwards  beneath  the  patient. 

2  It  will  be  remembered  that  the  more  the  arm  is  abducted  and  elevated  the  more 
superficial  do  the  axillary  vessels  become. 


REMOVAL  OF  THE  BREAST 


739 


abducted  to  open  out   the  axilla,  and  fastened  or   supported  in  this 
position. 

(1)  The  Incision.  The  surgeon  then  examines  the  probable  extent  oE 
the  breast  ^  and  determines  the  site  of  his  incisions.  The  advice  of  Mr. 
Handley  :  "  That  the  centre  of  the  growth,  not  necessarily  the  nip[)k', 
must  be  taken  throughout  as  the  central  point  of  the  operation  area," 
must  be  borne  in  mind.  'J'he  following  will  give  sufhcicnt  choice  :  A.  The 
usual  elliptical  incisions,  employed  on  a  very  wide  scale.     B.  The  same 


Fm.  296.      Incision  recommended  by  Sir  W. 

Watson  Cheyne.      X  indicates  the  site  of  the 

tumour. 


Fig.  297.     Incision  recommended  by  Sir 
W.  Watson  C!heyno.    X  indicates  the  posi- 
tion of  the  growth. 


with  angular  incisions  superadded,  as  in  Figs.  296,  297,  when  the  surgeon 
has  to  deal  with  a  growth  lying  near  the  periphery  of  the  breast.  C.  The 
incision  adopted  by  Dr.  Halsted  (Figs.  306  and  307).  D.  That  em- 
ployed by  Prof.  T.  C.  Warren,  of  Harvard  University  (Figs.  302,  303). 

The  incisions  used  by  Mr.  Handley^  are  shown  in  Fig.  298.  An 
annular  one,  five  or  six  inches  in  diameter,  surrounds  the  breast.  A 
curvilinear  one,  AB,  begins  above  at  the  lower  edge  of  the  pectoralis 
major,  near  its  insertion,  and  ends  by  joining  the  annular  one  also  near 
the  lower  border  of  the  great  pectoral.  This  incision  crosses  the  base  of  the 
axilla  and  marks  out  an  almost  semicircular  flap  of  sldn,  the  convexity 
of  which  reaches  back  almost  to  the  edge  of  the  latissimus  dorsi.  The 
linear  incision,  CD,  coming  off  from  the  lower  part  of  the  annular  one 
and  passing  for  two  inches  along  the  linear  alba,  allows  of  the  exposure 
of  the  deep  fascia  over  the  upper  part  of  the  abdominal  wall. 

1  Where  the  breast  is  large  and  pendulous  it  must  be  raised  before  the  line  of  the  lower 
incision  is  determined  ujjon. 

2  Cancer  oj  the  Breast,  1906,  p.  182. 


740 


OPERATIONS  ON  THE  THORAX 


(2)  Under-cutting  the  Edges  oJ  the  Skin  and  Exposure  of  the  Deep 
Fascia.  Before  going  further  with  the  details  of  the  operation  attention 
must  be  drawn  to  a  point  on  which  Mr.  Handley  has  insisted.'  As  a 
result  of  much  painstaking  work,  Mr.  Handley  concludes  that,  while 
mammary  carcinoma  may  spread  by  the  lymphatics  of  the  skin,  it  is 
rather  through  the  lymphatic  plexus  in  the  deep  fascia  that  the  chief 
advance  takes  place.  O^ang  to  the  continuity  of  the  deep  fascia,  the 
practical  importance  of  the  conclusion  is  obvious.     The  chief  bearing  on 


Fig.  2U8. 


the  operation  of  the  investigations  of  Mr.  Handley,  alluded  to  above,  is, 
in  his  owai  words,  as  follows  :  "  The  aim  should  he  to  remove  as  widely  as  is 
fracticahle  a  circular  area  of  deep  fascia  with  its  centre  at  the  primary  growth, 
remembering,  hoivever,  that  the  growth  extends  in  the  fascia  more  readily 
in  a  vertical  than  in  a  horizontal  direction.  He  recommends  that  a  circular 
area  of  deep  fascia,  ten  or  twelve  inches  in  diameter,  should  always  be 
removed,  the  situation  of  the  growth  and  not  that  of  the  iiipple  being  taken 
as  the  centre  of  the  circle."  The  use  of  the  expression,  "  removal  of 
the  pectoral  fascia,"  instead  of  "  removal  of  as  wide  an  area  as  possible 
of  the  deep  fascia,"   and  the   exclusive  attention  paid  to   the  axillary 

1  The  Centrifugal  Spread  of  Mammary  Carcinoma  in  the  Parietes  and  its  Bearing  on 
Operative  Treatment,  IQCi. 


REMOVAL  OF  TTTE  BREAST 


741 


glands  as  the  channels  of  dissonii nation,  have  led  to  the  neglect  in  the 
excision  of  the  deep  fascia  over  the  lower  part  of  the  thorax  and  the  upper 
part  of  the  abdomen.  It  seems  to  be  in  this  direction  that  the  sc()j)e  of  the 
operation  re* quires  exiension,  rather  tlian  in  the  direction  of  opening  up  the 
posterior  triangle.  'i'h(>  distance  from  the  nipple  to  the  clavicle  may  be 
taken  as  the  radius  of  the  circle  of  deep  fascia  round  the  growth  which  can 
be  removed  without  difficulty  by  undermining  the  skin  flaps  sufficiently. 
If  the  growth  starts  under  the  nipple,  the  deep  fascia  should  accordingly 
be  removed — above,  up  to  the  clavicle  ;  internally,  one  or  two  inches 
beyond  the  middle  line  ;  externally,  just  beyond  the  edge  of  the  latissinuis 
dorsi  ;  below,  to  a  horizontal  line  ruiming  at  least  two  inches  below  the  tip 
of  the  ensiform  cartilage.  If  the  growth  is  in  the  lower  and  inner  part 
of  the  breast,  the  circle  of  infected  deep  fascia  will  encroach  still  more 
on  the  surface  of  the  abdomen,  and  over  the  opposite  side  of  the  breast, 
and  removal  of  the  deep  fascia  in  these  directions  nnist  be  carried  out  yet 
more  widely.  "  In  order  to  obtain  access  to  the  up})er  part  of  the  abdom- 
inal wall  for  the  purpose  of  remo\ang  its  deep  fascia,  the  lower  angle  of 
the  incision  should  be  prolonged  downwards  for  two  or  three  inches  over 
the  linear  alba,  and  the  flaps 
undermined  to  a  corresponding 
extent.  Great  care  should  be 
taken  to  remove  every  part  of  the 
origin  of  the  pectoralis  major  from 
the  rectus  sheath.  The  surface 
of  the  latter  on  both  sides  of  the 
middle  line  should  be  most  care- 
fully cleaned,  as  should  also  the 
digitations  of  the  external  oblique, 
down  to  a  horizontal  line  running 
two  or  even  three  inches  below  the 
tip  of  the  ensiform  cartilage." 

With  one  of  the  incisions  re- 
commended above  there  is  no 
difficulty  in  undermining  the  skin 
edges  sufficiently  to  expose  this 
large  area  of  deep  fascia.  A 
sufficient  thiclcness  of  fat  must  be 
left  on  the  deep  aspect  of  the 
skin  to  ensure  its  vitality,  but 
the  knife  must  not  be  made  to 
pass  so  deeply  as  to  penetrate 
the  breast  tissue.  Any  bleeding 
vessel's  on  the  cut  surface  of  the 
skin  flaps  should  be  secured,  but 


Fig.  299.  The  lightly  shaded  area  represents 
the  extent  of  deep  fascia  removed  in  the 
operation  of  incision  of  the  breast  as  at 
jiresent  usually  performed.  The  darkly 
shaded  area  represents  the  additional  extent 
of  deep  fascia  which  should  in  future  be  re- 
moved to  ensure  that  the  circle  of  invaded 
fascia  shall  be  completely  circumscribed,  and 
not  intersected  and  partly  left  behind  below. 
The  line  surrounding  the  whole  shaded  area 
represents  the  extent  to  which  the  skin-flaps 
should  be  undermined.     (Handley.) 


as  thev  will  have  to  be 


those    on    the    deeper  surface  of 

the  wound  should  be  controlled  by  pressure 

again  divided  at  a  later  stage  of  the  operation. 

A  circular  incision  is  then  made  through  the  large  area  of  deeper 
subcutaneous  fat  and  deep  fascia  which  has  been  exposed  by  the  reflection 
of  the  skin  flaps.  Mr.  Handley  recommends  that  at  this  stage  a  fringe 
of  deep  fascia  should  be  raised  up  all  round  the  field  of  operation  until  the 
knife  reaches  either  the  margin  of  the  great  pectoral  muscle,  the  margin  of 
the  axillary  outlet,  or  the  edge  of  the  breast,  as  the  case  may  be.     Towards 


742 


OPERATIONS  ON  THE  THORAX 


the  outer  side  of  the  field  of  operation,  the  fascia  must  be  dissected  up 
from  over  the  anterior  edge  of  the  latissimus  dorsi  and  fiom the  serratus 
magnus. 

(3)  Division  of  Muscles.  The  margin  of  dcejj  fascia  which  has  been 
dissected  upon  the  inner  side  is  then  reflected  until  the  sterno-costal 
origin  of  the  pectoralis  major  is  reached.  This  is  cut  through  close  to  its 
attachment  to  the  costal  cartilages.  When  a  part  of  its  insertion  has  been 
divided  a  finger  may  be  insinuated  beneath  the  muscle,  and  by  drawing 

^^^  N  N PL 


^z^m^^^^^^^^- 


Fig 


C' 
300 


To  show  that  subcutaneous  nodules  do  not  necessarily  imply  the 
extension  of  growth  along  the  skin.  The  above  diagram  (Handley)  represents 
a  section  of  the  parietes  at  right  angles  to  the  surface  in  the  region  of  tlie  primary 
growth,  P  :  a  a,  skin  ;  b  b,  subcutaneous  fat ;  c  c,  deep  fascia.  The  sub- 
cutaneous nodules,  N  N  N,  may  arise  (1)  from  spread  of  growth  in  the  skin  in 
the  direction  of  the  lightly  dotted  line,  a  view  generally  held,  or  (2)  from  spread 
of  growth  in  the  deep  fascia,  along  the  heavy  interrupted  line,  with  occasional 
offshoots  to  the  skin,  giving  rise  to  subcutaneous  nodules.  Though  this  is  not 
the  accepted  view,  it  is  the  correct  one  in  Mr.  Handley's  opinion. 

this  forward  the  di\'ision  of  the  remainder  is  facilitated.  In  an  early 
case,  or  where  the  growth  is  situated  low  dovm,  the  cla\'icular  portion  may 
be  preserved.  The  breast  and  the  detached  muscle  are  then  drawn 
outwards  ;  the  external  anterior  thoracic  nerve  and  vessels  which  are 
seen  piercing  the  costo-coracoid  membrane  and  entering  the  dee"p  aspect 
of  the  muscle,  are  di\dded  and  the  vessel  secured.  The  pectorahs  minor 
now  comes  into  view.  This  muscle  is  then  di^nded  and  removed  at  its 
origin  and  insertion,  so  as  to  make  certain  of  getting  away  the  very 
delicate  fatty  tissue  on  it  and  beneath  it  which  is  rich  in  lymphatics  and 


Fig.  301.  A  key-diagram  to  show  the  conditions  found  in  a  section  taken 
from  the  upper  part  oi  the  abdominal  wall,  demonstrating  the  invasion  of  the 
deep  fascia  in  carcinoma  of  the  breast.  The  skin  at  this  level  was  free  from 
obvious  growth,  though  subcutaneous  nodules  were  present  higher  up.  Above 
is  seen  the  sulxutaneous  fat.  separated  from  the  rectus  by  A  A.  the  anterior 
layer  of  the  sheath.  The  dark  masses.  B.  are  cancer  nodules,  which  ongmated 
from  growth  lying  within  the  vessels  of  the  fascial  lymphatic  plexus.  Here  and 
there  they  are  sending  prolongations  towards  the  skin.     (Handley.) 

often  cancerous.  While  the  fascia  and  muscles  are  being  reflected 
numerous  vessels  will  be  divided.  They  should  quickly  be  secured  with 
forceps,  and  as  the  number  accumulates  they  should  be  tied  off  with  catgut. 
The  large  raw  surface  should  be  kept  covered  with  sterilised  pads  wrung 
out  of  hot  saline  solution  except  in  the  area  in  which  the  surgeon  is 
actually  working.  This  diminishes  the  shock,  aids  h  semostasis,  and  lessens 
the  possibility  of  infection. 

(4)  Clearing   out   the   Axillary    Contents.    When  the    pectorals   are 
removed  the  axillary  space  is  freely  exposed.     The  costo-coracoid  mem- 


REMOVAL  OF  THE  lUlEAST  743 

braiie  is  diviilod  just  below  the  clavicle,  and  the  first  part  of  the  axillary 
artery  and  the  termination  of  the  subclavian  vein  are  now  exposed  at  the 
highest  possible  point  (Fig.  304),  and  the  sheath  and  overlying  fatty 
tissue  are  carefully  removed  from  the  axillary  vein  in  its  whole  length, 
and  with  these  the  fat  and  glands  in  the  axilla  aerording  to  the  directions 
given  below.  The  numerous  small  veins  which  are  met  with  now  should 
be  carefully  tied  close  to  the  axillary  veins,  and  no  particle  of  extraneous 
tissue  should  be  included  in  the  ligature.  On  no  account  is  the  operator 
to  pull  out  the  glands  and  fat  from  the  axilla  with  his  fingers — a  step 
certain  to  leave  infected  tissues  behind.  The  need  of  getting  away  the 
disease  in  one  continuous  whole  is  now  especially  to  be  remembered.  In 
cleaning  the  sheath  a  scalpel  should  be  employed,  but  for  the  axillary 
contents  blunt-pointed  slightly  curved  scissors,  which  serve  not  only 
for  cutting  but  for  separating  structures,  are  very  useful.  The  inner 
and  posterior  walls  of  the  axilla  are  then  freed  from  all  fat  and  fascia 
connnencing  above  and  working  downwards.  Mr.  Handley  recommends 
that  the  digitations  of  the  serratus  magnus  muscle,  which  lie  in  direct 
contact  with  the  deep  surface  of  the  breast,  should  be  divided  at  their 
origin  from  the  ribs,  and  that  these  same  digitations  should  subsequently 
be  completely  removed  by  division  further  back  towards  the  scapula. 

Great  care  is  needed  in  cleaning  the  fatty  tissues,  and  especially  so 
if  enlarged  glands  are  present,  from  the  axillary  vein.  If  this  trunk  be 
injured  a  lateral  ligature  may  be  applied  if  the  opening  is  small,  "but  if 
there  is  an  extensive  tear  ligature  of  the  vein  below  and  above  the  opening 
will  probably  be  required.  This  is  spoken  of  by  some  operators  as  a  slight 
matter,  and  as  one  which  will  not  cause  after-trouble.  But  this  result 
is  not  to  be  relied  upon.  It  probably  depends  upon  the  level  at  which  the 
venae  comites  of  the  brachial  join  the  basilic  (a  somewhat  variable 
point),  and  the  relation  of  this  to  the  part  tied.  As  there  is  a  most  distinct 
risk  of  a  heavy  oedematous  arm  resulting,  the  only  excuse  for  resecting 
part  of  the  vein  is  when  an  enlarged  gland  is  adherent  to  it.  Whether 
it  is  needful  to  expose  and  clean  the  artery  is  doubtful  ;  Dr.  Halsted 
thinks  it  safer  to  do  so,  but  it  prolongs  the  operation  considerably.  Sir  W. 
Watson  Cheyne  practises  a  careful  step  at  this  stage  which  is  noteworthy. 
When  the  vein  has  been  cleaned  and  the  axilla  cleared  out  there  still 
remain  some  lymphatics  which  rmi  up  behind  the  vessel  towards  the 
posterior  triangle.  These  may  be  infected.  To  remove  them  the  vessels 
and  nerves  must  be  lifted  up,  and  this  mass  of  fat  and  glands  lying  in  the 
triangular  space  between  the  vessels  in  front,  the  scapula  outside,  and  the 
chest-wall  inside  should  be  taken  away. 

The  axillary  vessels  having  been  defined  and  cleaned,  the  surgeon  will 
now  be  more  at  ease  in  stripping  out  the  contents  of  the  axilla  from  its 
inner  and  posterior  walls.  The  fatty  fascia  which  ties  the  breast,  &c., 
to  these  regions  is  further  put  on  the  stretch  and  dissected  of?  from  the 
serratus  magnus  and  intercostals.  As  to  the  intercosto-humeral  nerve, 
it  is  not  worth  while  to  dissect  it  out  and  preserve  it.  The  lateral  branches 
of  the  intercostal  vessels  need  careful  cleaning  and  securing,  especially 
below  at  the  juncture  of  the  internal  and  posterior  wall,  where,  in  the 
thickest  part  of  the  serratus  magnus,  there  is  always  an  anastomosis 
between  the  above-mentioned  vessels  and  the  subscapular  artery.  This 
anastomosis  will  certainly  be  cut  into  if  the  fat  and  fascia  over  the  serratus 
magnus  have  been  efficiently  removed.  Unless  these  bleeding-points  are 
promptly  secured,  much  blood  will  be  lost,  and  a  collection  of  blood  may 


744  OPERATIONS  ON  THE  THORAX 

easily  take  place  here,  and  cause  trouble  afterwards.^  As  the  posterior 
wall  is  cleaned  the  subscapular  vessels  and  nerves  will  come  into  view. 
It  is  very  easy,  by  using  undue  force  or  haste  in  stripping  clean  the  sub- 
scapular or  other  veins,  to  tear  one  or  more  of  these  away  close  to  the 
parent  trunk,  sometimes  leaving  a  small  hole  punched  out  in  this  vessel. 
In  such  cases  the  haemorrhage  is  most  embarrassing,  and  must  be  met 
either  by  taking  up  the  aperture  with  a  lateral  ligature  of  fine  catgut,  or 
ligaturing  the  vein  above  and  below^ — a  point  alluded  to  above. ^  If  there 
be  time,  if  the  patient's  condition  be  favourable,  and  if  the  fat  strip  easily 
away,  the  subscapular  nerves,  especially  the  long  one,  should  always  be 
spared.  Under  other  conditions  no  time  should  be  spent  in  dissecting 
them  out. 

Sir  H.  Butlin  ^  writes  :  "  I  have  not  attempted  to  spare  the  sub- 
scapular nerves,  and  I  have  been  surprised  to  find  that  the  movement  of 
the  upper  extremity  is  remarkably  good,  provided  too  large  an  area  of 
integument  has  not  been  taken  away."  Loss  of  power  in  the  latissimus 
dorsi  should  not,  however,  weigh  for  a  moment  against  any  step  that 
favours  complete  removal  of  the  disease  ;  if  primary  closure  of  the  axilla 
and  primary  union  of  the  axillary  end  of  the  wound  be  secured — con- 
ditions which  are  always  possible— and  the  precaution  given  below  as  to 
the  position  of  the  limb  and  early  movement  be  followed,  a  very  useful 
arm  and  shoulder-joint  will  result.  Fig.  309  shows  how  much  elevation 
and  abduction  may  be  gained  three  weeks  after  the  operation,  even  where 
both  pectorals  have  been  removed  on  each  side,  if  the  after-treatment 
is  attended  to. 

While  cleaning  the  inner  w^all  of  the  axilla  the  nerve  of  Bell  will  be 
found  running  downwards  on  the  serratus  magnus  ;  this  nerve  should  also 
be  spared. 

(5)  Removal  of  the  Breast  and  the  Axillary  Contents.  The  posterior 
wall  of  the  axilla  having  been  now  cleaned  to  a  point  on  a  level  with  the 
latissimus  dorsi,  all  that  remains  is  to  sever  the  mass  of  breast,  &c.,  along 
the  line  where  the  deep  fascia  has  been  dissected  forwards  to  the  outer 
border  of  this  muscle. 

The  operator  now  scrutinises  the  wound  to  see  what  scraps  and  tags 
of  fatty  tissue  may  remain  in  dangerous  positions,  e.g.  over  the  subscapu- 
laris,  or  along  the  vessels,  or  in  the  apex  of  the  axilla.  In  spite  of  the 
greatest  care  to  get  the  diseased  structures  away  in  one  piece,  such  shreds 
of  tissue  may  be  left.  At  this  stage  the  huge  wound,  which  has  been  kept 
carefully  covered,  wherever  possible,  with  hot  moist  sterilised  gauze, 
should  show  a  floor  consisting,  from  wnthin  outwards,  of  muscle — e.g. 
above,  clavicular  part  of  pectoralis  major  ;  a  little  lower,  a  narrow  rim 
of  the  costo-sternal  portion  of  the  same  muscle,  external  intercostals,  upper 
part  of  external  oblique,  attachments  of  pectoralis  minor,  serratus  magnus, 
subscapularis,  teres  major,  and  latissimus  dorsi. 

(6)  Hsemostasis.  Bleeding  is  next  finally  attended  to.  Throughout 
the  operation,  in  order  to  diminish   the  shock  inseparable  from  these 

1  Such  a  collection,  leading  to  tension  on  the  flaps,  will  require  draining.  Again, 
from  the  proximity  of  the  axilla,  which  with  its  regrowing  hairs  it  is  not  always  easy  to  keep 
sterile,  any  fluid  here  may  become  infected. 

-  The  remarks  made  above  on  injury  to  the  vein  apply,  of  course,  with  increased 
significance,  to  the  artery.  Mr.  Sheild  says  that  he  has  seen  similar  trouble  to  that 
described  above  occur  by  cutting  arterial  branches  when  jiulled  on,  close  to  the  main 
trunk.  He  has  twice  since  seen  lives  in  great  ])eril  from  the  step  that  was  found  needful, 
viz.  ligature  of  the  main  trunk  above  and  below  the  openi?ig. 

•*  Operative  Surgery  of  Malignant  Disease,  p.  397. 


REMOVAL  OF  THE  BREAST  745 

extensive  and  prolonged  proceedings,  great  care  must  be  taken  to  secure 
every  bleeding-point,  and  to  tie  oil  tlie  forceps  before  they  accumulate, 
instead  of  trusting  to  their  being  moved  out  of  the  operator's  way  as 
required,  a  course  which  often  leads  to  their  becoming  entangled  with 
eacii  other.  But  at  this  stage  there  is  another  reason  for  rendering  the 
wound  as  dry  and  bloodless  as  possible.  Primary  union  depends  largely 
on  absence  of  any  after-oozing  and  tension  on  the  sutures,  which  are 
v^ery  likely  to  be  themselves  taxed  to  the  utmost.  Two  difficulties  arise 
here.  One,  that  owing  to  a  depressed  state  of  the  circulation,  vessels 
may  not  bleed  though  unsecured.  The  other  difficulty  is  of  a  different 
kind.  The  perforating  branches  of  the  internal  mannnaiy,  when  they  are 
cut  short  and  retract,  may  give  nuich  trouble.  If  they  caimot  be  secured 
by  the  use  of  Spencer-Wells  forceps  the  haMnorrhage  should  be  treated 
by  firm  pressure. 

At  tfie  conclusion  of  the  operation  the  extensive  wound  may  be 
irrigated  with  sterile  water,  or  better,  with  hot  sterile  saline  solution. 
This  washes  away  any  blood  clots  and  helps  to  stop  any  general  oozing 
which  cannot  otherwise  be  checked. 

(7)  Drainage  and  Closure  of  the  Wound.  The  axilla  should  be  drained 
by  means  of  a  medium  size  rubber-tube  with  several  lateral  windows, 
inserted  through  a  stab- wound  near  the  base  of  the  posterior  skin  flap. 
Mr.  Handley  also  advises  a  second  tube  to  drain  tlie  epigastric  region,  and 
where  there  has  been  much  oozing  this  should  certaiidy  be  employed. 
These  tubet;  should  be  completely  removed  in  twenty-four  or  forty-eight 
hours. 

No  definite  rule  can  be  given  as  regards  suturing,  since  the  incision 
chosen  will,  in  each  individual  case,  depend  upon  the  size  and  situation 
of  the  growth.  Generally  speaking  the  wound  should,  if  possible,  be 
completely  closed,  drainage-tubes  being  inserted  through  conveniently  j 
placed  small  cuts  in  the  flap.  If  the  skin  edges  have  been  undermined, 
and  the  deep  fascia  extensively  removed  as  recommended  above,  the  skin 
is  so  free  that  in  spite  of  the  large  area  removed  the  divided  edges  can 
usually  be  brought  together  with  fittle  or  no  tension.  In  some  cases 
the  wound  may  be  sutured  in  a  continuous  line,  in  other  cases  the  edges  of 
the  wound  may  be  more  easily  approximated  in  a  tri-radiate  fashion. 
Interrupted  or  continuous  silkworm-gut  sutures  should  be  employed. 
Every  care  must  be  taken  to  avoid  tension,  for  this  is  often  responsible  for 
much  pain  and  also  may  lead  to  sloughing  of  the  edges  of  the  skin,  thus 
interfering  with  primary  union.  The  latter  complication  may  also  be 
met  wuth,  owing  to  deficient  blood-supply,  if  the  skin  flaps  have  been  cut 
too  thin.  If  it  be  impossible  to  close  the  wound  completely  it  should  be 
sutured  as  far  as  possible,  and  the  raw  area  treated  by  skin-grafting  by 
Thiersch's  method  (p.  43).  While  this  may  be  employed  at  the  time  of 
the  operation  in  a  wound  which  cannot  be  completely  closed,  it  is  best 
to  deter  it  to  a  date  between  the  eighth  and  fourteenth  day.  Though  this 
involves  a  second  anaesthetic,  the  patient  will  be  in  a  much  better 
condition  ;  the  surface  of  the  wound  will  be  smaller,  and  a  level,  uniform 
one,  and  there  will  be  no  oozing. 

To  enable  the  surgeon  and  patient  to  dispense  with  the  necessity  of  skin-grafting, 
usually  a  second  operation,  Prof.  Warren  has  adopted  the  method  sho^vii  in  his 
excellent  illustrations  (Figs.  302,  303,  304,  .305). 

In  addition  to  the  free  racket-shaped  incision,  "  a  flap  should  be  marked  out  on 
the  outer  side  of  the  pectoral  region  (Figs.  302,  303,  304).     To  do  this,  the  knife 


746 


OPERATIONS  ON  THE  THORAX 


divides  the  skin  above  the  middle  of  the  first  incision,  i.e.  on  the  outer  edge  of  the 
wound,  on  a  line  di'awn  at  first  at  right  angles  to  the  said  incision  and  gradually 
sweeping  round  until  it  becomes  parallel  to  it  and  terminates  at  a  point  a  little  above 
the  level  of  the  lower  margin  of  the  wound.  This  flap  is  intended  to  be  turned  into 
the  lower  portion  of  the  wound.  .  .  .  This  flap  is  about  the  size  of  the  hand,  and 
when  first  turned  in  seems  to  be  totally  inadequate  for  the  purpose.     A  few  stitches 


Fig.  302.     Preliminary  dissection  of  the  integuments  in  all  directions,  leaving 

a  pyramidal  mass  of  tissues  to  be  removed  of  which  the  primary  nodule  is  the 

apex.     The  outer  lateral  flap  is  also  shown.     (Warren.) 


should  be  taken  at  the  axillary  and  sternal  ends  of  the  wound  first.  The  flap  is  then 
tmuied  in  (Fig.  305),  and  held  in  place  hj  a  temporary  stitch,  while  it  is  graduallj'' 
pushed  up  into  place  from  below  by  sutm-es  firmlj' '  girchng  '  together  the  edges  of  the 
skin  to  which  the  flap  was  originally  attached.  Thus  it  gradually  comes  about  that 
the  point  B,  which  was  originally  in  contact  with  point  A,  is  rolled  in  underneath  the 
flap,  and  forces  it  into  position.  Sutures  should  all  be  superficial,  as  deep  sutures 
cut  and  do  not  give  the  skin  included  by  them  a  chance  to  stretch.  In  order  to  enable 
the  edges  to  come  together  easily,  it  should  not  be  forgotten  that  it  is  necessary  to 
dissect  up  the  skin  for  a  considerable  distance  in  every  direction.     In  stout  patients 


REMOVAL  OF  THE  BREAST  747 

tlio  cavity  of  tlio  woiiiul  is  easily  closed,  but  the  problem  is  more  (lifruiill  in  thin 
individuals.  Experience  only  will  enal)!e  the  operator  to  determine  how  much  tension 
can  be  put  upon  tlie  lla])  in  inserting  tiie  iinal  stitches.  In  doubtful  cases  there  is  no 
objection  to  leaving  tlicin   untied,  as  the  opening  tlnis  left  serves  admirably  for 


Fig.  303.     Division  ot  ihe  jjccturalis  nnnui'.     Aoic   ln-ic  anu  m    l-ig.   .,\)i  the 

care  taken  to  leave  a  large  circumferential  zone  well  wide  of  the  disease.     The 

anterior  edge  of  the  latissimus  dorsi  is  shown  here  and  in  Fig.  304,  denoting  the 

limit  of  the  dissection  outwards.     (Warren.) 

drainage."     The  wounds  should  be  dressed  at  the  end  of  twenty -four  hours,  and  any 
gauze  drainage  then  removed. 

(8)  The  Dressing.  The  incision  is  then  covered  with  sterilised  gauze, 
over  which  is  placed  sterilised  pads  and  a  thick  layer  of  absorbent  wool, 
care  being  taken  that  a  thick  layer  of  dressings  is  placed  behind  where 
most  oozing  will  occur.  The  dressings  are  kept  in  position  by  firm  and 
even  bandaging  so  as  to  distribute  the  pressure  as  evenly  as  possible. 
The  forearm  should  not  be  included  in  the  bandage  but  allowed  to  rest 
evenly  and  comfortably  in  a  sling. 


748 


OPERATIONS  ON  THE  THORAX 


(9)  After-treatment.  Though  there  is  usually  some  slight  degree  of 
shock  it  is,  on  the  whole,  less  severe  than  might  be  expected  after  so 
extensive  an  operation.     For   tlie   treatment  of  shock  see  p.  29.     The 


Fig.  304.  The  division  of  the  pectorals  permits  the  retraction  downwards  and 
inwards  of  the  breast  and  axillary  contents  and  enables  the  operator  to  expose 
freely  the  axilla,  and  to  tie  the  main  branches  at  their  origin.  (AVarren.)  It 
will  be  noticed  that  Prof.  Warren  removes  the  breast  from  without  inwards. 
The  advantages  claimed  are  that  the  operation  is  shortened  and  the  hajniorrhage 
lessened  by  dividing  the  vessels  at  their  origin  at  the  beginning  of  the  deep 
dissection,  while  the  greater  part  of  the  wound  is  not  exposed  until  the  close  of 
the  operation.  Further,  a  free  dissection  of  the  axilla  is  permitted  up  to  the 
point  of  disappearance  of  the  axillary  lymphatics  beneath  the  clavicle;  before 
the  mass  to  be  removed  has  been  dislodged  from  its  attachments  and  allowed  to 
interfere  with  the  anatomical  relations  of  the  parts. 


patient  should  be  kept  on  the  sound  side  for  the  first  few  hours  after  the 
operation,  as  this  promotes  the  escape  of  any  vomit  well  away  from  the 
dressings,  while  it  also  helps  to  prevent  any  collection  of  fluid  at  the 


REMOVAL  OF  THE  BREAST  749 

axillary  end,  where  the  chief  cavity  has  been  made.  Afterwards  the 
patient  should  be  kept,  supported,  up  in  the  bed  as  much  as  possible,  to 
prevent  that  tendency  to  stasis  and  broncho-pneumonia  which  is  so  liable 
to  appear  in  the  subjects  of  chronic  bioucliitis,  obesity,  &c.     If  possible 


Fig.  30.5.  A,  The  flap  has  been  turned  in  and  eaught  with  one  suture.  It  is 
gradually  being  pushed  into  position  by  peripheral  sutures.  B  shows?how  the 
upper  half  of  the  outer  edge  of  the  wound  is  slid  under  the  lower  half.  Note 
the  shortening  of  the  long  axis  of  the  wound  by  the  stitching  on  the  lower 
border.     (Warren.) 

after  the  fourth  day  the  patient  should  be  lifted  into  an  arm-chair  and 
spend  an  hour  or  two  out  of  bed  daily.  These  patients  are  not  only  kept 
too  long  in  bed,  but  the  arm  is  usually  kept  close  to  the  side  too  long. 
For  the  first  few  hours,  to  check  any  oozing,  and  to  meet  any  restlessness 
after  the  anaesthetic,  the  arm  and  forearm  must  be  kept  securely  quiet 
in  a  sling.  But  after  this  the  arm  should  be  gently  and  easily  abducted 
by  a  large  pad  of  wool  in  the  axilla.     A  little  later  the  patient,  while 

1  hoc.  supra  cit. 


750  OPERATIONS  OX  THE  THORAX 

in  bed,  should  be  encouraged  to  keep  the  limb  away  from  her  side  with 
the  forearm  extended,  while  at  night  a  sling  should  again  be  resorted  to. 
In  about  ten  or  fourteen  days  more  active  outward  and  upward  move- 
ments should  be  practised.  While  after-limitation  of  movement  is 
partly  unavoidable  owing  to  the  necessary  free  removal  of  sldn,  &c.,  much 
of  the  after-stiffness  will  be  prevented  if  care  be  taken  at  the  time  of  the 
operation  to  secure  primary  closure  of  the  axillary  end  of  the  wound 
without  much  tension,  and  if,  later  on,  both  surgeon  and  patient  will 
dispense  vdth  the  too  usual  rigid  bandaging  of  the  arm  to  the  side,  and 
be  more  persistent  in  practising  early  movements.  A  com'se  of  massage 
is  often  very  beneficial. 

With  regard  to  the  dressing  of  the  wound,  the  first  dressings  will  prob- 
ably require  to  be  additionally  packed,  especially  behind,  during  the 
first  forty-eight  hours.  And  the  patient,  whatever  position  she  take, 
should  always  he  on  thick  gauze  pads  during  the  first  three  or  four  days, 
lest  any  discharge  come  through,  especially  when  she  is  left  undisturbed 
to  sleep,  and  reach  the  sheets.  If  drainage  has  been  employed  the  wound 
should  be  dressed  at  the  end  of  twenty-four  or  thirty-six  hours,  the 
drainage-tubes  removed,  any  over-tight  sutures  cut,  and  the  dressings 
left  imdisturbed  for  another  three  or  four  days.  If  no  drainage  has 
been  employed,  the  need  of  dressing  vd]\  generally  turn  upon  the  tension 
of  the  sutures.  As  the  skin,  owing  to  its  elasticity,  has  great  accommoda- 
ting power,  it  will  generally  be  fomid,  if  the  tension  has  been  distributed 
over  a  large  number  of  sutures,  that  no  stitch-necrosis,  or  very  httle,  takes 
place.  Such  a  step  adds  much  to  the  comfort  of  the  patient,  and  allows 
of  the  division  of  any  sutures  which  are  already  causing,  or  about  to  cause, 
slight  ulceration.  Another  advantage  gained  by  not  allo-wnng  the 
dressings  to  remain  unchanged  too  long  during  the  first  ten  days  is  that  an 
opportunity  is  secured  of  cleansing  the  axilla.  This  step  is  rendered 
advisable  by  the  difficulty  of  sterilising  a  region  like  this  at  the  time  of  the 
operation,  and  the  growth  of  hair  which  has  taken  place. 

Tie  desirabiUty  of  "K-ray  treatment  as  a  jjrophylatic  measure  against 
recurrence  is  discussed  on  p.  757. 

Halsteds  Method.  Prof.  Halsted  published  an  account  of  his  method 
of  removal  of  the  breast  in  the  Annals  of  Surgery.  November  1894.^  On 
accomit  of  the  excellent  work  done  by  him  in  many  directions,  and 
because  he  was  the  pioneer  of  the  modem  radical  operation,  the  following 
brief  details  of  his  original  operation  may  be  quoted  here. 

"(1)  The  skin  incisions  are  carried  at  once  and  everywhere  through  the  fat. 
(2)  The  triangular  flap  of  skin  (Fig.  .306)  is  reflected  to  its  base.  This  flap  consists 
of  skin  only.  The  fat  which  lined  it  is  dissected  back  to  the  lower  edge  of  the 
j^ectoralis  major,  where  it  is  continuous  with  the  fat  of  the  axilla.  (3)  The  costal 
attachments  of  the  pectoralis  major  (Fig.  307)  are  severed,  and  the  splitting  of  the 
muscle,  usually  between  its  costal  and  cla^^cula^  portions,  is  begun  and  continued 
to  a  point  about  opposite  the  scalene  tubercle.  (4)  At  this  point  the  cla^^cular  portion 
of  this  muscle  and  the  skin  overlying  it  are  cut  throiigh  up  to  the  clavicle,  exposing 
the  apex  of  the  axilla.  (5)  The  loose  tissue  under  the  cla\ncular  portion,  usually 
rich  in  lymphatics,  is  dissected  away.  (6)  The  splitting  of  the  muscle  is  continued 
outwards  to  the  humenis  and  the  part  to  be  removed  is  now  cut  through  close  to  its 
humeral  attachment.  (7)  The  whole  mass,  skin,  breast,  areolar  tissue  and  fat,  is 
raised  up  and  is  stripped  from  the  thorax  close  to  the  ribs  and  the  pectoralis  minor, 

^  Dr.  Willy  Meyer,  of  New  York,  doscrihed  independently  a  similar  operation,  about 
the  same  time  {New  York  Med.  Bee.,  Dec.  15, 1894),  in  which  the  breast,  pectoral  muscles 
and  axillarj-  contents  were  removed  in  one  maas.  Dr.  Meyer  gives  an  interesting  account 
of  ten  vears  experience  with  his  method  of  radical  operation  in  the  Journ.  Amer.  Med. 
Assoc.,' July  1905. 


KKArOVAL  OF  THE  BREAST 


51 


the  sheath  of  tlie  latter  nmsele  beinj?  inchided.  (S)  The  lower  border  of  the  pectoralis 
minor  having  been  elearly  ex|)Osed  it  is  divided  a  little  below  its  middle.  (!))  The 
areolar  tissue  over  the  minor  muscle  near  its  insertion  is  then  divided  as  far  out 
as  possibh;  and  reflected  inwards  to  allow  of  the  turning  upwards  of  this  part  of  the 
minor.     (H>)  The  upper  and  outer  portion  of  the  pectoralis  minor  is  drawn  ujjwards 


4 


Fig.  306.     (Halsted.) 

and  outwards.  (11)  The  small  veins  under  the  pectoralis  minor  are  dissected  free 
and  ligatured  close  to  the  axillary  vein.  (12)-Having  exposed  the  subclavian  vein 
at  the  highest  possible  point,  the  axillary  contents  are  dissected  away  with  the  greatest 
possible  care  with  the  helji  of  a  sharp  knife.  The  axillary  vein  should  be  stripped 
absolutely  clean.  It  maj^  not  be  always  necessary  to  expose  the  artery,  but  I  think 
it  is  well  to  do  this.  (13)  Having  cleansed  the  vessels,  the  mass  to  be  removed  should 
be  firmly  gi'asped  and  pulled  outwards  and  slightly  upwards^^with  sufficient  force  to 


752 


OPERATIONS  ON  THE  THORAX 


put  on  the  stretch  the  delicate  fascia  which  still  binds  it  to  the  chest.  This  fascia  is 
cut  away  close  to  the  ribs  and  the  serratus  magnus.  (14)  When  the  junction  of 
the  lateral  and  posterior  walls  of  the  axilla  has  been  reached,  an  assistant  takes  hold 
of  the  triangular  flap  of  skin  and  draws  it  outwards  to  assist  in  spreading  out  the 
tissues  which  lie  on  the  subscapularis,  teres  major,  and  latissimus  dorsi.  The  operator, 


Fig.  307.     (Halsted.) 

having  taken  a  different  hold  of  the  tumour,  cleans,  from  within  outward,  the 
posterior  wall  of  the  axilla.  The  subscapular  vessels  are  nicely  exposed  and  are 
secured  before  they  are  divided.  The  subscapular  nerves  may  or  may  not  be 
removed,  at  the  discretion  of  the  operator  .  .  .  they  may  often  be  spared  to  the 
patient  with  safety.  (15)  Having  passed  these  nerves,  the  operator  has  only  to 
turn  the  mass  back  in  its  normal  position,  and  to  sever  its  connection  with  the  body 
of  the  patient  by  a  stroke  of  the  knife.     All  has  been  removed  in  one  piece.     I  believe 


REMOVAL  OF  THE  BREAST 


753 


that  wc  should  never  cut  through  cancerous  tissue  when  operating,  if  it  is  possible 
to  avoid  doing  so.  .  .  .  The  oix^ration  as  we  perform  it  is  literally  a  bloodless  one. 
From  the  lirst  to  the  List  each  bleeding-spot  is  secured  with  an  artery  forceps  as 
quickly  as  possible.  .  .  .  The  axilla  is  never  drained  and  invariably  heals  by  lirst 
intention." 

C.  Long-continued  supervision  repeated  at  first  at  short  intervals.  The 
patient  should  be  kept  under  skilled  supervision,  and  lor  the  first  few 
years  an  inspection  of  the  scar  should  be  made  every  three  or  four  months. 


Fig.  308.     This  shows  the  continuous  whole  or  single  piece,  breast,  axillary  fat 
and  glands,  of  which  the  part  removed  should  consist.     (Halsted.) 

Any  localised  and  superficial  reappearances  in  or  near  the  scar  should  at 
once  be  attacked  widely  and  deeply  (p.  756)  ;  operations,  where  the 
disease  is  fixed,  involving  resection  of  one  or  more  ribs,  if  needful,  as  in 
the  cases  to  which  allusion  has  been  made  at  p.  769,  are  very  rarely 
to  be  advised. 

There  are  still  a  few  points  of  much  importance  to  be  discussed  before 
the  subject  of  removal  of  the  breast  for  cancer  can  be  said  to  have  been 
dealt  with.  Such  points  as ;  (i)  The  removal  of  both  breasts,  (ii)  The 
value  of  palliative  operations,  (iii)  Operations  for  reappearance  of  the 
disease,     (iv)  The  advisability  of  performing  such  operations  as  ampu- 

SURGERY  I  48 


754 


OPERATIONS  ON  THE  THORAX 


tatioii  at  the  shoulder-joint,  or  Berger's amputation,     (v)  Oophorectomy 
for  inoperable  carcinoma  of  the  breast. 

(i)  Removal  of  both  Breasts.  It  occasionally,  though  rarely,  happens 
that,  as  in  the  case  shown  in  Fig.  309,  a  patient  comes  for  advice  Avith 
cancer  of  both  breasts.  By  some  operation  at  this  stage  has  been  con- 
demned on  two  grounds:  viz.  its  certain  futility  and  its  additional 


^ 


Fig.  309.  E.  S.,  aged  54.  The  left  breast  had  been  removed  at  another  London 
hospital  in  February  1899,  the  pectoralis  major  being  left  entire.  Recurrence 
took  place  in  the  scar  towards  the  end^of  the  same  year.  Patient  was  admitted 
to  Guy's  Hospital  with  a  scirrhus  of  the  right  breast,  the  existence  of  which  had 
been  known  for  three  months.  Both  sides  were  operated  upon  simultaneously 
by  Mr.  Jacobson  and  Mr.  C.  T.  Hilton,  on  December  10,|^1900,  both  pectorals 
being  removed  on  each  side.  On  the  right  side  Mr.  Jacobf  on  found  it  possible, by 
extensive  undermining,  to  drag  the  flaps  together,  the  three  larger  dots  on  each 
side  showing  where  the  stout  silver  wire  used  had  caused  slight  tissue-necrosis. 
On  the  left  side  the  above  step  was  impossible.  The  photograph  was  taken  on 
January  3,  1901,  and  Thiersch's  grafting  was  resorted  to,  on  the  left  side,  on 
January  4.  The  amount  of  elevation  which  can  be  regained  in  three  weeks 
after  a  double  operation  is  also  shown. 

severity.     Such  a  rule  can  hardly  be  laid  down.     Each  case  must  be 
considered  by  itself. 

The  following  are  the  chief  points  which  will  guide  in  a  decision.     First 
and  foremost,  the  surgeon  must  decide  whether  the  growth  is  a  primary 


REMOVAL  OF  TIIK  HRKAST  755 

one  on  both  sides,  or  whether  on  one  side  it  is  secondary  to  the  other. 
In  the  latter  case  the  disease  is  so  widespread  that  operation  is  not  to  be 
recommended.  In  the  former,  if  there  be  no  evidence  of  visceral  or 
secondary  deposits  (beyond  any  in  the  axillae),  operation  may  be  recom- 
mended if  the  patient's  age  and  vitality  are  favourable.  And  here  ag 
is  a  point  of  much  importance.  If  the  patient  be  yomig,  the  presence  of 
bilateral  disease  is  probably  a  sign  of  the  mischief  being  widespread,  and 
operation  Avill  be  useless. 

When  operation  has  been  decided  upon,  the  question  will  arise  as  to 
whether  the  breasts  should  be  removed  simultaneously  or  no.  If  possible, 
the  two  breasts  should  be  removed  at  one  operation.  And  as  the  operation 
of  the  present  day  is  so  extensive  and  requires  such  prolonged  care, 
it  will  be  best  if  the  operation  is  done  simultaneously  by  different  operators. 
Such  a  step  much  diminishes  the  risk  and  also  the  discomforts  of  the 
patient,  especially  that  of  the  anaesthetic,  while  where  the  vitality  is 
good,  the  shock  is  not  dangerously  increased.  Extra  care  in  nursing 
will  diminish  the  additional  trouble  entailed  by  the  needful  restraint 
of  both  arms.  But  no  fixed  rule  can  be  laid  down  here.  Where  the 
vitality  is  poor,  where  there  is  any  bronchitis,  where  the  breasts  are  large 
and  the  wounds  necessarily  extensive,  it  may  be  well  to  postpone  the 
second  operation  for  two  or  three  weeks.  Where  it  is  clear  that  the 
operation  on  one  side  will  be  so  extensive  as  to  call  for  Thiersch's 
grafting,  this  may  indicate  the  advisability  of  removing  the  breasts  by 
two  operations. 

(ii)  The  Value  of  Palliative  Operations.  Patients  occasionally  come 
to  the  surgeon  asking  for  operation  mider  conditions  which  make 
it  certain  that  any  benefit  given  by  surgical  interference  will  be  only 
temporary.  The  following  may  be  among  the  reasons  that  arise  for 
consideration  :  (a)  Relief  from  pain,  which  otherwise  increases  daily  ; 
the  misery  of  waking  every  day  to  the  consciousness  of  an  incurable 
disease  ;  the  ulceration  in  advanced  cases  with  foul  discharge  and 
perhaps  haemorrhage  ;  the  restlessness  for  cure  (Paget).  (6)  Death  by 
deposits  in  the  viscera,  these  being  unseen,  is  less  distressing  to  the 
patient  than  death  by  the  original  disease  in  the  breast,  which  is  always 
under  her  eyes,  (c)  The  patient  may  have  special  reasons  for  wishing 
to  Hve  and  get  about  in  comparative  comfort  for  a  year  or  so. 

Thus,  in  a  case  mentioned  by  Sir  B.  Brodie,^  he  declined  at  first  to  operate  on  a 
lady  with  a  scirrhus  of  the  breast  on  the  point  of  ulcerating.  In  a  few  weeks  the 
patient  returned,  begging  to  have  the  breast  removed,  that  her  life  being  rendered 
more  comfortable  and  active,  she  might  accompany  in  society  an  only  daughter.  The 
ojjeration  was  successfully  performed,  and  at  the  end  of  two  years  the  patient  died 
of  secondary  pleuritic  effasion. 

No  general  rule  can  be  laid  dowTi  here.  Each  case  must  be  decided  on 
its  own  merits.  But  the  following  cautions  may  not  be  superfluous. 
Especial  care  should  be  taken  in  these  cases  to  exclude,  as  far  as  possible, 
the  presence  of  metastatic  deposits.  If  these  are  certainly  present  no 
operation  should  be  performed.  The  patient's  general  condition  and 
vitality  must  be  sufficiently  good.  There  must  be  gromids  for  honestly 
supposing  that  the  local  disease  which  it  is  proposed  to  attack  will  be 
got  away  ;  otherwise  the  latter  condition  of  the  patient  may  be  rendered 
worse  than  the  first.  Again,  in  these  palliative  operations  it  should  be 
clearly  explained  to  the  patient  and  her  friends  that  the  operation  will  only 
1  Led.  on  Path,  and  Surg.,  p.  202. 


756  OPERATIONS  ON  THE  THORAX 

be  palliative.  Some  patients,  and  especially  the  friends  of  some  patients, 
are  only  too  ready,  when  it  becomes  evident  that  no  cure  is  possible,  to 
forget  the  plain  and  honest  warning  that  was  given,  and  to  place  the 
entire  responsibility  on  the  surgeon.  And  this  leads  up  to  one  more  point. 
In  these  palliative  operations,  and  in  all  doubtful  operations  for  cancer, 
it  is  not  only  the  individual  patient  that  has  to  be  considered  :  the 
thoughtful  surgeon  will  remember  the  effect  of  his  operation  on  many 
other  potential  patients.  Thus,  a  palliative  operation  or  an  extensive 
operation  under  conditions  doubtful  of  success  is  performed,  both  sides 
of  the  question  having  been  honestly  put  before  the  patient.  The  opera- 
tion is  not  permanently  successful,  as  was  fully  explained  might  be 
the  case.  The  want  of  permanent  success  becomes  known  to  a  circle 
of  varying  extent.  We  do  not  sufficiently  consider  what  effect  this 
want  of  success  has  on  other  patients  also  sufferers  from  cancer  of  the 
breast,  but  quite  ignorant  of  the  conditions  in  which  the  operation  referred 
to  was  performed,  in-  leading  them  to  conceal  their  cancer,  at  the  time 
eminently  suited  to  operation,  until  the  most  favourable  opportunity  has 
passed  away. 

(iii)  Operations  in  the  Case  of  Reappearance  of  the  Disease.  A  very 
poor  prospect  of  success  is  offered  here,  chiefly  because  the  disease  always 
proves  to  be  more  extensive  than  appears  to  be  the  case.  This  is  especially 
true  of  recurrence  in  the  axilla.  Such  conditions  as  extensive  infiltration 
of  the  skin  either  by  shotty  nodules  or  by  the  evidence  of  "  peau  d'orange"; 
infiltration  of  glands  in  the  neck,  evidence  of  visceral  deposits,  implica- 
tion of  the  axillary  vessels  and  nerves,  prohibit  operation  absolutely. 
The  only  conditions  which  justify  hopefulness  in  dealing  with  local 
reappearance  are  (1)  small  nodules  in  the  scar  or  the  axilla,  or  (2)  infected 
areas  of  larger  extent  occurring  in  cases  where  the  operation  has  been  a 
limited  one,  and  not  on  the  wide  lines  which  have  been  recommended 
above.  And  the  chief  points  which  help  in  the  decision  are  the  degree 
of  mobility  and  the  size  of  the  reappearing  mass.  But  even  where  these 
and  other  points  appear  favourable,  the  real  extent  of  the  disease,  the 
fact  that  the  operation  has  now  to  be  performed  in  scar  tissue  and  not 
in  loose  fat,  and  that  the  anatomical  landmarks  are  much  altered,  militate 
greatly  against  success.  Local  reappearance  after  the  improved  operations 
of  to-day  is  much  rarer,  but  it  does  occur,  and  the  fact  that  in  these 
cases  the  preceding  operation  has  been  on  wide  lines  shows  that  here 
the  disease  from  the  first  has  had  an  extensive  hold  on  the  patient.  If 
the  recurrence,  though  local,  is  deeply  seated  in  the  tissues  of  the  scar, 
necessarily  scanty  after  removal  of  the  pectorals,  the  only  operation  likely 
to  be  useful  is  partial  resection  of  the  ribs,  as  in  the  cases  alluded  to  at 
p.  769.  If  the  recurrence  is  in  the  axilla  the  exploratory  incision  should 
be  of  the  freest,  as  these  are  just  the  cases  where  the  axillary  vein  may 
be  easily  opened. 

Finally,  we  must  all  allow  that  the  only  real  treatment  for  reappearance 
of  the  disease  is  preventive.  It  is  only  by  operating  on  the  first  occasion, 
on  the  widest  possible  lines,  and  in  the  most  thorough  manner,  that  we 
can  c^ally  meet  recurrent  disease.  In  Sir  Watson  Cheyne's  weighty 
words,  "  the  patient's  chance  lies  in  the  first  operation." 

(iv)  Removal  of  the  Entire  Upper  Extremities  or  Amputation  at  the  Shoulder- 
joint  for  Recurrent  Inoperable  Carcinoma.  At  the  present  day  these  operations 
will  bo  very  seldom,  if  ever,  called  for.  They  have  been  occasionally  performed  with 
the  object  of  giving  relief  to  the  agonising  jiain  and  heavy,  oedematous,  swollen. 


REMOVAL  OF  THE  BREAST  757 

immobile  state  of  the  limb  which  sonu'timcs  is  seen  to  follow  implication  of  the 
axillary  vessels  and  nerves.  Any  hoi)e  of  cure,  even  by  the  most  extensive  of  these 
operations,  is  quite  out  of  the  question.  Decided  relief  will  be  given,  but  it  will 
not  be  innnixed  relief.  If  any  such  oj)eration  be  performed  it  should  be  on  the  lines 
of  that  of  B(>rger  {see  p.  234)  and  not  an  amputafion  at  tlie  shoulder-joint,  in  which 
the  incisions  may  pass  dangerously  near  to  the  disease.  T\u'  late  IVIi'.  Clinton  Dent 
brought  such  a  case  before  tlie  Medico-(!hirurgical  Society.^ 

The  operation  is  scarcely  to  be  recommended.  It  is  palliative  only,  and  the  relief 
it  gives  is  temporary  and  obtained  only  at  great  cost.  It  sliould  certainly  not  be 
suggested  until  a  trial  has  been  mad(^  of  X-rays,  radium,  or  lym})hangeioplasty. 
Cases  with  agonising  pain  from  involvement  of  the  brachial  plexus  are  extremely  rare. 
Swollen,  heavj',  iinlematous  limbs  are  more  common,  but  here  lym])hangeioplasty  is 
likely  to  be  successful.  In  such  cases,  too,  r^^lief  can  almost  always  be  given  by 
elevation  of  the  limb  at  night,  aided  by  careful  bandaging  or  the  wearing  of  a  well- 
fitting  support.  Very  rarely,  owing  to  the  jiatient's  neglect,  this  condition  of  oedema 
has  gone  so  far  that  recurrent  attacks  of  erysipelas  or  sloughing  are  present.  In  some 
of  these  Berger's  operation  would  be  justifiable,  but  both  sides  of  the  case  should  be 
clearly  put  before  the  patient. 

The  heavy,  swollen,  cedematous  condition  of  the  arm  mentioned  above  may 
often  be  treated,  with  marked  relief,  by  the  comparatively  trivial  operation  of 
Ijauphangeioplasty  which  has  ah'cady  been  described  at  p.  55. 

(v)  Oophorecfomy  in  Inoperable  Carcinoma  of  the  Breast."  This  operation  is 
now  seldom,  if  ever  performed.  It  has,  however,  been  performed  ^^ith  sufficient 
frequency  to  justify  the  following  conclusions.  While  the  operation  has  in  a  certain 
number  of  instances  produced  a  decidedly  beneficial  result,  these  eases  have  not  been 
numerous  ;  and  in  every  such  case  the  benefit  has  been  temporary  only.  Mr.  Stanley 
Boyd  '  collected  fifty-four  cases  and  divided  them  into  two  groups  :  [a)  those  in 
which  oopliorectomy  seemed  to  produce  a  clear  and  decided  effect,  such  as  shrinking 
and  disappearance,  sometimes  rapid  and  even  temporarily  complete,  of  all  the  recur- 
rent growth  in  the  skin  and  glands,  with  disappeai'ance  of  pain  and  swelling  ;  (6)  those 
in  which  oophorectomy  had  but  little  or  no  effect.  Of  the  fifty-four  cases  thus 
classified,  Mr.  Boyd  found  that  nineteen  (35  per  cent.)  were  more  or  less  markedly 
benefited,  thirty-fom:  were  not  benefited  or  only  doubtfully  so,  and  one  died  of  ex- 
haustion. As  to  the  duration  of  the  benefit,  when  present,  Mr.  Boyd  considered 
that,  as  far  as  the  cases  available  for  drawing  conclusions  went,  in  the  majority 
the  growths  reappear  or  begin  again  to  increase  in  six  to  twelve  months.  It  is 
interesting  to  note  that  with  one  exception  all  the  patients  who  had  passed  the 
menopause  are  included  among  the  failiu'es.  When  it  is  remembered  that  oophorec- 
tomy is  not  to  be  relied  upon  for  checking  the  haemorrhage  and  growth  of  uterine 
carcinoma,  it  is  only  probable  that  little  might  be  expected  from  this  operation  for 
carcinoma  of  the  breast.  And  it  must  be  remembered  that  whatever  temporary 
benefits  the  operation  may  confer,  that  it  is  likely  to  produce  certain  unpleasant 
effects  of  its  own.  Finally,  it  is  to  be  noted  that,  in  two  of  the  eases  collected  by 
Mr.  Boyd,  oophorectomy  for  inoperable  carcinoma  of  the  breast  has  been  fatal,  in 
one  case  from  exhaustion,  in  the  other  from  intestinal  matting. 

X-ray  Treatment  and  Radium  Treatment  of  Malignant  Disease.  Some 
Conclusions.  There  is  still  considerable  difterence  of  opinion  as  to  the  results 
of  treatment  of  carcinomatous  growths,  inoperable  and  recurrent,  by 
X-rays  and  radium.  Both  these  agents  have  the  power  of  inhibiting  the 
growth  of  cancer  cells  and  sometimes,  apparently,  of  completely  destroying 
them,  provided  that  the  nodules  are  small  and  are  near  the  surface. 
These  conditions  are  fulfilled  in  those  cases  of  carcinoma  of  the  breast 
where  recurrences  appear  as  small  nodules  in  and  near  the  scar.  Such 
cases,  and  also  where  the  carcinoma  is  ulcerating,  are  therefore  very 
suitable  for  this  form  of  treatment.  Relief  from  pain  is  a  prominent 
feature.     Hsemorrhage  and  discharge  are  decidedly  lessened,  and,  in  a 

1  Brit.  Med.  Journ.,  March  12,  1898. 

^  The  credit  of  suggesting  this  operation  must  be  given  to  Dr.  Beatson,  of  Glasgow. 
He  considered  that  there  were  cases  where  it  was  of  service  in  prolonging  life  and  lessening 
suffering,  but  never  claimed  for  it  any  curative  power. 

'  Brit.  Mrd.  Journ.,  1900,  vol.  ii,  p.  1161. 


758  OPERATIONS  OX  THE  THORAX 

certain  proportion,  ultimately  cease.  Even  in  the  hopeless  cases  X-ray 
treatment  prolongs  life,  makes  the  patient  more  comfortable,  and  the 
last  hours  more  free  from  pain.  The  treatment  is  most  likely  to  fail 
in  cases  where  the  patient  is  yoimg,  the  persistence  large  in  amount  and 
active  in  its  progress,  and  on  the  other  hand  when  much  dense  fibrous 
tissue  is  present.  The  treatment  may  in  some  cases  be  harmful  («)  by 
stinuilating  the  rate  of  growth,  perhaps  by  the  employment  of  too  weak 
treatment,  (b)  by  too  rapid  destruction  of  large  areas  and  flooding  the 
system  with  toxins.  Deep  secondary  deposits  in  glands,  bones,  or 
\'iscera,  are  not  likely  to  be  affected.  The  following,  written  by  Sir  A. 
Pearce  Gould  in  1905,  is  still  true  at  the  present  day  : 

"Ulceration  of  scirrhus  mamma?  is  very  often  arrested,  foul  ulcers  become  clean, 
and  in  many  cases  the  ulcers  heal  up.  Growth  is  held  in  check,  or  partially,  or  in 
some  cases  wholly,  disappears.  I  have  seen  many  examples  of  each  of  these  three 
results  ;  e.g.  I  have  seen  an  extensive  absolutely  fixed  growth  in  the  breast  become 
so  much  loosened  and  free  from  the  chest  walls,  that  it  became  a  suitable  case  for 
excision,  and  the  operation  was  satisfactorily  accomplished.  I  have  had  two  cases 
of  those  big  cedematous  arms  from  secondary  supraclavicular  growth  in  which  the 
change  has  been  so  great  that  oedema  has  disappeared,  and  the  woman  has  resumed 
work. 

"  Eijithelioma  of  the  tongue  and  mouth  are  only  slightly  benefited,  and  only 
occasionally  are  secondary  epitheliomatous  growths  in  the  cervical  •'glands  im- 
proved. In  one  case  of  a  large,  deep  ulcer  tlu-eatening  to  open  into  the  deep  vessels 
of  the  neck,  rapid  healing  occmred  under  the  rays,  and  the  patient  died  from  another 
effect  of  the  disease,  broncho-pneumonia.  In  another  case  glandular  growths  have 
been  held  in  check,  and  have  ver^^chstinctly  lessened  in  size  ;  but  as  a  rule,  the  treat- 
ment is  very  disappointing  in  these  cases. 

"  I  have  seen  two  or  tlu'ee  very  striking  results  in  carcinoma  recti.  In  one,  a  largo 
f ungating  recurrence  after  excision  entirely  disappeared,  and  the  man  is  leading  an 
active  life  and  in  good  general  health.  In  another,  a  doctor,  who  was  laid  aside 
from  practice  entirely  for  six  months,  got  rid  of  his  locum  tenens  and  resumed  all  his 
work  in  a  busy  practice." 

X-ray  treatment  is  often  used  as  a  prophylactic  measure  against 
recurrence  after  the  complete  operation.  It  is,  of  course,  very  difficult 
to  estimate  the  effect  of  this.  At  any  rate  it  can  do  no  harm  and  should 
certainly  be  employed  where  the  operation  has  been  performed  at  an 
advanced  stage  of  the  disease.  Mr.  Handley  recommends  that  the  treat- 
ment as  a  prophylactic  measure  should  not  be  continued  for  more  than 
three  or  four  weeks. 

Other  Indications  for  Excision  of  the  Breast.  Sarcoma  of  the  breast 
is  not  unconnnon.  It  usually  appears  as  a  soft  rapidly  growing  tumour 
at  a  somewhat  earlier  age  than  is  usual  with  carcinoma.  In  such  a  case 
extensive  removal  on  the  lines  described  above  should  be  carried  out. 

Chronic  Cystic  Mastitis  (Multiple  Cystic  Disease).  This  disease, 
which  usually  occurs  in  women  over  forty,  is  characterised  by  the  appear- 
ance of  large  numbers  of  small  cysts  varying  in  size  from  a  pin's  head  to  a 
marble.  While  in  the  early  stages  palliative  treatment  alone  may  relieve 
symptoms  and  prevent  its  advance,  excision  of  the  breast  is  indicated  in 
more  advanced  cases  and  where  the  whole  breast  is  affected.  The  breast 
is  removed  by  an  elliptical  incision  including  the  nipple.  There  is  no  need 
to  remove  the  pectorals  or  the  axillary  contents.  Where  the  disease 
is  limited  to  a  part  of  the  breast,  excision  of  the  affected  portion  will  alone 
be  required. 

Tuberculous  Disease  of  the  Breast.  In  this  disease  there  may  be 
extensive  sinuses  and  pockets  preventing  efficient  local  treatment.     It 


REMOVAL  OF  THE  BREAST  759 

is  then  best  to  excise  the  affected  breast  by  means  of  the  elliptical  incision 
nuMitioned  above.  Tuberculous  axillary  glands  may  be  treated  at  the 
same  time. 

Treatment  of  Fihro-adenomata  of  the  Breast.  1'hese  innocent  tumours 
usually  occur  in  young  women  between  the  ages  of  15  and  25,  though 
occasionally  at  a  much  later  age.  They  are  easily  removed  by  means  of  an 
incision  in  a  radial  direction  where  they  are  nearest  the  surface.  The 
knife  then  passes  through  the  breast  tissue  until  the  capsule  of  the  tumour 
is  reached.  The  adenoma  then  readily  shells  out..  AH  vessels  must  be 
secured  or  a  h;ematoma  may  result. 

Thomas's  Method  of  Removal  of  Innocent  Mammarij  Tumours.  An  incision 
is  made  exactly  following  the  groove  between  the  skin  of  the  lower  half  of 
the  breast  and  that  of  the  chest.  On  reaching  the  muscles,  the  breast  is  dissected 
from  them  sufiRciently  to  allow  of  its  being  turned  upwards  so  as  to  expose  its 
])osterior  aspect.  A  straight  cut  is  then  made  through  this  over  the  tumour,  and  the 
latter  removed.  Tlie  gland  is  then  rejilaced.  Adequate  (kainage  must  be  pro- 
vided. The  scar  is  not  noticeable  save  when  a  free  incision  has  to  be  made,  e.g.  for 
a  tibro-adenoma  high  up  in  the  breast  ;  the  ends  of  it  then  show.  Owing  to  the 
excellent  I'esults  and  very  trivial  xiltimate  disfigui'ement  which  the  ordinary  method 
of  removing  tibro-adenomata  affords,  that  of  Dr.  Thomas  is  very  rarely  called  for. 
The  operation,  too,  is  not  always  easy  in  practice,  and  its  adoption  will  a  good  deal 
depend  upon  the  position  and  mobility  of  the  tumour. 


CHAPTER  XXXV 

PARACENTESIS  AND  INCISION  OF  THE  CHEST. 
RESECTION  OF  RIBS.    EMPYEMA 

PARACENTESIS  AND  INCISION  OF  THE  CHEST 

Indications   for   interference  in  pleuritic  efTusions.     Before  interfering 
operatively,  the  surgeon  has  two  points  to  consider  : 

(1)  Whether  fluid  is  present.  (2)  Whether  it  is  purulent  or  not. 
The  answer  to  the  first  question  will  depend  on  the  histoiy  and  the  physical 
signs  and  will  require  no  further  discussion  here. 

(2)  Is  the  fluid  purulent  or  not  ?  If  pus  is  present  it  will  not  be 
absorbed  ;  it  may  burst  into  the  lung,  may  burrow  about,  making  its  way 
externally,  causing  hectic,  caries,  and  lardaceous  disease. 

A.  Exploratory  'puncture.  A  large  hypodermic  syringe  and  needle 
should  be  used,  absolutely  sterile,  pervious,  and  the  needle  sufficiently 
long  and  not  too  flexible.  The  timely  use  of  this  may  save  much  delay. 
A  grooved  needle  should  never  be  trusted  to.  It  is  readily  plugged  by  a 
pellet  of  fat,  and  thick  pus  will  not  flow  along  it. 

B.  Presence  of  pyrexia  and  hectic.  This  is  not  always  reliable. 
Fallacies  :  (a)  They  may  be  absent,  or  little  marked,  in  empyema, 
especially  in  long-standing  cases,  the  alteration  of  the  pleura  or  the  degree 
of  tension  preventing  absorption.  Occasionally  the  disease  is  latent  for 
many  months,  (b)  Well-marked  pyrexia  may  be  present  in  serous 
effusions, 

C.  The  aspect  of  the  patient.  The  tint  is  often  ansemic  and  earthy 
in  long-standing  empyema,  and  the  finger-ends,  especially  in  children, 
clubbed.  "  If  a  child  be  seen  with  general  pallor  and  finger-clubbing, 
one  ought  to  think  of  empyema  rather  than  of  the  other  causes  of  clubbing, 
viz.  chronic  bone  disease,  bronchiectasis,  and  congenital  heart  disease  " 
(Barlow). 

D.  Age.     Empyema  is  common  in  children  and  young  adults, 

E.  Rigors.  These  are  often  slight,  irregular,  and  may  occur  only 
towards  evening.     In  children  they  are  often  absent  throughout. 

F.  Any  preceding  disease.  Empyema  is  not  unfrequently  seen  after 
pneumonia,  scarlet  fever,  measles,  childbirth,  pyaemia,  small-pox,  and 
especially  typhoid  fever.  The  onset  is  most  insidious  and  often  over- 
looked. If  a  patient  during  convalescence  seems  to  go  back,  loses  his 
appetite,  any  embarrassment  of  the  breathing  must  be  at  once  looked  for, 
and  empyema  suspected. 

G.  (Edema.     This  is  often  absent,  though  pus  is  present. 

H.  Other  signs,  especially  in  children,  must  be  remembered,  viz, 
unexplained  and  obstinate  diarrhoea,  emaciation,   &c. 

Treatment  of  Non-purulent  Serous  Effusions.  Question  of  operaticn. 
If   medical  treatment,  e.g.  absorbents  and  diuretics,  counter-irritation, 

760 


PARACENTESIS  OF  THE  CHEST  761 

dry  nutritious  diet,  &c.,  fail,  two  questions  arise  :  A.    What  is  the  danger 
of  leaving  the  fluid  ?     B.  What  is  the  risk  of  paracentesis  ? 

A,  Danger  of  leaving  the  fluid.  (I)  There  is  the  risk  of  sudden  death 
when  a  large,  quiet  effusion  persists.^ 

Dr.  Moxon  showed  that  the  effect  of  the  effusion  varied  with  the 
side  affected.  Thus  an  effusion  into  the  right  chest  not  only  pushes  the 
heart  over  to  the  left,  but  also  compresses  the  right  auricle,  and  so  shuts 
off  blood  from  the  heart,  thus  tending  to  produce  syncope  from  cardiac 
anaemia.  Effusion  on  this  side  also  tends  to  make  lateral  pressure  on  the 
inferior  vena  cava,  which  is  the  more  readily  bent  over  as  it  has  just 
passed  through  a  rigid  ring.  Effusion  into  the  left  chest  drives  the  heart 
over  to  the  right,  and,  pressing  on  the  left  auricle,  distends  the  right 
side  of  the  heart,  by  impeding  the  passage  of  the  blood  into  the  left 
ventricle,  and  thus  tends  to  bring  about  syncope  from  cardiac  plethora. 
There  is  also  a  tendency  for  the  right  lung  to  become  Oidematous,  owing 
to  its  being  engorged  with  blood. 

(2)  The  lung  may  become  more  and  more  tied  down  with  adhesions, 
e.g.  when  much  lymph  has  formed. 

(3)  The  sound  lung  may  become  engorged,  especially  if  the  patient 
is  submitted  to  a  chill. 

(4)  There  is  the  risk  of  slow  pus-formation,  especially  in  a  patient 
much  run  do\^^l,  where  the  effusion  is  secondary  to  some  other  disease, 
and  where  there  is  the  history  of  a  chill. 

B.  The  risks  of  paracentesis.  (1)  Shock.  This  is  especially  possible 
in  delicate  patients  with  a  nervous  dread  of  the  operation.  (2)  Syncope. 
A  special  cause  of  this  is  perhaps  alteration  of  the  position  of  the  heart 
and  large  vessels  by  removal  of  the  supporting  fluid.  (3)  Embolism 
from  the  detachment  of  clots  in  the  pulmonary  veins.  That  this  is  a 
real  risk  is  shown  by  a  case  of  Sir  B.  Foster's  in  which  clots  dislodged  from 
the  right  pulmonary  veins  caused  embolism  of  both  renal  and  iliac  arteries, 
with  a  fatal  result  from  albuminuria,  suppression  of  urine,  and  gangrene. 
Both  (2)  and  (3)  may  perhaps  be  prevented  by  not  drawing  off  all 
the  fluid,  and  drawing  it  off  slowly.  (4)  CEdema  of  the  lung.  This  is 
an  undoubted  danger.  Shortly  after  the  tapping  (the  effusion  being 
usually  a  large  one),  urgent  dyspnoea  comes  on  with  frothy  serous  expec- 
toration rich  in  albumen.  Death  usually  takes  place  in  about  twenty-four 
hours.  Dr.  Duffin's  explanation  of  this  is  probably  the  correct  one.  The 
compressed  lung,  after  the  removal  of  a  large  effusion,  corresponds  to  a 
limb  after  the  use  of  an  Esmarch's  bandage,  i.e.  the  vasomotor  nerves  are 
paralysed  :  thus  when  the  lung  expands,  sudden  stress  is  thrown  on 
toneless  vessels  ;  hence  the  transudation  of  sero-albuminous  fluid,  equiva- 
lent to  the  oozing  so  common  after  removal  of  the  bandage. 

Indications  for  Paracentesis  in  Non-purulent  Effusions.  (1 )  Threatened 
failure  of  the  heart's  action,  shown  by  the  failing  pulse,  the  extremities 
growing  cold,  &c.  (2)  In  all  cases,  and  at  any  date,  when  the  fluid  is  so 
copious  as  to  compress  the  opposite  lung.  The  base  of  this  should  be 
carefully  watched,  and  any  expectoration  noted.  (3)  In  all  cases  where, 
with  a  large  effusion,  there  have  been  one  or  more  attacks  of  orthopnoea. 
Relief  will  be  most  emphatically  called  for  when,  with  this  history,  the 

1  Sir  T.  C.  Allbutt  records  the  case  of  a  girl  who  had  been  brought  to  Addenbrooke's 
Hospital  with  a  large,  quiet,  serous  effusion.  Having  got  out  of  the  cart  which  had 
brought  her,  she  was  walking  slowly  across  the  green  in  front  of  the  hospital,  when, 
without  a  cry  or  a  stagger,  she  was  seen  to  fall  dead. 


762  OPERATIONS  ON  THE  THORAX 

patient  lives  some  distance  off,  when  he  is  no  longer  young  and  the  chest 
no  longer  yielding,  or  when  the  opposite  lung  is  at  all  oedematous.  (4)  In 
all  cases  in  which  a  pleuritic  effusion,  occupying  half  one  pleural  cavity, 
has  existed  three  or  four  weeks,  and  shows  no  sign  of  progressive 
absorption . 

Paracentesis  for  Serous  Effusions.  The  site  of  juncture.  This  is 
decided  by:  (1)  Physical  signs.  (2)  The  result  of  the  exploring  needle. 
Common  sites  are  :  (a)  The  sixth  space  in  front  of  the  posterior  axillary 
fold,  a  spot  which  has  the  advantage  of  being  thinly  covered,  and  where 
the  ribs  are  well  apart.  (6)  In  the  seventh,  eighth,  and  ninth  spaces 
behind,  in  the  scapular  line.   The  eighth  space  is  here  very  frequently  used. 

The  patient  having  been  turned  somewhat  over  on  to  his  sound  side, 
if  he  can  bear  this,  and  brought  to  the  edge  of  the  bed,  or,  if  he  must  be 
raised,  so  supported  that  he  can  be  readily  lowered  in  case  of  faintness,  the 
surgeon,  ha\"ing  seen  that  the  spot  chosen  for  puncture  is  sterihsed,  and 
that  his  aspirator  is  thoroughly  clean  and  in  good  working  order,  fixes 
his  nail  just  above  the  lower  rib,  and,  holding  the  needle  so  that  it  cannot 
penetrate  too  deeply,  plmiges  it  straight  into  the  pleural  cavity,  and  then 
brings  it  into  connection  with  the  vacuum.  If  the  skin  is  very  thick,  and 
the  needle  slender,  it  is  well  just  to  make  a  pmicture  "with  a  scalpel's  point. 
In  either  case  it  is  the  skin  wound  which  pains. 

The  following  practical  points  should  be  remembered  :  (1)  Not  to 
catch  the  needle  on  a  rib,  a  mistake  which  is  easy  when  the  ribs  are 
close  together.  (2)  To  be  sure  and  enter  the  chest  cavity,  a  thickened 
pleura  or  false  membranes  sometimes  interfering  ^"ith  this.  (3)  To  avoid 
injury  to  the  lung,  by  not  plunging  the  needle  in  too  deeply,  or  by  guarding 
the  point  when  it  has  entered.  Usually  the  Imig  is  at  a  considerable 
distance,  but  when  the  collection  is  a  localised  one  this  accident  may  easily 
take  place.  (4)  The  fluid  should  not  be  drawn  off  too  quickly  or  com- 
pletely ;  if  successive  vacua  are  required,  the  later  exhaustions  should 
not  be  too  complete.  The  patient  should  always  be  warned  against 
making  any  sudden  movement  or  a  deep  inspiration.  If  the  flow  stops 
suddenly,  it  may  be  due  to  a  kink  in  the  tube,  or  to  a  pellet  of  lymph 
plugging  the  needle.  The  flow  should  always  be  stopped  at  once  :  (a)  if 
the  patient  faints,  this  being  due  sometimes  to  the  consequent  displace- 
ment of  viscera  ;  (6)  if  any  blood  suddenly  appears  in  the  fluid,  this 
coming  usually  from  the  rupture  of  vascular  adhesions,  more  rarely  from 
a  wound  of  the  lung  ;  (c)  if  an  irritating  cough  is  set  up,  this  being  due 
sometimes  to  the  mifolding  of  a  temporarily  compressed  lung. 

When  the  needle  is  withdrawn,  the  puncture'  should  be  at  once 
closed  vaih  collodion  and  sterile  wool  or  gauze. 

On  the  question  of  anaesthesia  or  local  analgesia  the  remarks  at  pp.  582, 
765  should  be  referred  to.  As  a  rule  the  pain  is  so  momentary  that 
these  are  not  needful. 

Incision  of  the  Chest  for  Serous  Effusions.  This  is  indicated  in  certain 
cases  of  long-standing  effusion  where  paracentesis  has  been  performed 
more  than  once,  and  has  on  each  occasion  been  followed  by  rapid  re-collec- 
tion of  the  fluid.  A  warning  is  needed  here — as  to  the  great  risk  of  a  sinus 
following  and  thus  infection,  especially  where  the  chronic  effusion  is 
tuberculous,  an  incision  here  being  a  very  risky  step. 

Sir  R.  Godlee  ^  is  emphatic  upon  this  jwint :    "  The  surgeon  is  often  asked  to 
open  these,  especiaUy  if  the  fluid  has  become  slightly  turbid.     My  experience  is 
^  Diseases  of  the  Chest,  with  Dr.  Fowler,  p.  59G. 


EMPYEMA  763 

that  if  this  be  done,  the  fatal  conclusion  is  hastened.  Such  patients  are  able  to  get 
along  very  well  with  a  very  con.sid('ral)l('  collect  ion  of  fluid  in  the  chest ;  but  when  a  free 
opening  is  made,  tliey  become  much  more  sliort  of  breath,  and,  as  tlie  discharge  is 
copious  for  a  long  t  ime.  it  is  very  likely  tliat  septic  organisms  will  be  allowed  to  enter. 
This  is  the  begiiuiing  of  the  end.  I  have  in  a  few  tul)ercuIous  cases  which  were,  so  to 
speak,  halfway  ln'tween  serous  effusions  and  empyematii,  given  considerabh;  relief 
by  inserting  two  cannulas  one,  in  front,  made  to  c()mniuni(;ate  by  a  tube  with  a  large 
bottle  of  sterilised  boric  lotion,  the  other,  far  back,  being  put  in  communication  with 
the  syphon  or  bottle  aspirator.  The  Huid  was  slowly  exhausted,  antl  its  plic  taken 
by  the  boric  lotion.  As  soon  as  the  latter  flowed  quite  clear  into  the  bottle,  the 
anterior  cannula  was  removed,  and  as  much  as  ])Ossil)le  was  exhausted  from  the 
chest.  This  appeal's  sometimes  to  diminish  veiy  considerably  the;  ra])idity  of  the 
reaccumulation.  Possi})]y  other  fluids,  such  as  tincture  of  iodine  and  water,  might 
prove  more  efficacious." 

EMPYEMA 

The  fre(|uc'iicy  of  this  in  childi'en  ^  has  ]>eeii  ah'cady  alluded  to.  At 
this  time  of  life  the  prognosis  is  good,  as  the  lungs  are  more  likely  to  be 
free  from  morbid  changes.  The  formation  of  pus  may  be  very  rapid  at 
this  early  stage  of  life,  pus  being  present  by  the  fourth,  fifth,  or  seventh 
day.  The  importance  of  this  is  considerable.  Thus :  (a)  the  pleura 
is  soon  altered,  thickened,  and  less  prone  to  heal  ;  (b)  the  lung  becomes 
tied  down  ;  (c)  the  drainage-tube  is  readily  blocked  ;  {d)  subdivisions 
may  form  in  the  cavity,  and  so  thorough  drainage  and  obliteration  are 
rendered  difficult. 

Another  important  point  is,  that  pus  in  the  pleural  cavity  is  frequently 
localised  and  encysted  in  children.  This  is  not  uncommon  in  the  middle 
third  of  the  thorax,  the  pus  being  limited  above  by  adhesions,  and  below 
by  the  fixing  of  the  lower  lobe  to  the  chest  wall.^  Thus,  at  this  spot  loud 
bronchial  breathing  and  modified  resonance  may  be  present.  Finally, 
in  children  small  multiple  collections  are  not  uncommon. 

The  surgeon  will  very  likely  be  asked  the  question  whether  the  pus 
need  be  withdrawn,  and  if  it  will  not  be  gradually  absorbed.  The  chances 
of  this  are  extremely  small,  and  the  risks  of  leaving  it  very  great.  They 
are :  (a)  external  perforation,  leading  to  the  unfavourable  results  of 
insufficient  drainage,  caries,  and  amyloid  disease.  The  most  Hkely 
sites  are — in  front,  above  and  below  the  nipple  ;  antero-laterally,  in  the 
fifth  space,  just  outside  the  rib  cartilages,  (b)  Lung  perforation,  leading 
to  gangrene  and  hectic,  (c)  General  tuberculosis,  an  old  empyema,  even  if 
caseated  and  inspissated,  being  infective,  (d)  The  empyema  may  also 
burst  into  the  oesophagus  or  pericardium.  In  other  cases  it  has  been 
known  to  track  downwards  behind  the  diaphragm  and  give  rise  to  a 
lumbar,  gluteal,  or  even  a  psoas  abscess.  In  such  cases  pulsation  of  the 
swelling  has  been  observed,  synchronous  either  with  respiration  or  with 
the  heart-beat. 

TREATMENT  OF  EMPYEMA 

A.  Simple  Puncture  with  Aspirator  or  Fine  Trocar.  This  is  seldom 
curative.  The  cannula  will  entirely  fail  to  remove  the  flocculent  or 
fibrinous  masses  which  are  often  present,  and  the  existence  of  which  we 

1  Out  of  forty-four  and  sixteen  consecutive  cases  of  pleuritic  effusion  at  Great  Ormond 
Street,  Sir  T.  Barlow  found  twenty-seven  and  fourteen  to  bo  purulent. 

2  While  the  commonest  form  of  localised  empyema  is  that  lying  between  the  lung  and 
costal  pleura,  two  others  may  be  met  with  :  that  between  the  diaphragm  and  the  lung, 
and  the  variety  situated  between  two  lobes  or  between  the  lung  and  mediastinum. 


764  OPERATIONS  ON  THE  THORAX 

have  no  means  of  foretelling  (p.  766).  Aspiration  will  certainly  need 
repetition  and  is  only  justifiable  in  a  few  conditions  :  (a)  in  bilateral 
empyemata  ;  (b)  if  the  patient  is  very  young  or  very  timid  ;  (c)  if  the 
collection  is  very  small  or  multiple  ;  (d)  in  advanced  phthisis  or  pyaemia  ; 
(e)  as  a  temporary  or  palliative  measure  in  malignant  disease,  or  in  old  or 
feeble  patients.  Patients  thus  treated  should  be  kept  under  close  observa- 
tion. In  some  cases  preliminary  aspiration  i  s  to  be  strongly  recommended 
before  opening  and  draining  the  pleural  cavity,  namely  in  large  empyemata 
of  the  left  side  where  the  heart  is  displaced.  By  aspiration,  twenty-four 
or  forty-eight  hours  before  the  chest  is  opened,  the  danger  of  syncope 
(which  may  be  fatal),  arising  from  sudden  displacement  of  viscera,  may 
thus  be  averted. 

B.  Incision.  This,  with  a  very  few  exceptions,  is  the  best  method. 
Its  chief  advantages  are  the  free  drainage  which  it  gives.  Although  the 
method  of  simple  incision  has  met  with  success,  yet  generally  speaking  a 
pece  of  rib  is  resected  as  well,  to  allow  of  free  drainage. 

The  chief  advantages  of  this  are  as  follows  :  (1)  Perfectly  free  drainage 
is  provided  for,  since  the  largest  sized  drainage-tube  can  be  used,  and 
there  is  no  longer  the  fear  of  compression  of  the  tube  by  closely  placed 
ribs.  (2)  The  aperture  is  large  enough  to  allow  the  surgeon  thoroughly  to 
explore  the  cavity  with  his  finger.  Its  extent  and  the  character  of  its 
walls  may  thus  be  gauged,  and  further  valuable  information  at  times 
obtained,  e.g.  a  case  of  pyaemia  under  Sir  W.  Savory,  in  which  a  dis- 
tended pericardium  was  felt  through  an  opening  in  the  left  pleura.  This 
was  opened  through  the  same  womid,  and  twenty-four  ounces  of  pus 
evacuated.^  (3)  The  large  masses  of  fibrinous  lymph  so  often  found 
lining  the  cavity  can  escape,  and  prolonged  discharge  perhaps  thereby 
prevented.  Where  such  masses  are  present  the  empyema  is  very  fre- 
quently due  to  the  pneumococcus,  and  especially  requires  early  and  com- 
plete evacuation.  Such  empyemata  are  common  in  children,  and  while 
sometimes  of  a  mild  type,  are  always  liable  to  cause  serious  complications, 
e.g.  pericarditis  or,  more  remotely,  peritonitis  and  arthritis.  It  is  the 
large  masses  mentioned  above  which  especially  call  for  a  free  opening 
and  removal  of  a  rib,  for  if  retained  they  not  only  prevent  complete 
evacuation,  but  are  sources  from  which  further  invasion  by  the  cocci  or 
their  toxins  may  take  place. 

The  disadvantages  are  that  the  operation  is  more  prolonged  and  also 
somewhat  more  difiicult  than  simple  incision.  There  are  practically 
no  disadvantages  as  regards  the  effect  on  the  rib  itself,  for  new  bone 
formation  is  generally  quite  rapid  enough  and  caries  and  necrosis  are 
almost  unlaiown.  Removal  of  a  piece  of  rib  is  then  to  be  recommended, 
except  where  the  necessary  appliances  are  not  to  hand,  or  the  condition 
of  the  patient  forbids  any  but  the  shortest  possible  operation.  The  ques- 
tion will  occasionally  arise  whether  a  single  or  a  double  opening  is  required. 
A  single  opening  is  usually  sufficient  in  children  and  in  young  adults, 
especially  where  the  history  is  a  recent  one.  The  site  usually  chosen 
is  the  seventh,  eighth,  or  ninth  space  in  the  posterior  axillary  line,  or  in 
the  same  space  just  outside  the  line  of  the  angle  of  the  scapula.  In 
adults  the  chief  part  of  the  opening  should  be  anterior  to  the  latissimus 
dorsi,  an  incision  through  a  well-developed  muscle  having  certainly  the 
risk  of  causing  oozing  afterwards,  which  may  be  very  serious  in  a  very 

'^  Path.  Soc.  Trans.,  1884.  See  also  a  case  recorded  by  Dr.  Fawcett  and  Mr.  F.  J. 
Steward  {Clin.  Soc.  Trans.,  vol.  xxxiv,  p.  46). 


EMPYEMA  765 

weakly  patient.  Hutton  ^  recoiiimeiids  incision  over  the  sixth  rib  in  the 
mid-axillary  line,  because  (1)  this  is  the  last  point  to  which  the  lung 
expands  ;  and  (2)  it  is  more  conil'ortable  to  the  patient.  A  double  open- 
ing is  very  occasionally  required,  e.g.  in  very  large  cavities  in  adults  when 
the  pus  is  foetid ;  when  the  case  is  of  very  long  standing ;  when  the 
pus  is  pointing  high  up  and  anteriorly,  and  thus  the  drainage  is 
inadequate.  The  best  instrument  to  cut  upon  in  making  the  counter- 
operation  is  a  stout  silver  probe.  To  this  a  drainage-tube  can  be  attached 
by  silk,  and  easily  drawn  into  place. 

The  chief  points  of  importance  in  the  operation  are  the  following  : 
Amongst  the  first  will  arise  the  question  of  giving  an  ancesthetic.  An 
anaesthetic  may  safely  be  given  in  the  vast  majority  of  cases.  Chloroform 
is  the  most  suitable,  on  account  of  the  greater  struggling  (undesirable 
with  viscera  displaced),  the  dyspnoea  set  up  by  the  mucus,  and  the 
bronchitis  subsequent  to  the  administration  of  ether  ;  but  the  way  in 
which  the  anaesthetic  is  given  is  of  more  importance  than  the  anaesthetic 
itself. 

Sir  F.  Hewitt  says  : 

"  With  regard  to  the  most  appropriate  anaesthetic,  it  is  difficult  to  lay  down 
definite  rules.  The  condition  of  the  patient  must  be  the  chief  guide.  From  the  point 
of  view  of  the  surgeon  chloroform  is  preferable  to  ether  ;  but  there  are  many  cases 
in  which  this  latter  anaesthetic  should  be  used  in  preference  to  chloroform.  When- 
ever possible,  ether  or  an  ether  mixture  should  be  chosen  ;  for  although  it  may  cause 
some  increase  in  the  difficulty  of  breathing,  the  circulation  will  be  well  maintained. 
It  should,  of  course,  be  given  by  a  semi-open  inhaler.  The  greater  the  respiratory 
difficulty  the  lighter  should  be  the  anaesthesia." 

The  position  of  the  patient  is  a  matter  of  considerable  importance. 
Though  the  breathing  will  be  less  affected  if  the  patient  is  on  his  side 
wth  the  healthy  side  uppermost,  yet  in  many  cases  the  operation  can  be 
far  more  satisfactorily  and  quickly  performed  with  the  affected  side 
uppermost.  The  position  should  always  be  the  subject  of  a  consultation 
between  the  anaesthetist  and  the  surgeon,  but,  generally  speaking,  when 
the  respiration  is  seriously  affected  the  healthy  side  should  be  uppermost 
to  allow  free  action  of  the  healthy  Imig. 

Local  analgesia  (p,  582)  should  certainly  be  used  where  a  general 
anaesthetic  is  thought  inadvisable.  Mr.  G.  L.  Chiene  ^  used  the  following 
mixture  :  four  parts  of  2  J  per  cent,  eucaine  B  ;  one  part  of  1  to  1000  of 
adrenalin  chloride.  Thirty  minims  of  the  above  solution  were  injected 
into  the  subcutaneous  tissue  over  the  line  of  the  long  axis  of  the  rib. 
Twelve  minutes  were  allowed  to  elapse,  and  then  the  usual  operation 
performed  ;  this  was  accomplished  painlessly,  more  of  the  solution  being 
applied  to  the  periosteum  before  the  rib  was  excised.  The  tissues  in 
the  region  of  the  injection  became  blanched ;  there  was  practically  no 
bleeding,  no  pain  even  when  the  bone  was  cut  through,  and  no  after- 
haemorrhage. 

When  no  rib  is  removed  the  operation  is  performed  as  follows  :  The 
patient  being  supported  over  the  edge  of  the  bed  or  table,  partly  rolled 
over  to  the  sound  side,  or,  if  this  is  impracticable,  suitably  propped  up, 
the  surgeon,  having  cleansed  the  part,  fixes  a  finger-nail  just  on  the  upper 
margin  of  the  lower  rib  in  the  space  chosen  (p.  762),  and  makes  an  incision 
down  to  the  muscles  for  one  and  a  half  or  two  inches,  just  above  his  nail. 

1  Brit.  Med.  Journ.,  vol.  ii,  p.  1321,  1898. 

2  Scot.  Med.  and  Surg.  Journ.,  September  1904,  p.  215. 


766  OPERATIONS  OX  THE  THORAX 

lu  every  case  the  presence  of  pus  at  the  spot  chosen  should  first  be 
verified  with  an  exploring  needle.  This  incision  ha\'ing  exposed  the 
muscles,  a  steel  director  is  driven  through  into  the  chest  ca\4ty,  care  being 
taken  not  to  plimge  it  too  deeply.^  A  pair  of  dressing-forceps  is  then  run 
along  the  director  and  opened  widely  both  horizontally  and  vertically. 
Owing  to  the  gush  of  pus  which  is  now  \-iolently  expelled,  it  is  well  to 
throw  a  sterihsed  piece  of  gauze  over  the  wound,  while  the  pus  is  escaping.^ 
This  prevents  any  entrance  of  air,  and  regulates  an  otherwise  perhaps  too 
rapid  exit  of  fluid.  The  opening  is  next  thoroughly  dilated  by  means  of  a 
pair  of  lithotomy-forceps  or  sequestrum-forceps,  the  jaws  of  which  are 
carefully  separated,  and  the  size  of  the  ca^^ty,  the  proximity  of  the  lung 
and  the  degree  of  granulation  formation  all  investigated. 

When,  as  will  usually  be  the  case,  a  'portion  of  rib  is  to  be  removed, 
the  steps  of  the .  operation  are  slightly  difierent.  The  incision  is  made 
directly  over  the  rib  and  straight  down  to  the  bone,  the  periosteum  being 
di\"ided.  The  periosteum  is  now  stripped  off  the  rib  for  a  distance  of 
about  an  inch  and  a  half  with  a  slightly  curved  raspatory,  care  being 
taken  thoroughly  to  clear  the  pleural  surface.  The  rib  is  then  di^^lded 
in  front  and  behind.  This  can  in  most  cases  be  accomplished  with  a 
strong  bone-forceps,  or  special  rib-forceps,  but  if  the  ribs  are  large  and 
dense  it  may  be  necessary  first  to  cut  a  groove  "^ith  a  saw. 

The  piece  of  rib  is  now  removed,  and  the  ca\'ity  opened  with  director 
and  dressing-forceps  as  above  described,  care  being  taken  to  push  in  the 
director  exactly  over  the  upper  border  of  the  rib,  in  order  to  avoid  the 
intercostal  vessels.  Ha^'iug  in  this  way  made  a  free  opening,  and  the 
pus  ha^'ing  been  evacuated,  any  large  flakes  of  lymph  may  be  removed  by 
the  surgeon's  finger  or  a  blunt-edged  scoop,  and  a  drainage-tube  inserted. 
This  should  be  of  large  size,  and  just  sufficiently  long  to  reach  the  cavity 
without  projecting  too  far  into  it.  Any  coifing  of 
the  tube  in  the  cavity  is  useless,  and  may  be  harmful. 
The  inner  end  of  the  tube  should  carry  one  or  two 
large  lateral  openings.  An  ordinary  tube  should  be 
securely  fixed  in  position  by  means  of  safety  pins, 
in  order  to  prevent  it  from  slipping  into  the  pleural 
ca\'ity,  or  a  silkworm-gut  suture  may  be  used  to 
stitch  the  tube  securely  to  the  skin.  Another  method 
easily  pro\'ided  is  to  slit  the  outer  end  of  the  tube  into 
Fig  310  ^^^^^  strips  and  attach  each  of  these  by  silver  wire  to 

a  small  square  of  india-rubber  sheeting.  Mr.  Bilton 
Pollard's  tube  (Fig.  310)  is  very  simple  and  efiicient.  One  of  the  methods 
given  should  always  be  adopted  to  prevent  the  tube  shpping  into  the 
pleural  ca\*ity. 

Hutton^  has  recently  described  a  drainage-tube  fitted  with  a  duck-bill  valve, 
which,  while  allowing  the  exit  of  pus  during  expiration,  prevents  the  entrance 
of  air  dming  inspiration,  thus  promoting  a  more  rapid  expansion  of  the  limg.  The 
advantages  claimed  are  : 

(1)  That  it  hastens  materially  the  expansion  of  the- lung. 

(2)  That  it  is  simple,  inexpensive,  and  comfortable. 

^  If  the  chest  is  being  opened  low  down,  and  the  above  warning  not  remembered,  the 
director,  or  the  dressing-forceps  which  follow  it,  may  easily  be  sent  into  the  peritoneal 
cavity. 

2  Occasionally,  if  the  patient  struggles,  air  is  drawn  into  the  pleural  cavity  after  the 
escape  of  the  pus.  and  then  is  expelled  into  the  connective  tissue  of  the  wound,  constituting 
emphysema.     This  will  all  pass  off  spontaneously.  ^  Loc.  supra  cit. 


EMPYEMA  7G7 

(.'{)1"'li;i(  by  liastcniiif^lliccxpaiisioii  ol  the  lung  it  will  obviate,  in  many  cases,  the 
necessity  of  E.slaiuler's  operation,  which  means  the  deprivation  of  the  use  of  one  lung. 

(4)  It  is  devoid,  of  risk,  as  it  only  aids  nature  by  enabling  the  lung  to  keep  the 
advantage  it  has  gained  by  each  expiratory  effort. 

Judging  from  the  above  points,  and  from  the  satisfactory  results  which  Mr. 
Hutton  describes,  this  apparatus  is  worthy  of  more  extended  trial. 

Hseuiorrhage  during  the  operation  is  usually  slight,  and  gives  no 
anxiety  afterwards.  If  any  point  give  trouble,  resisting  Hgature,  after 
picking  up  the  tissues  with  Spencer- Wells  forceps,  a  pair  of  these  left 
on  for  twelve  hours  will  meet  the  case  ;  a  bit  of  a  rib  quickly  resected  will 
give  access  to  a  wounded  intercostal  artery. 

The  opening  must  be  sufficient,  and,  if  there  is  any  doubt  about  this, 
a  further  portion  of  rib  should  be  resected  without  hesitation,  especially 
where  these  are  very  close  together,  or  where  the  pus  is  foul  {vide  infra), 
or  contains  large  flocculent  masses. 

If  the  question  of  washing  out  the  cavity  arise,  probably  from  the 
discharge  being  fold,  it  should  be  remembered  that  this  proceeding,  how- 
ever gently  done,  has  occasionally  brought  about  grave  and  even  fatal 
results  very  suddenly.  Whether  these  have  been  due  to  absorption,  to 
reflex  nervous  disturbance,  or  to  dislodgment  of  thrombi  is  micertain, 
but  it  is  beyond  question  that  in  several  cases  symptoms  of  impending 
collapse  and  even  death  have  followed  on  washing  out  an  empyema,  and 
that,  too,  in  a  patient  well  on  in  convalescence.  Again,  it  cannot  be  too 
strongly  insisted  upon  that  foetor  calls  for  a  freer  opening,  not  for  washing 
out.  If,  however,  it  is  decided  to  make  use  of  injections,  dilute  and 
bland  ones,  e.g.  tr.  iodi,  should  be  used,  and  these  should  be  gently 
run  in  with  a  fmmel  and  tubing,  the  elevation  of  which  does  not  exceed 
eighteen  inches  ;  fluid  should  never  be  thrown  in  with  a  syringe.  Care 
must  be  taken  that  the  fluid  escapes  as  fast  as  it  runs  in  ;  the  patient 
must  always  be  recumbent. 

During  the  prolonged  after-treatment  everything  should  be  done  to 
improve  the  general  health.  Change  of  air  is  here  a  cardinal  point,  first 
getting  the  patient  from  his  room,  then  outside  the  house,  and  lastly,  if 
possible  to  the  seaside.^ 

A  point  of  no  small  importance  in  the  after-treatment,^  especially  in 
young  subjects  with  flexible  spines,  is  to  encourage  early,  systematic 
deep  breatliing  and  gymnastic  exercises,  thus  to  promote  expansion 
of  the  chest,  and  so  minimise  that  sad  sequela  of  empyema,  irremediable 
lateral  curvature. 

Bier's  treatment  is  often  of 'the  greatest  service  in  the  after-treatment 
of  these  cases.  A  Bier's  glass  cup  of  sufficient  size  to  encircle  the  wound 
completely,  usually  three  or  four  inches  in  diameter,  should  be  employed. 
It  should  be  applied  for  ten  minutes  once  or  twice  a  day,  when  the  dressings 
are  being  changed.     Its  action  is  threefold :  (a)  it  sucks  out  pus  from  the 

1  Last  and  most  important  of  all — unfortunately  for  hospital  patients  a  treatment 
that  cannot  often  be  utilised — ^comes  Margate  air.  Any  seaside  air  is  beneficial,  but 
weather  and  season  permitting,  I  do  not  believe  there  is  any  corner  of  England  so  quickly 
restorative  to  children  with  empyema  as  that  in  which  Margate  and  Broadstairs  are 
situated  ;  and.  personally,  I  set  more  store  by  a  change  of  this  kind  after  the  first  three  or 
four  weeks  have  passed  than  in  any  continuation  of  antiseptic  dressings."  (Goodhart, 
Diseases  of  Children,  p.  345.) 

2  Should  a  sinus  persist  injection  of  an  emulsion  of  bismuth  may  be  tried.  This 
method  of  treatment  is  described  and  a  number  of  cases  thus  treated,  by  Dr.  Ochsner, 
of  Chicago,  ill  a  paper  on  "  The  Treatment  of  Fistulas  and  Abscesses  following  Operations 
for  Empyema  "  {Ann.  Surg.,  1909,  vol.  1,  p.  151). 


768  OPERATIONS  ON  THE  THORAX 

cavity  ;  (b)  it  causes  passive  hyperaemia  and  thus  has  the  antibacterial 
action  of  Bier's  treatment ;  (c)  it  probably  assists  in  the  expansion  of 
the  lung.  In  cases  which  are  not  doing  well,  i.e.  where  the  temperature 
remains  high  and  where  suppuration  continues,  the  effect  is  often  remark- 
able. It  may,  with  advantage,  be  adopted  as  a  routine  treatment  after 
the  third  day. 

Before  leaving  the  subject  of  the  operative  treatment  of  empyema 
a  few  words  should  be  said  about  the  dressing  of  these  cases.  This 
should  be  strictly  aseptic  from  first  to  last,  i.e.  cleansing  the  parts  incised, 
disinfection  of  instruments,  taking  care  that  the  pus  escapes  into 
antiseptic  dressings,  a  sufficiently  free  opening,  adequate  drainage, 
abundant  dry  gauze  and  wool  dressings,  changed  twice  perhaps  in 
the  first  twenty-four  hours,  and  then  daily  for  the  first  week.  Later 
on,  when  the  patient  is  going  to  the  seaside,  he  can  easily  be  instructed 
to  remove  with  clean  hands  and  cleanse  daily  the  short  pieces  of  drainage- 
tube  which  keep  the  external  opening  patent,  and  to  apply  over  the 
sinus  a  dressing  of  boracic  acid  lint  and  carbolised  tow,  or  whatever 
antiseptic  dressing  is  thought  desirable. 

Where  an  empyema  exists  on  each  side,  the  wisest  course  is  to  open 
and  drain  one,  and  at  the  same  time  to  aspirate  the  other,  which  should 
be  opened  a  few  days  later. 

Date  at  which  the  drainage-tube  may  be  dispensed  with.  In  children 
with  a  recent  history  a  few  days  may  suffice  ;  in  adults  three  to  four 
weeks  must  usually  elapse. 

Comphcations  of  Empyema  and  Reasons  for  Cases  not  doing  well. 
(1)  A  persistent  infected  condition,  in  spite  of  two  openings,  free  drainage, 
&c.  (2)  Failure  of  the  lung  to  expand  owing  to  dense  adhesions  and 
also,  possibly,  to  fibroid  changes  in  the  lung  itself.  (3)  Tuberculous 
disease.  (4)  Lvmg  mischief  on  the  opposite  side — e.g.  broncho -pneumonia, 
bronchitis.  This  is  especially  dangerous  in  patients  over  forty.  (5) 
Caries  of  the  ribs,  multiple  spontaneous  openings,  with  burrowing  sinuses 
beneath  the  skin.  (6)  Age,  from  the  feebler  powers  of  repair  and  the 
more  rigid  condition  of  the  chest  as  fife  advances.  (7)  Cardiac  dilatation. 
(8)  Inflammation  of  other  serous  and  the  synovial  membranes,  e.g.  when 
the  pneumococcus  is  present.  (9)  Size  of  the  empyema.  The  smaller 
and  the  more  locahsed  the  collection  the  better  the  prognosis.  (10)  Collec- 
tion of  pus  forming  in  the  opposite  pleura.  (11)  A  broken-do ^tl  consti- 
tution ;  intemperance  ;  kidney  disease.  (12)  Sir  R.  Godlee  ^  reminds 
us  that  a  curious  complication,  viz.  cerebral  abscess,  has  been  noticed  in 
a  sufficient  number  of  instances  to  make  it  unwise  to  overlook  the  possible 
association  of  one  with  tTie  other.  Judging  from  Dr.  Fagge's  remarks 
on  thoracic  disease  as  a  cause  of  cerebral  abscess,^  it  would  appear  that 
disease  of  the  lung  itself  is  oftener  the  primary  lesion  upon  which  the 
abscess  of  the  brain  depends. 

According  to  SirW.  Gowers,^  these  abscesses  "never  result  from  true  tuberculous 
cavities  ;  the  abscess  is  single  in  about  half  the  cases,  and  is  generally  situated  in  the 
cerebral  hemispheres,  especially  in  the  posterior  lobes.  The  cerebellum  is  not  often 
affected,  and  never  suffers  alone."  Sir  R.  Godlee*  writes  :  "  These  abscesses  are 
seldom  amenable  to  surgical  treatment.  I  have  opened  one  vrithout  good  result, 
probably  because  it  was  not  single,  and  I  have  searched  for  one  which  appeared  to 
give  positive  evidence  of  berag  situated  in  the  motor  area,  but  was  really  in  the 
occipital  lobe." 

^  Diet,  of  Surg.,  vol.  i,  p.  459.  ^  Prin.  and  Pract.  of  Med.,  vol.  i*  p.  546. 

^  Diseases  of  the  Nervotts  Sysiein,  2nd  ed.,  vol.  ii,  p.  477.  *  Loc.  supra  cit..  p.  617. 


RESECTION  OF  RIBS 


769 


RESECTION  OF  RIBS 

Indications.^     'I'liese  are  chiefly  : 

A.  (a  lies  of  ribs. 

i^.   In  the  majority  of  cases  of  empyema. 

V.  For  a  wouiul  of  an  intercostal  artery. 

D.  For  removal  of  growths. 

Dr.  E.  Rixford,  of  San  Francisco,  in  an  instructive  paper,^  quotes 
the  following  four  cases.  He  points  out  that,  as  in  the  modern  operation 
for  carcinoma  of  the  breast,  all  the  subcutaneous  tissues  arc  removed 
down  to  the  periosteum  and  intercostal  nmscles  ;  if  any  reappearing 
nodule  is  to  be  successfully  dealt  with,  the  underlying  portion  of  the 
chest  wall  must  be  removed  with  it.  The  following  are  the  abstracts  of 
Dr.  Rixford's  four  cases.     There  were  no  deaths  from  the  operation. 

Case  I.  Reappearing  carcinoma  of  breast  over  fifth  rib  ;  resection  of  fourth  and 
fifth  ribs  ;    no  evidence  of  reappearance  after  two  years.     Case  II.     Reappearing 


Fig.  311.     A,  Doyen's  rib  raspatory.     B,  Rib  shears. 


carcinoma  of  breast  at  edge  of  sternum  ;  resection  of  foui'tli  and  fifth  costal  car- 
tilages with  edge  of  sternum  ;  rea^jpearance  in  mediastinum  after  eight  montlis, 
disappearing  under  the  X-rays,  but  reappearing  five  months  later.  Case  III. 
Reappearing  carcinoma  of  breast  at  edge  of  sternum  ;  resection  of  third  and  fourth 
costal  cartilages  with  half  of  breadth  of  sternum  ;  reappearance  in  original  scar 
apart  from  the  field  of  the  last  operation  ;  death  from  general  carcinosis  five  months 
later.  Case  IV.  Reappearing  carcinoma  of  breast  at  edge  of  sternum  ;  removal 
of  ends  of  first  and  second  ribs  and  portion  of  sternum  and  mediastinal  glands  ; 
internal  mammary  arterj^  tied  at  its  origin  ;  further  recurrence  below  ;  resection 
of  third  and  fourth  ribs  ;  patient  well  six  months  after  last  operation,  twenty-two 
months  after  operation  by  Halsteads  method. 

Dr.  Rixford's  method  of  meeting  the  compUcation  of  pneumo-thorax 
is  given  at  p.  775.     This  subject  is  further  discussed  at  p.  780. 

A.  In  obstinate  caries,  where  more  than  one  rib  is  affected,  where 
previous  treatment,  including  gouging,  fails,  resection  should  be  at  once 

^  See  also  chapter  xxxv,  on  operations  on  the  lung  and  the  mediastinum. 
^  Aim.  of  Surg.,  January  190G,  p.  35. 
SURGERY    I  49 


770  OPERATIONS  ON  THE  THORAX 

performed.     It  is  a  very  simple  operation  in  these  cases,  as  the  soft  tissues 
are  nearly  healthy  and  the  periosteum  is  retained. 

An  incision  about  two  inches  long  being  made  over  the  centre  of  the 
carious  rib,  and  the  muscles  peeled  off  with  a  blunt  dissector,  the  perios- 
teum is  next  incised  and  separated  from  the  upper  and  under  aspect  with 
an  elevator,  blunt  and  slightly  curved,  so  as  to  pass  readily  under  the 
rib  and  lever  it  upwards.  The  rib  being  thus  raised,  it  is  easily  chvided  at 
one  limit  of  its  exposed  part,  partly  with  a  narrow-bladed  saw,  partly  with 
sharp,  curved  cutting-forceps.  The  soft  parts  are  next  peeled  away 
from  the  under  aspect,  and  the  rib  divided  at  the  corresponding  spot  and 
removed. 

B.  In  most  cases  of  empyema ,  e.g.{l)  when  the  drainage  is  insufficient, 
the  discharge  foul,  in  spite  of  one  or  two  free  openings  ;  (2)  when  the 
ribs  are  too  close  together  for  a  tube  of  sufficient  size  ;  (3)  when  an 
empyema  cavity  still  persists,  though  sweet,  in  spite  of  free  incision,  good 
drainage,  and  careful  dressing.  In  the  first  two  classes  of  cases  removal 
of  a  small  piece  of  one  or  two  ribs,  as  above  described,  will  be  sufficient, 
but  in  some  of  these  latter  cases  the  operation  will  necessarily  be  a  much 
more  severe  one.  When  called  to  a  case  of  persistent  sinus  and  discharge 
after  the  incision  of  an  empyema,  the  surgeon  on  examination  may  find 
that  the  cavity  which  remains  is  small,  and  that  the  discharge  is  due  to 
a  persistent  sinus-track  only.  This  should  be  dilated,  part  of  a  rib 
removed,  and  both  sinus  and  cavity  thoroughly  curetted.  Other  causes 
which  have  to  be  thought  of  where  a  sinus  persists  with  an  empyema 
cavity  of  small  size  are  :  a  small  collection  of  pus  after  inefficient  drainage, 
caries  of  a  rib,  poor  vitality  of  the  patient,  and  a  draiuage  tube  which  has 
slipped  into  the  cavity. 

But  in  the  majority  of  cases  of  long-standing  em])yemata  the  cavity 
remaining  is  an  extensive  one,^  and  the  condition  of  things  is  not  so  simple 
and  so  easily  dealt  with.  Obliteration  has  taken  place,  often  very  im- 
perfectly, owing  to  the  lung  not  being  able  to  expand,  to  the  ribs  having 
fallen  in  all  they  can,  to  the  diaphragm  having  risen,  and  the  opposite  lung, 
the  heart,  &c.,  having  come  over  as  far  as  they  are  able  ;  while  the  cavity, 
often  large,  which  thus  remains  is  lined  with  much  thickened  scar- 
like tissue,  covered  with  granulations  of  but  poor  vitality.  Here  portions 
of  several  ribs  must  be  removed,  and  the  operation  perhaps  repeated,  in 
order  that  the  walls  of  the  cavity  may  still  further  collapse,  and  thus 
obliterate  the  cavity  while  an  opportunity  is  given  for  exploring  this 
thoroughly. 

The  spot  chosen  for  the  resection  of  the  ribs  should  be,  as  far  as  possible, 
opposite  to  the  lung  which  can  expand  no  more,  and  the  pieces  of  ribs 
removed  should  correspond  as  closely  as  may  be  to  the  anterior  and 
posterior  limits  of  the  cavity  which  it  is  desired  to  close.  The  size  of  the 
cavity  should  be  estimated  as  far  as  possible  with  the  aid  of  sterilised 
bougies  and  pewter  probes.  But  the  use  of  these  through  a  fistula  gives 
very  little  information.  Any  really  useful  estimate  can  only  be  arrived 
at  after  removal  of  parts  of  at  least  two  ribs. 

Operation  (Fig.  .312).  Estlander  removed  portions  of  three  or  four 
ribs  through  small  incisions.  Schede  went  further,  making  use  of  large 
flaps,  removing  the  ribs  more  extensively  and,  in  addition,  all  the  perios- 

1  If  the  empyema  is  satisfactorily  opened  and  drained,  with  excision  of  a  portion  of 
a  rib,  at  an  early  stage,  and  if  after-treatment,  including  the  systematic  use  of  Bier's 
cupping  glasses,  is  carried  out,  these  cases  will  be  very  rare. 


RESKCTION  OF  RIBS 


771 


teiini,  intercostal  structures,  and  costal  pleura  over  the  empyema  cavity. 
While  tliis  operation  is  based  upon  sound  reasoning,  it  is  usually  an  ex- 
tremely severe  one,  and  the  patient's  vitality  and  resisting  power  are 
often  low.  In  the  case  of  a  cavity  of  moderate  size  situated  anteriorly 
or  antero-laterally,  the  operation  can  be  quickly  done,  and  a  result  is 
obtained  in  a  short  time.  The  cavity  is  usually  extensive,  and — its  worse 
feature,  owing  to  the  rigidity  and  inability  to  collapse  of  the  parts  behind 
— it  is  here,  viz.  under  the  scapula  and  vertebral  portion  of  the  ribs,  that 
the  chief  part  of  the  cavity  will  be  found.  Further,  it  is  only  the  bones 
which  here  add  to  the  difficulties  of  the 
operation,  but  the  muscles  are  larger  and 
the  loss  of  blood  greater. 

If  the  surgeon  begin  by  raising  an 
extensive  flap  in  order  to  obtain  adequate 
exposure  of  the  cavity,  he  may  find  that 
he  has  done  too  much.  It  is  better  to  find 
out  what  has  to  be  done  as  his  operation 
proceeds.  The  first  step  is  to  make  out  the 
lowest  part  of  the  cavity.  As  a  rule  the 
fistula  does  not  correspond  to  this.  As 
there  is  not  sufficient  fluid  present  to  enable 
an  exploratory  puncture  to  decide  the  lowest 
level  of  the  empyema,  this  point  must  be 
cleared  up  with  a  finger  introduced  from  the 
fistula,  sufficiently  dilated,  with  the  addi- 
tional removal  of  pieces  of  one  or  two  ribs 
here  to  begin  with.  The  operator  having 
placed  himself  on  safe  ground  by  finding 
the  base  of  the  empyema,  begins  the  central 
part  of  his  free  curved  incision  here.  All 
the  soft  parts  down  to,  but  not  including, 
the  periosteum  are  raised  from  the  lowest  two  ribs,  and  two  to  three 
inches  of  these  are  freely  resected.  Care  must  be  taken  now  and  later  to 
leave  the  periosteum  on  the  rib  (the  only  safe  guide  being  not  to  strip 
of?  all  the  muscular  tissue)  and  by  no  means  to  detach  it.  If  it  be  left 
behind,  it  w^ill  throw  out  material  which  wdll  be  quite  as  unyielding  as  the 
bones  taken  away.  The  ribs  are  removed  by  carrying  a  periosteal  elevator 
under  them,  keeping  it  close  to  the  posterior  aspect,  to  one  limit  of  the 
exposed  surface,  and  the  bone  divided  here,  partly  with  a  strong-backed 
narrow  saw,  partly  with  curved  cutting-forceps  or  rib  shears.  The  rib  is 
then  raised  where  cut,  and  severed  with  the  shears  at  its  other  extremity. 
Each  piece  of  rib  removed  should  show  clean-cut  edges  and  be  covered 
with  periosteum.  Now,  and  throughout  the  operation,  the  finger  should 
keep  the  surgeon  accurately  informed  as  to  the  limits  of  the  cavity, 
■especially  when  he  approaches  these  in  dividing  the  ribs.  As  the  use 
of  the  fingers  is  the  only  way  of  safely  delimiting  the  cavity,  the  hands 
must  be  repeatedly  resterilised.  By  thus  freely  removing  two  ribs  at 
the  lowest  part  of  the  cavity,  the  surgeon  has  rendered  himself  safe 
in  this  direction,  and  also  obtained  access  for  more  complete  palpation 
of  the  extent  of  the  empyema.  We  will  suppose  that  it  extends  anteriorly 
and  posteriorly  as  well  as  upwards.  The  incision  do^vn  to  the  bones  is 
enlarged  upwards  and  forwards  and  the  soft  parts  raised  as  before  ; 
with  two  or  more  fingers  as  a  guide,  the  ribs  or  costal  cartilages,  according 


Fig.  312. 


772  OPERATIONS  ON  THE  THORAX 

to  the  extent  of  the  cavity  anteriorly,  are  cut  through  successively,  the 
remaining  intercostal  structures  being  severed  with  blmit-pointed 
scissors.  The  amount  of  bleeding  now  met  with  \\i\\  vary  wth  the 
condition  of  the  costal  pleura.  If  this  be  much  thickened,  the  intercostal 
vessels  will  be  partly  obliterated,  but  in  every  case,  owing  to  the  condition 
of  thg  patient,  each  vessel  is  to  be  clamped  and,  if  possible,  tied.  This  is 
rendered  easier  by  the  free  access  given.  The  ribs  being  severed  in  front, 
the  incision  is  prolonged  in  a  curvihnear  direction  backwards  and  upwards 
over  this  aspect  of  the  empyema,  the  flap  still  more  raised,  and  the  ribs 
and  intercostal  structures  severed  above  and  finally  behind.  If  the 
parts  removed  do  not  include  the  costal  pleura,  and  if  this  be  much 
altered,  thickened,  and  gristly,  it  must  be  taken  away.  Serious  haemor- 
rhage need  not  be  feared  if  the  structm-e  be  snipped  through  gradually 
with  curved  blunt-pointed  scissors,  any  vessels  met  with  being  easily 
secured  as  they  are  divided.  If  the  cavity  be  a  foid  one,  or  coated  with 
ill-formed  lymph  and  granulation  tissue,  it  should  be  gently  wiped  over 
with  sterihsed  gauze,  but  no  curette  should  be  employed,  as  is  sho\^^i  by 
the  following  case  ; 

A  woman,  set.  56,  was  admitted  with  a  right-sided  empyema  cavity  of  some 
months'  duration  and  foetid  discharge.  The  left  lung  was  evidently  the  seat  of  bron- 
chitis. The  cavity,  moderate  in  size  and  antero-lateral,  was  easily  dealt  with  on  the 
lines  given  above.  Believing  that  toxaemia  from  the  very  foul  condition  of  the 
cavity  largely  explained  the  condition  of  the  patient,  ]\Ir.  Jacobson  thoroughly 
cm'etted  the  lining  membrane,  trying  to  exercise  especial  care  when  he  approached 
what  might  be  the  root  of  the  lung,  pericardium.  &c.  The  next  morning  the  right 
foot  was  noticed  to  be  cold.  Gangrene  followed,  necessitating  amputation  above 
the  knee  joint,  the  patient  sinking  four  days  later.  The  necropsy  did  not  clear  up 
the  spot  whence  the  thrombus  had  been  detached.  The  left  hmg  was  the  seat  of 
tuberculous  mischief. 

The  flap  of  soft  parts,  however  large  and  bulky  it  may  have  appeared, 
will  always  prove  too  scanty  for  the  covering  in  of  the  gap  left.  It  must 
be  fastened,  well  depressed,  so  that  it  is  in  contact  ^^^th  the  lung,  by 
means  of  a  few  salmon-gut  sutures  and  large  gauze  pads.  "  Decortica- 
tion "  of  the  lung  is  referred  to  later. 

An  operation  -performed  on  the  above  lines,  with  the  view  of  obtaining 
a  thorough  exploration  of  the  cavity  and  then  the  gradual  removal  of  all 
ribs  and  pleura  that  is  needful,  is  the  one  best  adapted  to  the  largest 
number  of  cases.  But  owing  to  the  condition  of  the  majority  of  the 
patients,  the  operator  must  be  prepared  for  having  his  hand  stayed  and 
the  need  of  completing  the  removal  of  the  needful  parts  in  more  than 
one  stage.  While  such  later  operations  destroy  in  a  measure  what 
has  been  gained  at  the  first,  it  is  the  choice  of  a  lesser  evil,  and  the  patient 
or  the  friends  must  be  prepared  for  it. 

A  few  points  still  need  to  be  referred  to. 

Where  the  gi-eater  part  of  the  cavity  proves  to  be  posterior,  in  the  vertebro- 
scapular  region,  the  condition  of  the  patient  will  be  the  chief  guide.  The  improve- 
ment in  these  cases,  local  and  general,  brought  about  by  a  well-executed  ojDeration 
in  front  is  always  very  great.  If  the  condition  of  the  patient  justify  further  attempts 
at  obtaining  an  absolute  cure,  the  choice  lies  between  removal  of  the  lower  part  of  the 
scapula  by  a  continuation  backwards  of  the  posterior  horn  of  the  free  curved  incision 
(Fig.  312),  or  resection  of  the  posterior  parts  of  the  ribs  by  raising  a  trapdoor-shaped 
flap  over  them,  between  the  vertebrse  and  the  scapula.  Continental  surgeons  have 
frequently  employed  the  fii'st  method.  C.  Beck,  of  New  York,  mentions  ^  two  cases 
in  which  he  removed  the  lower  part  of  the  scapula,  one  in  a  boy  of  6|,  as  part  of  a 
single  operation,  complete  healing  following.  In  the  other  case,  a  man  of  40,  the 
1   Ann.  of  Surg..  1904.  vol.  i,  p.  419. 


HESECTION  OF  RIBS  773 

lower  part  of  flic  scapula  was  taken  away  in  the  last  of  a  series  of  seven  operations, 
'i'hc  cavity  had  now  gratlually  tilled  up,  but  a  large  defect  was  still  left  where  the 
axillary  region  was  not  yet  covered  by  skin.  The  same  surgeon  ^  advises  the  follow- 
ing method  in  those  rarer  eases  where  the  persistence  of  the  troubh;  is  due  to  the 
main  cavity  being  apical.  The  increased  local  risk  here,  owing  to  the  vicinity  of  the 
subclavian  vessels  and  the  fixity  of  the  parts,  is  obvious. 

\Vith  the  arm  at  right  angles,  the  incision  is  led  close  to  the  lower  border  of  the 
peetoralis  major  till  it  ends  at  the  lower  part  of  the  anterior  margin  of  the  deltoid. 
The  nuiseles  are  then  dissected  superiorly  until  the  axillary  region  is  free.  The 
vessels  and  muscles  are  grasped  by  strong  blunt  hooks  and  j)ulled  upwards.  Some- 
times separation  is  possible  only  by  the  aid  of  lateral  incisions  into  both  pectorals. 
Thus  the  vessels  are  temporarily  put  liors  de  combat,  and  the  ribs  can  be  removed 
according  to  the  indicate(l  i)rinci])les.  If  it  is  very  difficult  to  reach  the  first  rib  by 
means  of  the  ])ect()ro-axiIIary  incision,  then  the  clavicle  is  to  be  resected  temjiorarily. 

Decortication  of  the  Lung.  Removal  of  the  pulmonary  jileura  with  the 
view  of  allowing  the  lung  to  exjtand  was  advocated  by  Delorne  in  1S94  2  and  G.  R. 
Fowler.''*  It  has  been  claimed  that  this  method  should  largely  replace  the  opera- 
tions of  Estlander  and  Schede,  but  as,  owing  to  the  usual  position  of  the  lung,  free 
removal  of  the  overlying  parts  will  be  first  needful,  it  appears  to  me  to  increase  con- 
sidera  bly  t  he  severity  of  an  operation  already  very  great.  The  visceral  pleura  is  rarely 
in  that  thickened  altered  condition  with  which  we  are  so  familiar  in  the  case  of  the 
costal  pleura.  Lastly,  even  if  the  visceral  pleura  be  successfully  removed  over  the 
needful  extent — and  the  movements  of  the  diaphragm  and  pericardium  are  sure 
to  be  embarrassing — the  lung  will  not  expand.  It  is  not  from  within,  but  from 
without,  by  sufficiently  extensive  removal  of  the  rigid  overlying  parts,  that  we  must 
hope  to  gain  the  obliteration  of  the  cavity. 

In  all  these  operations  precautions  against  shock  must  be  taken  before 
and  during  as  well  as  after  their  performance,  and  it  is  always  well  to  have 
a  supply  of  oxygen  at  hand. 

With  regard  to  the  date  at  which  ribs  should  be  partially  resected  in 
long-standing  cases  of  empyema,  most  surgeons  who  see  much,  of  these 
troublesome  cases  wnll  agree  that  the  operation  should  be  performed 
as  soon  as  the  natural  powers  of  obliteration  are  at  a  standstill,  care  being 
taken  that  the  patient  has  recovered  from  the  effects  of  the  first  operation  , 
and  perhaps  recruited  his  strength  at  the  seaside.  About  three  months 
will  be  a  sufficient  interval,  as  a  rule.  Waiting  longer  only  encourages 
local  and  general  conditions  which  affect  the  operation  unfavourably. 

C.  Woimd  of  Intercostal  or  Internal  Mammary  Artery.  When  haemor- 
rhage from  one  of  these  vessels  cannot  be  otherwise  dealt  with,  removal  of 
a  rib  will  give  much  readier  access  to  the  spot,  and  a  ligature  will  arrest 
the  bleeding  far  more  satisfactorily  than  the  ingenious  devices  mentioned 
in  the  text-books. 

D.  For  Removal  of  Growths.  An  attempt  may  justifiably  be  made  to 
remove  a  growth  arising  from  the  ribs  if  the  following  conditions  are 
favourable.  The  growth  should  be  of  a  moderate  size,  not  involving 
parts  of  more  than  four  ribs  ;  its  history  should  be  a  slow^  one  ;  its  outhne 
should  be  nodulated,  well-defined,  and  its  surface  hard,  pointing  to  a 
chondroma  or  osteo-chondroma,  the  skin  over  it  thinned,  perhaps,  but  not 
infiltrated.  There  should  be  no  dulnessin  the  neighbourhood  of  the  growth, 
the  breath  sounds  should  be  normal,  and  there  should  be  no  enlargement 
of  the  axillary  or  the  inguinal  glands.  The  following  is  one  of  the  first 
successful  cases : 

Zarubin,  of  Kharkov,  related  *  the  case  of  a  young  Cossack  who  sought  his  advice 
for  a  steadily  growing  and  occasionally  jjainful  tumour  of  seven  years'  standing. 

1  Ann.  of  Sii-g.,  1904,  vol.  i,  p.  419.  2  Amer.  Y ear-Book  oj  Med.  and  Surg.,  1902 

3  Ibid,  and  Med.  Neivs,  June  1.5,  1901. 

*  Trans,  of  the  Kharkov  University  Society,  1891,  Supplement  to  Brit.  Med.  Jouni. 
August  1,  1891. 


774  OPERATIONS  ON  THE  THORAX 

It  measured  21  centimetres  horizontally  and  19  vertically,  occujiying  the  right  side 
of  the  chest  between  the  nijjple  and  the  i:)Ost-axillary  lines  from  the  sixth  to  the 
ninth  rib.  The  new  growth  was  hard,  nodulated,  immovable,  and  non-adherent 
to  the  skin.  The  integuments  over  it  were  thinned,  but  otherwise  normal,  and  the 
nearest  lymphatic  glands  apj^arently  unaffected.  An  osteo-chondroma  of  the 
thoracic  wall  was  diagnosed.  .  The  huge  mass  was  removed,  together  with  the  in- 
volved portions  of  the  seventh,  eighth,  and  ninth  ribs.  The  gap  left  in  the  chest 
measured  17  centimetres  in  a  horizontal  and  16  in  a  vertical  direction.  On  opening 
the  thoracic  cavity  the  lung  collapsed,  but  only  partially,  owing  to  pleural  adhesions 
around  the  perij^hery  of  the  new  growths.  No  serious  respiratory  or  cardiac  dis- 
turbances occurred,  and  the  hsemorrhage  was  only  trifling.  The  cavity  was  gently 
cleansed  with  gauze  soaked  in  a^l  per  cent,  solution  of  boracic  acid,  and  the  skin 
wound,  conical  in  shape,  closed.  The  growth,  much  larger  than  an  adult  head, 
weighed  over  6  lbs.  For  the  first  two  days  the  patient  was  much  collapsed  and 
cyanosed,  and  suffered  from  agonising  cough  and  obstinate  vomiting.  The  healing 
of  the  wound  was  complete  in  two  months.  The  author  alludes  to  ten  other  cases  of 
resection  of  the  thoracic  wall  for  new  growths,  of  which  six  recovered,  while  four 
died.  The  methods  of  dealing  with  the  pneumothorax  in  such  ojierations  are  given 
at  p.  780. 

The  two  following  cases  ^  illustrate  most  of  the  points  in  operations  on 
such  growths. 

Case  I  was  inider  the  care  of  Prof.  Keen,  of  Philadelphia.  A  woman,  set.  25 
noticed  a  swelling  about  the  size  of  an  egg  near  the  angle  of  the  right  scapula  three 
months  after  an  injury  to  the  right  side.  On  admission,  eight  months  later,  she 
presented  a  swelling  in  the  postero-lateral  aspect  of  the  right  chest,  extending  from 
the  erector  spinse  to  the  right  breast,  and  from  the  fifth  to  the  eleventh  ribs  inclu- 
sive. The  skin  was  not  infiltrated,  and  there  was  no  evidence  that  the  lung  was  in- 
volved. On  exposure  of  the  growth  by  a  horse-shoe  shaped  flap  it  was  found  to  be 
mushroom-like,  with  an  attachment  much  smaller  than  the  main  mass.  In  order  to 
remove  as  little  of  the  chest  wall  as  possible.  Prof.  Keen  fii'st  separated  the  growth 
gradually  from  the  ribs,  of  which  the  fifth,  sixth,  seventh,  and  eighth,  with  the  inter- 
vening tissues,  were  involved.  The  pleura  was  next  separated  from  the  anterior 
surface  of  the  ribs  with  a  periosteal  elevator,  and  each  of  the  four  ribs  mentioned 
above  divided  with  forceps  anteriorly  and  posteriorly  without  opening  the  pleural 
cavity.  With  scissors  the  soft  parts,  including  the  pleura,  were  rapidly  divided, 
an  aperture  being  thus  made  in  the  chest  wall  measuring  18  cm.  vertically  by  12 
transversely.  The  patient  "suffered  very  little  indeed"  from  the  pneumothorax, 
which  was  dealt  with  by  the  operator  drawing  the  lung  up  into  the  opening  with 
his  hand  and  suturing  it  to  the  circumference  of  the  opening  with  a  continuous 
catgut  suture.  The  patient  recovered,  and  seven  months  later  there  was  no  evidence 
of  reappearance  of  the  disease.     The  growth  was  a  mixed  spindle-celled  sarcoma. 

Case  II.  A  man,  set.  41,  was  admitted  under  the  care  of  Dr.  C.  B.  Porter,  of 
Boston,  with  the  history  of  three  months'  pain  and  swelling  in  the  right  side.  A 
dome-shaped  swelling,  the  size  of  half  a  cocoa-nut,  was  present  with  its  centre 
at  the  level  of  the  eighth  rib  in  the  anterior  axillary  line.  There  was  no  evidence 
of  involvement  of  the  lung.  By  a  flap-incision  the  greenish-black  capsule  of  the 
growth  was  exposed.  On  opening  this  severe  ha-morrhage  took  place,  only  con- 
trolled by  curetting  away  the  growth  from  the  ribs.  Of  these  the  seventh,  eighth, 
and  ninth  were  divided  in  the  mid-axillary  line,  three-fourths  of  an  inch  from  the 
growth.  On  elevating  the  ends  of  the  cut  ribs  the  lung  was  seen  partially  collapsed. 
The  sudden  shock  now  anticipated  was  not  experienced.  The  intercostal  muscles 
between  the  sixth  and  seventh  ribs  were  next  divided,  with  the  costo-chondral 
ligaments  and  cartilage.  On  elevating  the  upper  portion  of  the  ribs  thus  divided, 
the  growth  was  found  to  have  extended  into  the  plem'al  cavity,  its  intra-thoracic 
portion  being  covered  by  parietal  pleura.  The  intercostal  muscles,  costo-chondral 
ligaments,  and  cartilage  of  the  ninth  and  tenth  ribs  were  next  divided.  It  was  now 
found  that  the  lower  end  of  the  intra-thoracic  growth  was  adherent  to  the  diaphragm. 
As  it  could  not  be  dissected  away,  the  diaphragm  was  cut  through  by  an  elliptical 
incision  half  an  inch  from  the  margins  of  the  growth  ;  the  ribs,  piece  of  diaphragm, 
and  growth  were  removed  together.  When  the  diaphragm  was  opened  the  intestines 
came  through  ;  they  were  replaced  and  held  back  by  gauze  while  the  opening  was 
sutured      The  pleural  cavity  was  drained  by  gauze.     Considerable  shock  supervened, 

1  Trans.  Amer.  Surg.  Assoc,  1901,  pp.  383,  494. 


RESECTION  OF  RIBS  775 

coming  on  gradually  aii(l  not  due  to  the  pneumothorax.  Dyspnoea  was  much 
relieved  by  oxygen  administered  during  the  Hist  week.  About  a  month  after  the 
operation  it  was  necessary  to  reopen  the  u|)per  end  of  the  incision  to  evacuate  several 
ounces  of  serum.  The  patient  was  seen  sixteen  months  after  the  operation  with  no 
evidence  of  reappearance  of  the  growth.  A  hernia  of  tlie  lung  was  present,  due  in 
part  to  the  patient's  work  in  a  stooping  position.  The  growth  was  chiefly  a  giant- 
celled  sarcoma  originating  in  one  of  the  ribs. 

The  conditions  contra-indicating  operation  will  be  made  plain  from 
those  already  given.  Cases  of  sarcoma  dating  to  an  injury  and  of  rapid 
growth,  and  those  of  secondary  origin,  e.g.  after  an  amputation  of  a  limb, 
should  be  left  untouched,  owing  to  the  probable  involvement  of  lungs, 
liver,   &c.,  and  the  certainty  of  rapid  recurrence. 

The  occurrence  of  pneumothorax  is  the  complication  which  chiefly 
requires  attention.  While  rightly  dreaded,  and  while  special  means  have 
been  devised  to  meet  it  {see  p.  780),  it  is  clear  from  the  cases  pubhshed 
that,  as  long  as  the  entrance  of  air  is  not  large  and  sudden,  operations 
involving  partial  removal  of  one  side  may  be  safely  completed  without 
the  need  of  any  special  devices  or  of  resorting  to  artificial  respiration. 
The  means  adopted  have  been  dragging  up  the  lung  with  blunt-nosed 
forceps,  attaching  it  by  sutures  to  the  margin  of  the  wound,  and  the  use 
of  tampons.  On  this  point  Dr.  E.  Rixford,  of  San  Francisco,  writes  of 
his  cases  in  which  he  removed  part  of  the  chest  wall  for  reappearing  car- 
cinoma of  the  breast  (p.  769)  :  "  In  these  cases  there  were  no  outward 
symptoms  incident  to  the  production  of  pneumothorax.  It  was  noticed, 
of  course,  that  the  respiration  became  immediately  deeper  and  more  rapid 
so  soon  as  air  entered  the  pleural  cavity,  but,  aside  from  the  violent 
flapping  of  the  heart  from  right  to  left,  terrifying  to  look  at  but  without 
noticeable  effect  on  the  pulse,  there  was  no  special  inconvenience  to  patient 
or  operator.  ...  In  the  cases  here  reported  the  writer  found  that  the 
respiration  could  be  greatly  modified  and  the  tremendous  lateral  excur- 
sions of  the  heart  and  mediastinal  tissues  almost  completely  checked  by 
the  simple  procedure  of  stopping  up  the  opening  in  the  chest  wall  with  a 
wet  towel.  The  towel,  folded  into  two  or  three  thicknesses,  is  made  to  slip 
beneath  the  partially  loosened  section  of  chest  wall  which  is  to  be  removed, 
and  is  drawn  forwards  as  new  cuts  are  made.  It  is  important  to  close 
the  opening  at  the  moment  of  complete  expiration,  when  the  chest  is 
largely  emptied  of  air.  When  this  was  done  the  lung  expanded,  and  the 
exaggerated  and  fatiguing  expiratory  efforts  were  at  once  quieted." 

Thus  far  removal  of  growths  from  the  ribs  has  been  considered. 
Those  affecting  the  sternum  are  rarer. 

Prof.  Keen  ^  relates  a  case  in  which  he  resected  the  manubrium  inner  third  of  left 
clavicle,  and  lower  third  of  the  sterno-mastoid  for  a  sarcoma.  The  muscle  was 
divided  first  at  the  junction  of  its  middle  and  lower  thirds,  and  the  inner  end  of  the 
left  clavicle  removed.  The  cartilage  of  the  first  rib  having  been  divided  about  one 
inch  from  the  sternum,  and  the  soft  parts  behind  the  sternum  separated  with  the 
finger,  the  manubrium  was  divided  horizontally  just  above  its  junction  with  the 
gladiolas.  Fifteen  months  after  the  operation  there  was  no  reappearance  of  the 
growth.  A  list  of  seventeen  other  cases  in  which  resection  of  the  sternum  was 
performed  for  growths  is  given. 

Dr.  P.  B.  Griffiths,  of  Cardiff,  records  a  case  of  resection  of  the  sternum  for 
sarcoma. 2  The  most  interesting  feature  is  that,  while  the  growth  appeared  to  be 
well  defined  and  limited,  its  extensions  were  wide  and  deep.  Complete  removal  was 
impossible.  In  this  case  also  but  slight  shock  was  noticed  when  one  pleural  cavity 
was  opened.  The  patient  survived  four  months.  The  necropsy  showed  the  existence 
of  deposits  in  both  pleura,  in  the  liver,  and  about  the  spine  below  the  pancreas. 

1  Med.  and  Surg.  Rep.,  March  27,  1897.  2  lancet,  October  11,  1902. 


776  OPERATIOXS  OX  THE  THORAX 

OPERATIVE  INTERFERENCE  IN  INJURIES  OF  THE  CHEST 

Reference  here  will  first  be  made  to  a  most  important  class  of  injm-y 

occasionally  met  with  in  hospital  practice,  riz.  : 

Penetrating  Wounds  of  Chest  involving  the  Diaphragm  and  Contents 
oi  the  Abdomen.     These  injuries  are  only  rarely  met  with  in  this  country. 

Dr.  D.  H.  Williams,  of  Chicago,^  draws  the  following  conclasions.  In  many 
penetrating  wounds  of  the  chest  hermetic  sealing  of  any  wounds  and  conservative 
treatment  is  indicated  where  there  is  no  evidence  of  injury  to  the  heart,  internal 
mammary  or  intercostal  vessels.  Wounds  below  the  fifth  rib,  especially  on  the  left 
side,  should  be  explored  in  order  to  ascertain  whether  the  diaphragm  and  abdominal 
viscera  have  been  injured.  Without  such  exploration  no  diagnosis  can  be  made 
until  perhaps  it  is  too  late.  Parts  of  the  fifth  to  the  eighth  rib,  accorcUng  to  the  site 
of  the  wound,  having  been  resected.-  if  the  injury  be  on  the  left  side,  any  opening  in 
the  diaphragm  will  probably  be  found  fUled  \\ith  omentum.  This  is  cleansed  and 
reduced  into  the  abdomen,  and  the  opening  closed  with  a  pturse-string  stitch.  The 
incision  is  now  extended  over  the  left  lateral  abdominal  wall  into  the  abdomen,  and 
the  condition  of  the  liver,  spleen,  kidney,  and  colon  investigated.  Three  most  in- 
structive cases  are  given  in  which  injuries  to  some  of  the  above  viscera  were  oi)erated 
on  with  complete  success. 

Modem  Gunshot  Injuries  of  the  Chest.  Such  recent  wars  as  that  in  South 
Africa  and  the  American  one  in  the  Philippines  show  that  wounds  of  the  chest 
are  the  most  hopeful  of  all  visceral  injuries.  Wounds  of  the  large  vessels,  roots  of 
the  lung  and  heart,  and  those  involving  the  abdomen  also  are  exceptions.  G.  H. 
Makins,  C.B.,-  states  that  the  frequent  escape  of  the  thoracic  viscera  from  injury, 
putting  aside  the  lungs,  was  remarkable  ;  and  that,  as  a  rule,  the  frequent  pul- 
monary wounds  needed  little  interference  on  the  part  of  the  surgeon.  While 
pneumothorax  was  rare.  ha?mothorax  was  the  most  frequent  of  the  complications  of 
wounds  of  the  chest.  In  90  per  cent,  or  more  of  the  cases,  the  haemorrhage  was  of 
parietal  som-ce.  With  regard  to  the  treatment  of  hsmothorax,  if  rest  was  employed 
early  few  serious  cases  occurred.  For  hsemothorax  of  a  later  date  Mr.  Makins 
lays  do^vn  the  following  rules  :  (1)  Haemothorax.  even  of  considerable  severity,  will 
undergo  spontaneous  cure.      An  early  rise  of  temperature    may  be  disregarded. 

(2 )  Tapping  is  indicated  when  pre.s.sure  on  the  lung  causes  serious  sj-mptoms.  In  such 
cases  the  collection  has  u.sually  been  rapid  ;  hence  a  fresh  haemorrhage  is  always 
probable  when  the  local  pressiire  has  been  removed.  Evacuation,  therefore,  should 
not   be  necessarily  complete,  and  should  be  followed   Vjy  the  most  absolute  rest. 

(3)  Tapping  may  be  needed  as  a  cUagnostic  aid,  or  (4)  for  the  evacuation  of  serum 
pres.sed  from  the  clot.  (5)  Early  free  incision  is,  as  a  rule,  to  be  steadfastly  avoided. 
(6)  Incision  and  ligature  of  a  parietal  arterj'  are  very  rarely  needed.  (7)  If  a 
hsemothorax  suppurates,  it  must  be  treated  on  the  ordinary  lines  of  an  empyema. 
As  to  primary  empyema.  Mr.  ilakins  only  saw  one  case  which  illustrated  the  dis- 
advantages of  extracting  bullets  on  the  field  where  the  conditions  present  prevent  the 
en.surance  of  asepsis.  In  the  earlj-  part  of  the  campaign  secondary  empyemata  not 
uncommonlj'  followed  drainage  of  a  hsemothorax.  At  this  time  an  early  rise  of  tem- 
perature was  believed  to  be  due  to  breaking  down  of  the  clot.  Subsequent  ex- 
perience showed  that  this  was  not  the  case.  Owing  to  the  difficulty  in  clearing  out 
the  clot  and  the  need  of  drainage,  suppuration  was  common  and  most  troublesome, 
small  collections  iLsually  forming  and  late  residual  ab-scesses  following  not  infre- 
quently. 

Major  Holt,  R.A.M.C.,  D.S.O.,*  writes  that :  "  In  many  of  the  cases  examined, 
from  the  anatomical  sites  of  the  wounds  of  entry  and  exit  coupled  with  the  justifiable 
assumption  that  the  small  bore  bullet  passes  between  these  points  in  a  straight  line, 
it  is  impossible  to  avoid  the  conclusion  that  the  heart  or  jx'ricarcUum,  or  lung,  as  the 
case  may  be.  was  wounded  ;  yet  the  symptoms  present  were  only  such  a.s  were  at 
other  times  found  in  cases  where  these  structures  were  undoul^tedlj'  not  within  the 
wound  area,  in  fact  they  were  pirrely  negative."     He  further  says:     "External 

1  Ann.  of  Surg.,  1904,  vol.  ii.  p.  675. 

^  The  operator  must  now  be  prepared  for  the  ri.sks  of  pulraonarj-  collap.se  and  pneumo- 
thorax (p.  780). 

^  Surg.  Exper.  in  South  Ajrica,  p.  382. 

*  Surg.  Cases  noted  in  the  South  Ajrican  War,  edited  by  Surg.-G'en.  Stephenson. 


INJURIES  OF  THE  CHEST  777 

iKciiiorrhago  was  distinctly  rare.  ...  As  a  rule,  small  bore  wouruls  of  the  cliest 
remained  aseptic;  and  healed  immediately." 

A.  "  AVhen  the  thoracic  wall  was  penetrated,  the  symptoms  mentioned  in  the 
214  cases  noti-d  were,  in  order  of  frequency,  as  follows:  "(I)  Hamiojitysis  ;  (2)  Dj'sp- 
noca;  (:))  Fever;  (4)  Dulness  to  ])ercussion  ;  (5)  Ha'mothorax;  (6)  I'ain';  (7)  Pyo- 
thorax  ;  (8)  Collapse  and  shock  ;  (9)  Extensive  surgical  emphysema  ;  (10)  Severe 
cough  ;  (II)  Friction  rubs  ;  (12)  Deficient  chest  movement  ;  (13)  Cyanosis  ;  and 
(14)  Pneumothorax." 

B.  "  l^ullet  tracks  were  recorded  in  almost  every  conceivable  direction  and  of 
every  possible^  length,  from  one  an  inch  or  so  long  which  opened  the  pleura  to  the 
full  length  of  tlu^  thorax.  As  a  rule,  antero-posterior  penetrating  wounds  were  much 
less  sei'ious  than  the  longitudinal  ones,  and,  generally,  the  nearer  the  middle  line  the 
more  s(>rious  was  the  lesion  ;  even  the  cardiac  area  was  apparently  traversed  with  but 
unimi)ortant  after-results  in  a  considerable  number,  of  instances.  Longitudinal 
tracks  were  mostly  of  greater  severity,  being  complicated  by  injuries  to  abdominal 
viscera,  aiul  the  mortality  was  correspondingly  high.  Probably  most  of  the  wounds 
about  the  root  of  the  lung  were  immediately  fatal,  though  several  cases  of  recovery 
were  recoided.  Several  cases,  however,  were  recorded  where  the  bullet  passed  from 
the  upper  to  the  lower  outlet  of  the  chest,  or  vice  versa,  with  very  little  harmful 
result." 


CHAPTER  XXXVI 
OPERATIONS  ON  THE  LUNG  AND  THE  MEDIASTINUM  ^ 

During  the  past  ten  years  or  so  there  has  been  a  great  advance  in  this 
branch  of  surgery,  and  it  is  probable  that  the  next  few  years  ^\'ill  see 
still  further  progress.  Until  a  few  years  ago  the  surgery  of  the  thorax 
was  practically  limited  to  incision  of  the  thoracic  wall,  with  or  without 
excision  of  one  or  more  ribs,  for  the  purpose  of  draining  collections  of 
pus.  Now  as  the  result  of  much  brilliant  work  by  many  surgeons  it  has 
been  shown  that  the  thorax  can  be  freely  opened  and  that  operations  on 
the  lung,  heart,  and  mediastinal  contents  can  be  readily  and  safely 
accomplished.  The  great  danger  of  these  operations  consists  in  the  free 
entry  of  air  into  the  pleural  cavity  leading  to  collapse  of  the  lung.  The 
pneumothorax  thus  produced  is  at  once  followed  by  the  appearance  of  very 
serious  symptoms,  and  often  by  the  death  of  the  patient.  The  advance  of 
surgery  of  the  thorax  has  been  possible  owing  to  a  better  understanding 
of  the  production  of  a  pneumothorax,  the  reasons  why  serious  symptoms 
are  caused,  and  especially  of  the  ways  by  which  collapse  of  the  Imig  can  be 
prevented. 

It  will  thus  be  necessary  first  of  all  to  consider  the  symptoms  of 
traumatic  pneumothorax,  and  the  way  in  which  they  are  produced  : 
the  means  of  preventing  collapse  of  the  Imig  will  then  be  considered.  Of 
course,  only  a  very  brief  sketch  of  this  subject  can  be  given  here.  For  a 
full  account,  with  many  references  to  the  bibliography  of  the  subject  the 
reader  is  referred  to  the  "  Surgery  of  the  Lung,"  by  Profs.  Garre  and 
Quincke,  translated  into  English  by  Dr.  Barcroft,  1912. 

Symptoms  produced  as  the  result  of  a  large  opening  in  the  thoracic  wall. 
The  air  can  now  enter  freely  the  pleural  cavity,  and  the  pressure  of  the  air 
in  the  pleural  cavity  of  the  injured  side  is  that  of  the  external  air.  The  result 
is  that  the  lung  on  the  injured  side  immediately  collapses.  Dyspnoea,  with 
irregular  jerky  breathing,  and  cyanosis  quickly  appear;  then  the  respir- 
atory movements  become  slow  and  deep  and  the  pulse  tense  and  slow, 
and  finally  cessation  of  breathing  and  arrest  of  the  action  of  the  heart. 

Something  besides  the  mere  collapse  of  the  Imig  is  necessary  to  account 
for  these  symptoms,  for  one  lung  is  capable  of  supplpng  the  blood  with 
sufficient  oxygen  to  support  life.  Neither  is  displacement  of  the  heart 
a  satisfactory  explanation.  The  correct  explanation  is  that  given  by 
Murphy.^  He  has  proved  that  the  symptoms  are  due  to  a  displacement 
of  the  mediastinum  interfering  with  the  action  of  the  somid  Imig.    When 

^  For  further  information  on  this  subject  see  "  Surgery  of  the  Lung,"  by  Garre  and 
Quincke,  translated  by  Dr.  Barcroft,  1912.  Reference  may  also  be  made  to  the  dis- 
cussion Ijefore  the  International  Congress  of  Surgery,  1911  ;  and  to  a  paper  on  "  Recent 
Advances  in  the  Surgery  of  the  Lung  and  Pleura,"  by  Mr.  Morriston  Davies  (Brit.  Journ. 
Surg.,  vol.  i,  p.  228).  ^  Journ.  Amer.  Med.  Assoc,  1898. 

778 


OPKI^ATIONS  OX  TIIK  LUXG  AND  MEDIASTINUM    779 

there  is  a  large  opening  in  the  ph'ura  the  pressure  of  the  air  in  that  cavity 
will  be  that  of  the  atmosphere.  When  inspiration  occurs  there  will  be 
a  negative  pressure  in  the  sound  pleural  cavity,  while,  owing  to  the  free 
entry  of  air  on  the  injured  side,  the  pressure  remains  mialtered,  i.e.  is  that 
of  the  atmosphere.  The  result  is  that  the  mediastinum  is  sucked  over 
to  the  sound  sitle,  interfering  with  due  inflation  of  the  uncollapsed  lung. 
On  expiration,  or  with  such  elforts  as  coughing  or  groaning,  there  will  be  a 
positive  pressure  on  the  sound  side,  while  owing  to  the  air  in  the  pleural 
cavity  on  the  injured  side  being  able  to  escape  freely,  the  pressure  there 
will  remain  unchanged.  The  mediastinum  will  therefore  bulge  over  to 
the  damaged  side,  tiius  impeding  proper  emptying  of  the  sound  lung. 
There  will  thus  be  alternate  movements  of  the  mediastinum,  to  the  sound 
side  in  inspiration  and  to  the  damaged  side  in  expiration,  which  prevent 
satisfactory  action  of  the  uncollapsed  lung.  These  movements  have 
been  described  as  "  fluttering  "  of  the  mediastinum. 

The  following  well-recognised  clinical  facts  are  explained  by,  and 
indeed  confirm,  the  above  explanation.  It  is  well  known  that  a  small 
opening  may  be  made  in  the  pleura  without  any  untoward  result.  In  this 
case  the  air  cannot  enter  freely,  so  that  there  is  always  a  small  negative 
pressure  on  the  injured  side.  Under  these  circumstances,  though  the 
action  of  the  healthy  lung  is  slightly  impeded,  the  loss  is  so  small  that 
it  is  compensated  for  by  increased  frequency  and  depth  of  respiration. 

When  adhesions  exist  between  the  parietal  and  the  visceral  surfaces 
of  the  pleura,  the  thorax  may  be  widely  opened  without  serious  symptoms. 
Here  the  adhesions  prevent  collapse  of  the  lung  on  the  injured  side,  the 
mediastinum  is  more  or  less  fixed,  and  only  very  slight  oscillation  can  take 
place.  This  fact  gives  an  important  hint  as  to  the  mode  of  preventing 
a  pneumothorax  in  the  course  of  an  operation  on  the  thorax. 

It  is  ivell  recognised  that  an  extensive  opening  may  he  safely  made  for 
the  purpose  of  draining  an  empyema.  Here,  though  the  lung  on  the  injured 
side  may  be  completely  collapsed  and  air  enters  the  pleural  cavity  on 
this  side  with  the  greatest  freedom,  serious  symptoms  are  comparatively 
seldom  met  with.  The  explanation  of  this  is  that  owing  to  inflammatory 
thickening  the  mediastinum  has  become  so  fixed  that  little  or  no 
"  fluttering  "  can  take  place. 

Pneumothorax  is  more  serious  on  the  right  side  than  the  left.  This  is 
owing  to  the  greater  size  of  the  right  lung. 

Methods  of  preventing  and  guarding  against  the  dangers  of  extensive 
pneumothorax.  The  following  have  all  been  employed  in  operations  on  the 
thorax.  Generally  speaking  the  methods  fall  into  two  groups  ;  (a)  Where 
collapse  of  the  lung  on  the  injured  side  is  prevented  by  mechanical 
fixation.  As  has  been  sho^vn,  this  limits  movements  of  the  mediastinum 
and  so  prevents  serious  symptoms.  (6)  Collapse  of  the  lung  is  prevented 
either  by  supplying  air  and  the  anaesthetic  at  a  pressure  higher  than 
that  of  the  atmosphere,  and  hence  of  the  air  in  the  opened  pleural  cavity  ; 
or  by  supplying  the  anaesthetic  at  the  ordinary  atmospheric  pressure  and 
diminishing  the  pressure  in  the  opened  pleura.  The  former  are  simple 
and  require  no  special  apparatus,  while  the  latter  are  complicated  and  can 
only  be  carried  out  by  means  of  special  apparatus  which  is  generally 
both  elaborate  and  expensive. 

In  all  cases  in  actual  practice  a  small  opening  in  the  pleura  should  first 
be  made  and  the  effect  of  the  gradual  entry  of  air  on  the  patient  noted. 
The  small  opening  is  subsequently  enlarged  to  the  required  extent. 


780  OPERATIONS  ON  THE  THORAX 

(1)  When  the  proposed  operation  is  for  any  septic  process  in  the 
lung  it  is  very  probable  that  adhesions  between  the  two  pleural  surfaces 
already  exist.  If  this  is  so,  collapse  of  the  lung  will  be  prevented  and  the 
pleural  cavity  may  be  safely  opened. 

(2)  Adhesions  are  not  always  found,  even  when  some  inflammatory 
disease  of  the  Imig  is  present,  or  the  adhesions  may  be  at  some  distance 
from  the  opening.  Under  these  circumstances  the  lung  will  collapse  and 
serious  symptoms  are  very  probable.  A  most  important  practical 
observation  as  to  the  treatment  to  be  adopted  under  these  circumstances 
was  made  by  W.  Muller.^  He  was  removing  a  sarcoma  of  the  ribs  adherent 
to  the  lung.  "  The  pleura  was  rent  and  an  opening  was  made  in  the 
thoracic  wall  quite  as  big  as  the  palm  of  the  hand.  At  this  moment 
the  tumour  released  sank  somewhat  with  the  lung  into  the  thoracic 
cavity,  which  was  immediately  followed  by  a  condition  of  the  most  critical 
collapse  :  the  breathing  ceased,  the  pulse  was  not  perceptible,  but  the 
symptoms  changed  as  soon  as  the  tumour  was  grasped  and  drawn  forward. 
Now  it  was  clear  that  it  was  inseparably  adherent  to  the  right  lower  lobe 
of  the  lung.  "When  the  lung,  thereupon  set  free,  suddenly  collapsed, 
immediately  a  condition  of  serious  collapse  again  occurred.  The  lung, 
quickly  seized  again  and  drawn  up  immediately,  filled  again  on  inspiration 
and  the  symptoms  of  collapse  disappeared." 

Tt  may  be  taken  for  granted  then  that  when  serious  symptoms  follow 
collapse  of  the  lung,  danger  can  be  averted  by  grasping  the  lung  with 
special  forceps  (Fig.  -U-o;,  which,  while  securing  a  firm  hold,  do  not  lacerate 
its  substance,  and  drawing  the  lung  into  the  wound.  In  this  way  the 
mediastinum  is  fLxed  sufficiently  to  prevent  any  serious  oscillation. 

(3)  Suture  of  the  lung  to  the  parietal  pleura.  While  the  above  simple 
manoeuvre  may  be  employed  to  relieve  the  immediate  symptoms  it  is 
only  a  temporary  measure.  For  the  operation  to  proceed  it  is  necessary 
to  fix  the  lung  to  the  chest  wall  by  sutures.  These  should  be  made  to  pass 
for  1  or  2  cm.  into  the  lung  tissue  and  then  through  the  intercostal  muscles 
or  even  roimd  a  rib.  Owing  to  the  likelihood  of  infection  of  the  pleura 
this  cavity  should  be  completely  cut  off.  In  some  cases,  and  where  the 
condition  of  the  patient  admits  of  it,  an  interval  of  a  few  days  may  be 
allowed  to  elapse  and  the  operation  be  completed  in  two  stages. 

(4)  Macewen  ^  found  that  the  follo\nng  very  simple  manoeu\Te  was 
quite  efficient  in  averting  the  danger  of  a  free  opening  in  the  pleura. 
The  patient  is  turned  over  so  that  the  opening  occupies  the  lowest  position 
of  the  thorax.  The  weight  of  the  heart  and  of  the  lung  on  the  iiijured 
side  are  then  sufficient  to  prevent  the  fluttering  of  the  mediastinum  and 
the  symptoms  are  at  once  relieved.  He  also  recommends  compression 
of  the  chest  and  of  the  abdomen  to  force  the  air  out  of  the  pleural  cavity, 
to  bring  the  lung  into  contact  \vith  the  parietal  pleura. 

(5)  By  means  of  a  cabinet  enabling  the  operation  to  be  performed  under 
a  reduced  pressure.  This  ingenious  method  was  first  employed  by 
Sauerbruch  and  has  proved  most  successful  in  practice.  The  chief 
objections  are  its  costliness  and  elaborate  construction,  which  have 
prevented  its  ever  coming  into  general  use. 

A  detailed  description  of  these  chambers  is  not  called  for  here.  The  principle  on 
which  they  work  is  as  follows.     An  air-tight  chamber  is  constructed  of  sufficient  size 

1  Deutsche  Zettschrif.  f.  Chir..  vol.  xxxvii. 
^  West  London  Medical  Journa/,  Ju\y  1906. 


OPERATIONS  ON  THE  LUNG  AND  MEDIASTINUM    781 

to  contain  the  body  of  the  patient,  the  operator,  and  the  necessary  assistants.  The 
pressure  of  the  air  within  the  chamber  can  be  reduced  by  7-10  mm.  of  mercury 
by  an  electrically  driven  sue!  ion  pump.  In  one  of  the  walls  is  an  oval  0[)fning  through 
which  th(>  head  of  the  patient  ])rojects  to  the  exterior,  the  neck  being  encircled  by 
an  air-tight  collar  of  india-rul)ber.  The  amesthetic  is  thus  adniiiiistercd  at  the 
pressure  of  the  atmosphere  while  the  pressure  of  the  air  in  the  chamber  and  also  of 
that  admitted  into  the  ])leinal  cavity  is  about  7  mm.  less.  The  ana-sthetist  and  the 
operator  can  only  communicate  by  telephone. 

Various  attempts  liave  been  made  to  modify  the  original  apparatus  to  render 
it  more  efficient,  and  at  the  same  time  less  cumbersome  and  costly.  One  of  the 
best  known  of  these  is  that  of  Willy  Meyer,  of  New  York,  which  he  calls  "  the  uni- 
versal differential  cabinet."  Briefly,  it  consists  of  two  air-tight  chambers,  a  smaller 
and  a  larger,  the  former  being  contained  within  the  latter.  The  larger  is  the  operating 
room,  while  the  smaller,  which  is  provided  with  an  opening  guarded  by  an  air-tight 
rubber  collar  for  the  neck  of  the  patient,  is  for  the  ana?sthetist.  The  smaller  is  the 
positive  pressiu-e  chamber  and  the  larger  the  negative  pressure  chamber. 

(6)  By  means  of  a  cabinet  enabling  the  anaesthetic  to  be  administered 
under  increased  pressure.  This  method  was  first  employed  by  Brauer. 
It  consists  of  an  air-tight  chamber  with  an  aperture  for  the  head  of  the 
patient  and  two  smaller  side  apertures  for  the  arms  of  the  anaesthetist. 
Compressed  air  is  conveyed  to  the  chamber  and  leaves  it  by  a  shaft  in 
which  a  sliding  weight  ensures  the  necessary  resistance  to  its  escape. 
The  anaesthetic  may  be  administered  in  the  usual  way  on  a  mask,  or  the 
Roth-Drager  apparatus  may  be  used. 

(7)  The  anaesthetic  may  be  administered  under  increased  pressure  by 
means  of  an  air-proof  mask.  This  method  was  first  used  by  Tiegel,  whose 
apparatus  need  not  be  described  here. 

(8)  By  intra-tracheal  insufflation  of  ether.  This  is  the  most  recent 
method  and  is  probably  the  most  satisfactory.  It  has  the  advantages  of 
comparative  simplicity  and  portability,  and,  as  has  already  been  pointed 
out,  is  the  most  satisfactory  method  of  administering  the  anaesthetic  in 
many  other  cases,  e.g.  goitres  and  growths  in  the  mouth,  and  hence  is  more 
likely  to  be  available.  The  method  has  been  put  on  a  thoroughly  practical 
footing  by  Dr.  Elsberg,  of  New  York,  who  first  described  his  apparatus  in 
the  Annals  of  Surgery,  February  1911. 

"  The  apparatus  consists  of  a  blower  driven  by  an  electro-motor.  In  reserve  are 
bellows  worked  by  foot.  The  air  passes  through  a  vessel  containing  warm  water, 
where  it  is  warmed  and  saturated  with  moisture  ;  in  another  it  absorbs  the  anaesthetic 
(ether).  On  the  far  side  of  the  reservoir  a  pipe  conveying  oxygen  from  a  cylinder  opens 
into  the  air-pipe ;  this  can  be  made  use  of,  or  not,  as  desired.  There  is  a  mercury 
manometer.  A  rubber  tube  leads  to  the  cannula.  Dr.  Elsberg  recommends  a  woven  silk 
catheter,  about  30  cm.  long,  Avhich  is  pushed  thi'ough  the  glottis  till  it  nearly  reaches 
the  bifm-cation  of  the  trachea,  and  is  then  inflated  from  a  blower  with  air  at  a 
pressure  of  20  mm.  mercmy.  By  this  powerful  cm-rent  of  air  a  sufficient  quantity  of 
oxygen  to  arterialise  the  blood  reaches  the  alveoli,  but  there  arises  immediately  just 
as  powerful  a  counter  current,  which  streams  outwards  along  the  walls  of  the  trachea. 
With  it  the  exhalations  of  carbon  dioxide  are  carried  away  ;  it  also  at  the  same  time 
hinders  the  influx  of  blood  or  secretions  into  the  larynx  and  trachea."  For  the 
introduction  of  the  catheter  a  direct  vision  laryngoscope  (such  as  Briining's)  is  em- 
ployed. ^ 

Dangers  of  operating  under  differences  of  pressure,  (a)  Failure  of  the 
apparatus.  This  may  occur  with  any  of  the  above-mentioned  methods, 
and  failure  may  happen  just  at  the  critical  time.     Should  this  occur  the 

1  Garre  and  Quincke,  loc.  supra  cit.,  p.  48.  A  paper  by  Dr.  F.  E.  SMpway  entitled 
"A  Criticism  of  .some  recent  Methods  of  Anaesthesia"  (Brit.  Journ.  Surg.,  vol.  i,  p.  90) 
may  also  be  advantageously  referred  to.  In  addition  to  the  intra-tracheal  insufflation 
of  ether,  the  intravenous  injection  of  ether  and  hedonal  is  considered. 


782  OPERATIONS  ON  THE  THORAX 

patient  should  be  put  into  the  position  recommended  by  Mace  wen,  or 
the  hnig  drawn  forward  as  recommended  by  MuUer. 

(h)  Vomiting.  This  is  one  great  objection  to  the  use  of  the  tight- 
fitting  mask,  though  Tiegel  has  endeavoured  to  guard  against  it  by  adding 
an  extra  bag  to  receive  any  vomited  material. 

(c)  Garre  and  Quincke  mention  the  possibihty  of  acute  dilatation  of 
the  stomach  and  refer  to  one  case  in  which  this  led  to  a  fatal  result. 

(d)  The  same  authors  point  out  that,  as  the  result  of  the  difference 
in  pressure,  the  capillaries  of  the  lung  are  compressed.  This  impedes 
the  circulation  through  the  lung  and  soon  throws  a  strain  on  the  right 
auricle.  In  cases  of  weak  or  diseased  hearts  they  recommend  that  the 
difference  of  pressure  should  not  exceed  4  or  5  mm.  of  mercury.  In  no 
case  with  cabinet  or  mask  should  there  be  a  difference  of  pressure  of  more 
than  10  or  12  mm.  of  mercury,  and  only  in  intratracheal  insufflation  can 
a  pressure  of  20  mm.  of  mercury  be  safely  used. 

The  following  conditions  may  call  for  operative  treatment.  Needless 
to  say,  in  all  cases,  the  greatest  possible  care  must  be  taken  in  the  diagnosis 
and  localisation  of  the  disease. 

(1)  Injuries.  Only  a  small  proportion  of  these  will  call  for  operation, 
even  when  pneumothorax  or  haemothorax  is  present.  The  chief  indication 
is  haemorrhage  into  the  pleural  cavity  which  does  not  improve  with 
palliative  treatment.  In  such  cases  the  effused  blood  may  be  removed 
by  aspiration  and  the  patient  then  carefully  watched  :  if  in  spite  of  this 
the  dyspnoea  and  cyanosis  increase,  and  the  pulse  becomes  progressively 
more  rapid  and  feeble,  showing  a  continuation  of  the  haemorrhage,  opera- 
tion may  offer  the  only  chance  of  saving  the  patient's  life.  Other  indica- 
tions are  :  (a)  Where  there  is  a  large  w^ound  of  the  thoracic  wall  allowing 
free  entry  of  air.  (b)  Immediate  operation  is  indicated  when  there  is  a 
double  pneumothorax  (Kocher).  (c)  When  the  diaphragm  has  been 
injured,  allowing  the  protrusion  of  some  abdominal  viscus  into  the  pleural 
cavity.  It  is  usually  extremely  difficult  to  diagnose  the  exact  nature  of  the 
injury,  and  it  must  be  remembered  that  a  large  number  of  even  serious  cases 
recover  \Nithout  operation.  In  all  cases  the  possibility  that  other  thoracic 
structures  in  addition  to  the  lung  maybe  injured  must  be  borne  in  mind. 

(2)  Pulmonary  suppurations  (excluding  tuberculous  cavities).  This  is 
probably  the  most  frequent  indication  for  operations  on  the  lung.  Garre 
and  Quincke  ^  classify  these  abscesses  as  follows  : 

(1)  Acute  abscesses.^ 

(a)  Acute  simple  abscesses.     These  may  follow  pneumonia. 
(6)  Acute  putrid  abscesses  and  pulmonary  gangrene. 

(2)  Chronic  simple  abscesses  (and  bronchiectases). 

(a)  Chronic  simple  abscesses. 
{b)  Chronic  putrid  abscesses. 

(3)  Abscesses  caused  by  foreign  bodies.  In  many  of  the  above  the 
suppuration  is  really  due  to  minute  particles  of  septic  foreign  material 
such  as  vomit,  or  septic  material  from  the  upper  air  passages.  Foreign 
bodies  in  the  surgical  sense  may,  however,  be  drawai  dowai  into  the  smaller 
bronchi  and  may  then  cause  bronchiectasis  with  formation  of  much  foul 
pus.  Or  the  foreign  body  may  ulcerate  through  the  bronchus  and  cause 
an  abscess  in  the  surrounding  pulmonary  tissue. 

1  Loc.  supra,  cit.,  p.  109. 

2  See  Dr.  B.  T.  Tilton,  "The  Operative   Treatment  of  Acute  Abscess  of  the  Lung" 
{Ann.  Simj.,  1907,  vol.  xlvi,  p.  405). 


OPERATIONS  ON  THE  LUNG  AND  MEDIASTINUM    783 

Before  operating  accurate  diagnosis  and  localisation  of  the  disease 
are  essential. 

Garr6  and  Quincke  lay  down  the  following  juincipli's  for  operating  on  pulmonary 
suppurations.  («)  Pulmonary  .suj)puration.s  should  Ik-  treated  surgically  on  principle, 
above  all  acute  ones,  so  that  they  may  not  become  chronic.  Acute  supi)urations  may, 
it  is  true,  clear  up  without  operation,  and  may  therefore  be  observed  from  three  to 
eight  weeks  before  being  operated  upon,  (b)  Putrescence  and  accompanying  gan- 
grene render  operation  imperative.  Only  in  the  case  of  small  septic  foci  and  general 
good  condition  can  one  wait  in  the  hope  of  spontaneous  healing,  (c)  In  cases  of 
acute  diffuse  gangrene  an  attempt  may  be  made,  if  a  local  diagnosis  is  successful,  to 
make  an  incision  in  the  disea.sed  area  and  to  drain  it.  {d)  In  the  case  of  chronic 
abscess  and  bronchiectasis  an  operation  is  to  be  recommended  on  principle  ;  here 
extensive  resection  of  the  thorax  is  as  important  as  the  opening  of  the  abscess. 
(e)  When  secretion  is  slight,  success  has  been  achieved  also  by  mere  colla])se  of  the 
lung  (extra-pleural  thoracotomy  or  artificial  pneumothorax).  (/)  Pulmonary  lobes 
transformed  by  bronchiectasis  should  be  resected,  (g)  When  there  are  several 
cavities  each  case  must  be  decided  on  its  own  merits,  (h)  In  chronic  cases  with 
several  cavities  in  one  lobe,  extensive  fissure  or  resection  of  the  lobe  is  indicated.  If 
two  lobes  on  one  side,  or  even  both  lower  lobes  are  affected,  this  is  generally  a  contra- 
indication to  any  operation,  (t)  Even  incomplete  healing  of  a  pneumotomy 
with  permanent  bronchial  fistula  may  be  of  considerable  benefit  to  the  patient. 
[j)  Pleural  adhesions,  it  is  true,  make  pneumotomy  easier,  but  are  not  a  necessary 
preliminary,  (k)  Profuse  htemoptysis  may  demand,  when  local  diagnosis  of  the 
source  is  possible,  opening  and  plugging  of  the  cavity. 

(3)  Tuberculous  disease.  In  only  very  few  cases  can  there  be  any 
reasonable  prospect  of  success  in  operative  treatment  of  tuberculous 
disease  of  the  lung. 

The  following  operations  have  been  carried  out,  and  the  surgeons  using 
them  claim  a  certain  amount  of  success. 

(a)  Excision  of  tuberculous  foci  or  even  of  the  ivhole  of  an  ajfected  lobe.  If  the 
disease  is  advanced  or  extensive,  the  opposite  lung  will  also  probably  be  affected. 
If  not  extensive,  general  treatment  will  probably  be  successful.  Hence  this  operation 
can  seldom  or  never  be  called  for,  especially  with  the  improved  modern  methods  of 
medical  treatment.  One  of  the  most  remarkable  cases  of  successful  excision  for 
tuberculous  disease  is  a  patient  whose  left  lung  was  completely  removed  by  Sir  W. 
Macewen  for  extensive  tuberculous  disease  in  1895  ;  sixteen  years  later  this  patient 
was  well  and  able  to  earn  his  living. 

(6)  Formation  of  an  artificial  pneumothoraxA  It  has  been  argued  that  the  natural 
process  of  healing  a  cavity  in  the  lung  is  hindered  by  collapse  of  the  lung  being 
impossible,  so  that  the  cavity  is  kept  open  by  the  rigid  chest  wall.  Forlarlini  and 
Murphy  suggested  that  the  process  of  healing  might  be  rendered  possible  by  gradually 
injecting  air  into  the  pleural  cavity  so  as  to  bring  about  collapse  of  the  diseased  lung. 
The  pneumothorax  is  produced  by  introducing  a  hollow  needle  tlu-ough  the  sixth  or 
seventh  intercostal  space  in  the  anterior  axillary  line.  Filtered  air,  or,  better,  nitrogen, 
is  then  cautiously  injected  into  the  pleural  cavity  until  the  pressm'e,  as  showTi  by  a 
manometer  connected  with  the  needle,  is  about  that  of  the  atmosphere.  Subsequent 
injections  are  necessary  at  first  at  intervals  of  a  few  days  and  afterwards  at  intervals 
of  three  or  four  weeks.  The  pneumothorax  has  to  be  kept  up  for  a  long  time,  possibly 
1 J  to  2  years.     The  treatment  may  be  impossible  owing  to  extensive  adhesions. 

(c)  It  has  been  proposed  that  the  retraction  of  the  lung  in  the  process  of  natural 
cure  should  be  aided  by  resection  of  the  overlying  ribs.  Various  operations  have  been 
carried  out,  especially  in  Germany,  with  this  object.  They  vary  from  excision  of 
large  portions  of  the  first  and  second  ribs  only,  to  the  formation  of  a  wide  gap  in  the 
axilla,  by  excising  portions  of  many  ribs  so  that  a  lateral  gap  in  the  bony  wall  of  the 
thorax  four  or  five  inches  wide  is  produced.  Excision  of  about  one  inch  of  ribs  one  to 
nine  at  their  angles,  with  removal  of  a  narrow  strip  of  the  corresponding  costal 

1  Dr.  Clive  Riviere,  in  a  paper  on  "  The  Pneumothorax  Treatment  of  Phthisis  " 
{Practitioner,  December  1914),  describes  the  indications  for  this  method  of  treatment 
and  the  technique  of  the  operation.  See  also  a  discussion  on  "  The  Treatment  of  Phthisis 
by  the  Induction  of  Pneumothorax,"  opened  by  Dr.  T.  D.  Lister  before  the  Therapeutical 
Section  of  the  Roy.  Soc.  Med.  (see  Proc.  Roy.  Soc.  Med.,  Ther.  Sec,  May  1915). 


784  OPERATIONS  OX  THE  THORAX 

cartilages  close  to  the  sternum,  has  also  been  carried  out.  These  severe  operations 
have  a  very  distinct  mortalitj',  even  in  the  hands  of  those  who  frequently  perform 
them,  and  the  benefit  derived  in  many  cases  is  not  great.  The  justifiability  of  these 
procedures  is  thus  open  to  doubt. 

(d)  It  was  pointed  out,  as  long  ago  as  1858,  by  Freund,  that  in  many  phthisical 
patients  there  is  an  abnormal  shortness  and  fixity  of  the  first  rib,  narrowing  the 
antero-posterior  diameter  of  the  superior  aperture  of  the  thorax.^  It  has  been 
thought  that,  by  impeding  or  actually  preventing  the  inflation  of  the  apex  of  the 
lung,  there  was,  under  these  cii'cumstances,  a  predisposition  to  tuberculous  disease, 
and  that  when  it  had  once  appeared  the  natural  process  of  cure  was  hindered.  It 
has  therefore  been  suggested  that  in  cases  of  apical  phthisis,  where  the  disease  does 
not  extend  below  the  second  costal  cartilage,  that  division  of  the  first  cartilage  or 
excision  of  2  or  3  cm.  of  the  first  rib  or  of  its  cartilage  should  be  carried  out.  Division 
of  the  first,  second  and  third  cartilages  has  also  been  carried  out. 

(4)  Actinomycosis  of  the  Lung.  This  rare  disease  may  spread  to  the 
Imig  from  adjacent  organs,  or  the  fmigus  may  be  directly  drawn  down  into 
the  hmg  through  the  bronchi,  usually  with  some  foreign  body  such  as  a 
grain  of  corn.  It  is  liable  to  extend  to  the  thoracic  wall  forming  abscesses 
and  fistulse.  A  number  of  cases  have  been  successfully  treated  by  incising 
and  opening  up  the  various  sinuses  and  fistulse  and  scraping  away  the 
diseased  tissues.  Garre  and  Quincke  ^  recommend  wide  resection  of 
ribs  over  the  diseased  area  and  extensive  resection  of  the  diseased  tissues. 
Kocher  is  in  favour  of  the  former,  and  less  severe  mode  of  treatment. 

(5)  Hydatid  disease.^  This  is  by  no  means  uncommon  and  is  said 
to  account  for  from  7  to  12  per  cent,  of  all  cases. of  hydatid  disease.  The 
diagnosis  is  usually  made  from  the  occurrence  of  portions  of  ruptured  cysts 
in  the  sputum.  The  two  layers  of  the  pleura  are  Hkely  to  be  adherent,  thus 
simplifying  operation.  The  ribs  over  the  affected  area  are  incised,  and 
the  lung  tissue  is  then  incised  until  the  cyst  is  reached.  Incision  and 
drainage  are  to  be  preferred  to  excision. 

(6)  Tumours  of  the  lung.  These  may  be  sarcomata  or  carcinomata 
extending  inwards  to  the  kmg  from  the  chest  wall,  or  dermoid  cysts,  or 
sarcomata  or  carcinomata  occurring  primarily  in  the  limg  or  bronchi.  The 
latter  are  extremely  rare,  and  are  not  likely  to  be  diagnosed  sufficiently 

1  This  question  has  been  recently  investigated  bj-  ilr.  Morriston  Davies  in  a  paper 
on  "The  First  Rib  and  Apical  Tuberculosis,  based  on  a  study  of  402  specimens  "  {Brit. 
Journ.  Surg.,  vol.  i.  p.  55).  He  comes  to  the  following  conclusions  :  (1)  Neither  abnormal 
shortness  nor  ossification  of  the  first  costal  cartilage  predisposes  to  apical  pulmonary 
tuberculosis.  (2)  Abnormal  shortness  of  the  first  costal  cartilage  does  not  encourage 
ossification  in  that  cartilage.  (3)  The  formation  of  a  false  joint  in  the  rigid  cartilage 
does  not  tend  to  lead  to  the  cure  of  apical  tuberculosis.  (4)  The  balance  of  evidence  is 
against  the  probability  of  the  operation  for  the  division  of  the  first  costal  cartilage  in 
cases  of  apical  tuberculosis  producing  any  material  improvement. 

^  Loc.  siipj-a  cit. 

3  John  O'Connor,  of  Buenos  A3Tes,  discusses  the  treatment  of  pulmonary  hj'datids 
and  reports  three  cases  on  which  he  has  operated  {Lancet,  May  23,  1903).  Of  the  three 
cases,  two  were  very  serious  ones  ;  all  recovered.  The  diagnosis  of  pulmonary  hydatids 
may  be  attended  with  much  difficult}-,  especially  where  the  cj-st  has  not  ruptured  into  a 
bronchus.  In  such  cases,  the  locaUty  in  which  the  patient  has  resided,  the  unilateral 
situation  of  the  aiiection,  with  probabh^  a  sharply  defined  outUne  not  corresponding  with 
the  usual  site  of  a  pleural  effusion  or  hepatic  enlargement,  taken  in  connection  with 
cUmiiiished  breath  sounds,  vocal  and  tactile  fremitus,  with  an  antecedent  hacking,  irritating 
cough  with  or  without  pain,  and  associated  with  bronchitic  sputum,  should  lead  one  to 
suspect  hydatid  disease.  AVhen  rupture  has  taken  place,  there  is  a  history'  of  sudden 
evacuation  of  a  quantity  of  fluid,  foUowed  bj'  frequent  and,  at  times,  considerable  haemop- 
tysis. Later  an  intra-pulmonary  abscess  may  develop,  in  which  case  sj-mptoms  of  general 
toxaemia  promptlj-  show  themselves.  Microscopical  examination  of  the  sputum  is  the 
only  means  of  making  a  positive  diagnosis.  An  exploring  needle  should  be  used  not  only 
for  diagnosis  but  for  localising  the  cyst.  Mr.  H.  B.  Robinson  has  recorded  a  case  of  suc- 
cessful removal  of  a  hydatid  cyst  of  the  upper  lobe  of  the  right  lung  {Clin.  Soc.  Trans., 
vol.  xxxii,  p.  115). 


OPERATIONS  ON  THE  LUNG  AND  MEDIASTINUM    785 

early  to  admit  of  operation.  Lipomata,  fibro-sarcomata,  and  myxo- 
sarcomata  of  the  pleura  also  occur.  The  prospect  is  best  where  the 
growth  has  extended  from  the  thoracic  wall  to  the  lung,  for  here  the  tumour 
can  be  grasped  and  the  lung  thus  drawn  forward  into  the  opening  in 
the  thoracic  wall.  In  a  few  cases  malignant  growths  of  the  lungs  have 
been  treated  by  resection  of  the  diseased  lobe  or  lobes  after  a  more  or  less 
extensive  opening  in  the  chest  wall. 

Transpleural  Operations  on  the  Abdomen.  These  may  be  mentioned 
here, as  resection  of  one  or  moreribsand  opening  of  the  pleura  are  necessary 
parts  of  the  operation.     Transpleural  laparotomy  may  be  called  for  for 


Fig.  313.  Incisions  for  exposing  the  mediastina  :  A,  Incision  for  Milton's 
anterior  mediastinal  thoracotomy,  for  exposing  the  superior,  anterior,  and 
middle  mediastina.  B,  Incision  for  anterior  thoracotomy  by  an  osteoplastic 
resection  of  the  part  of  the  sternum  corresponding  with  the  third,  fourth,  and 
fifth  costal  cartilages  (exposing  the  anterior  and  middle  mediastina) .     ( Bickham. ) 

opening  and  draining  an  abscess  of  the  liver  which  is  situated  on  the 
superior  surface  and  is  pushing  up  the  diaphragm,  and  for  opening  a 
subphrenic  abscess.  The  presence  of  pus  must  always  be  verified  by  an 
exploring  needle.  Portions  of  the  seventh,  eighth,  ninth,  tenth  ribs 
or  their  cartilages  will  have  to  be  excised  according  to  the  position  of  the 
abscess.  The  pleural  cavity  is  then  opened,  and  must  be  shut  off  by 
suturing  the  costal  to  the  diaphragmatic  pleura  around  the  proposed 
incision  in  the  diaphragm.  This  structure  is  then  incised  and  a  drainage 
tube  inserted  into  the  abscess  cavity. 

The  Operation.  It  is  not  necessary  to  describe  in  detail  each  of 
the  above-mentioned  operations.  The  general  principles  of  each  have 
already  been  indicated  and  these  may  be  amplified  by  the  follo^ving 
remarks. 


SURGERY  I 


50 


786 


OPERATIONS  ON  THE  THORAX 


Asepsis.  The  greatest  care  must  be  taken  to  avoid  infection,  for 
should  this  occur  an  empyema  Tvill  be  the  probable  result  and  this  serious 
complication  may  lead  to  a  fatal  termination.  If,  as  will  very  likely 
be  the  case,  there  is  already  some  septic  process  going  on  in  the  lung,  the 
pleural  cavity  must  be  shut  ofi  by  suturing  the  parietal  to  the  visceral 
pleura  around  the  field  of  operation,  or  by  plugging  with  sterile  gauze, 
or  both  these  means  may  be  combined. 

The  anaesthetic,  and  the  dangers  of  pneumothorax.  These  have 
already  been  discussed,  and  the  latter,  especially,  will  receive  the  close 
attention  of  the  operator.  If  high  or  low  pressure  chambers  are  at 
hand  they  should  certainly  be  used,  but  they  are  not  essential,  and 


Fig.  314.     Powerful  rib  retractor  for  operations  on  the  lung. 


even  the  most  extensive  operations  have  been  carried  out  ^nthout  their 
assistance.  The  advantages  of  the  intra -tracheal  insufflation  of  ether 
may  be  again  insisted  upon. 

Opening  the  thorax  and  exposure  of  the  lesion.  The  disease  should 
be  exactly  locaHsed  and  the  incision  must  be  made  where  this  is  nearest 
the  surface.  Garre  and  Quincke  advise  against  excision  of  ribs  over  the 
heart  or  pericardium,  as,  if  this  is  done,  there  will  be  a  pulsating  scar 
and  very  possibly  cardiac  disturbances.  The  thorax  may  be  opened  in 
one  of  the  following  ways  :  (a)  A  long  incision  is  made  along  a  rib  and 
the  soft  parts  are  dissected  up  so  that  when  retracted  three  or  four  ribs 
are  exposed.  The  rib  immediately  over  the  focus  is  then  excised  sub- 
periosteally.  It  is  best  not  to  widely  open  the  chest  at  first,  but  only  to 
make  an  opening  sufficient  to  allow  of  an  examination  to  ascertain  the 
extent  of  the  disease.  If  necessary,  then,  one  or  more  ribs  may  be  excised 
above  and  below  the  first.  In  any  case,  more  room  may  be  obtained 
by  retracting  the  ribs  above  and  below  by  powerful  retractors.  Often 
excision  of  one  rib  combined  with  retraction  will  give  sufficient  room. 
Air  should  not  be  allowed  to  enter  the  pleural  cavity  too  rapidly  :  hence, 


OPKUATIONS  ON  THE  LUNG  AND  MEDIASTINUM    787 

a  small  incision  into  the  pleura  is  made  at  first  and  th(>  effect  of  this 
noted.     The  opening  is  then  increased.     I'hc  lung  sliould  be  drawn  to 


A.  B.  C.  D. 

Fig.  315.     Special  instruments  for  operations  on  the  lung.     A,  Lung  spatula. 
B,  Lung-seizing  forcejis.     C,  Lung  hilus  forceps.     D,  Lung  clamps. 

the  wound  by  special  forceps  which  secure  a  firm  grip  and  do  not  damage 
the  tissue. 


1-^ 


Fig.  316.     Fixation  of  the  lung  and  investigation  thereof.     (Picot.) 

(6)  The  ribs  may  be  exposed  freely  by  a  curved  incision,  and  by 
reflecting  a  flap  of  the  soft  parts. 

(c)  A  rectangular  flap  of  skin  and  soft  parts  may  be  turned  back. 
The  ribs  are  then  divided,  either  by  bone  forceps  or  by  a  Gigh's  saw  at 
the  free  margin  of  the  flap,  and  partly  divided  and  fractured  at  the  base 


788 


OPERATIONS  OX  THE  THORAX 


of  the  flap  ;  a  hinge-like  flap  of  ribs  and  intercostal  muscles  can  then  be 
turned  back  and  the  lung  thus  \videly  exposed  (Fig.  317). 

(d)  Either  of  the  above  incisions  may  be  enlarged  or  converted  into  a 
T-shaped,  H -shaped,  or  L-shaped  incision  if  more  room  be  required. 


Fig.  317a.    Temporarj-  resection  of  the 

thoracic  wall  accordance    to    Delonne 

with  the  lung  fixed. 


Fig.  317b.    Temporary  resection  of  the 

thoracic    wall    accordance    to   Delonne 

with  the  lung  fixed. 


Opening  and  draining  a  cavity  in  the  lung.  If  the  cavity  is  an  old 
standing  one,  the  pulmonary  tissue  around  will  probably  be  indurated 
and  it  may  be  incised  with  the  knife.  If  recent  the  lung  tissue  will  be 
unthickened  and  a  Paquelin  cautery  may  then  be  used.  The  cavity 
may  safely  be  sought  for  by  a  large  exj)loring  needle.     When  deeply  placed 


Fig.  318.     W.JMeyer's  suture  of  the  bronchus.     (According  to  a  drawing  by 

Schumacher.) 


the  needle  may  be  left  in  situ  and  the  incision  gradually  deepened,  using 
it  as  a  guide.  In  the  case  of  an  old  cavity  Quincke  and  Garre  advise 
extensive  resection  of  the  thickened  overlying  lung  tissue  so  as  to  allow 
sinking  in  of  the  chest  wall,  and  thus  helping  obliteration.  In  a  gan- 
grenous cavity  loose  sloughs  may  be  removed,  but  any  which  are  adherent 
should  be  left  to  loosen  gradually  and  come  away.  Drainage  is  best 
effected  by  moist  sterile  gauze.  The  cavity  must  not  be  irrigated  on 
account  of  the  danger  of  fluid  entering  the  bronchi. 


OPKKATIONS  ON  THE  LUNG  AND  MEDIASTINUM   789 

Excision  of  a  lobe  or  a  portion  of  a  lobe.  Two  important  points  here 
are  {a)  tlie  control  of  htoinoirliaiic  and  (h)  the  closure  of  divided  bronchi. 
Haemorrhage  may  be  controlled  by  temporary  compression  of  the  hilum  ; 
special  forceps  have  been  (lesi<j;ned  I'oi- this  pur^jose  (Fig.  31")).  If  only  a 
small  portion  is  to  be  excised  the  lung  can  be  compressed  with  long  wide 
clamp  forceps.  When  the  diseased  part  has  been  removed  all  line  bronchi 
and  all  vessels  that  can  be  seen  are  tied  with  fine  silk.  For  suturing  the 
wound  in  the  lung  Garrcand  Quincke  recommend  fine  silk  and  advise  that 
the  stitches  should  be  inserted  not  far  from  the  margin, and  that  they  should 
be  made  to  extend  close  to  the  bottom  of  tlie  wound.  When  a  whole  lobe 
or  lung  is  removed  the  vessels  must  be  separated  and  secured  at  the  hilum. 
Great  care  has  to  be  taken  in  closing  the  main  bronchus  on  account  of  the 
danger  of  tension  pneumothorax,  if  air  escapes,  and  also  of  infection.  It 
can  be  closed  by  ligaturing  not  too  tightly  and  then  sewing  lung  tissue 


Fig.  319.  Operations  upon  the  thoracic  cavity :  A,  Posterior  mediastinal 
thoracotomy,  by  thoracoplastic  flap.  B,  Position  for  paracentesis  thoracis  in 
the  eighth  intercostal  space  in  the  line  of  the  inferior  angle  of  the  scapula.  The 
scapula  is  here  represented  retracted  slightly  outward,  to  increase  working-space 
between  vertebrae  and  scapula  in  the  removal  of  parts  of  the  fourth,  fifth,  and 
sixth  ribs.     (Bickham.) 

over  it.  W^illy  Meyer  recommends  crushing  several  centimetres  of  the 
bronchus  with  stout  crushing-forceps,  after  the  vessels  have  been  secured. 
The  crushed  portion  is  ligatured  and  invaginated  and  the  bronchus  sutured 
over  the  stump  (Fig.  318). 

Closure  of  the  opening  in  the  chest  wall  :  Drainage  of  the  pleural 
cavity.  In  the  case  of  aseptic  operations  of  short  duration  the  wound 
in  the  chest  wall  should  be  completely  closed.  If  ribs  have  been  resected 
the  intercostal  muscles  and  the  parietal  pleura  are  accurately  united  with 
sutures  of  catgut.  Before  the  opening  is  finally  closed  all  air  must  be 
forced  out  of  the  pleural  cavity.  This  may  be  done  by  fully  inflating 
the  lung,  if  one  of  the  methods  of  securing  differential  pressure  has  been 
employed  ;  or  Mace  wen's  method  of  compressing  the  thorax  and  abdomen 
may  be  tried.  The  muscles  and  skin  are  then  accurately  sutured.  The 
whole  wound  must  be  quite  air-tight.  If  the  operation  has  been  performed 
for  some  septic  cavity  in  the  lung  the  ribs  should  always  be  freely  resected 
in  order  to  allow  of  falling  in  of  the  chest  wall  and  obliteration  of  the 
cavity.     If  the  ribs  have  been  at  first  resected  subperiosteally  the  peri- 


790  OPERATIONS  ON  THE  THORAX 

osteum  should  be  dissected  away,  or  an  area  of  periosteum,  intercostal 
muscles  and  parietal  pleura  may  be  completely  removed ;  the  cut  edge 
of  the  parietal  pleura  should  then  be  sutured  to  the  Imig  and  the  super- 
ficial soft  parts  sutured,  sufficient  space  being  allowed  for  drainage  of  the 
cavity.  When  the  operation  has  been  prolonged,  when  all  air  cannot 
be  expelled,  e.g.  after  excision  of  a  lobe,  or  when  some  septic  focus  has  been 
opened,  the  pleural  cavity  should  be  drained.  Most  operators  recommend 
that  the  original  wound  should,  if  possible,  be  completely  closed  and  that 
a  tube  should  be  inserted  through  a  small  incision  in  the  lowest  part  of  the 
pleura,  e.g.  in  the  tenth  space  in  the  scapular  line.  Some  form  of  valvular 
drainage-tube,  i.e.  one  that  will  allow  any  effusion  to  escape  but  will  not 
allow  of  the  entry  of  air,  should  be  used.  Thiersch  has  suggested  a  simple 
method  which  can  be  easily  improvised  ;  it  consists  of  a  stout  rubber 
tube  which  projects  into  the  pleural  cavity,  while  to  its  outer  extremity 
is  fastened  an  open  rubber  finger  stall,  or  a  short  length  of  thin  rubber 
colotomy  tubing.  On  expiration  any  efiusion  is  forced  out,  but  on 
inspiration  the  thin  tube  collapses  and  forms  a  valve  preventing  the  entry 
of  air. 

Difl&culties  and  dangers  in  opening  a  lung  cavity.  These  have  already 
been  indicated,  but  they  may  be  summed  up  as  follows  : 

(1)  Dyspnoea,  coughing,  and  choking  expectoration  with  the  anaes- 
thetic. 

(2)  Dyspnoea,  cyanosis,  and  collapse  on  opening  the  pleura. 

(.3)  Missing  the  cavity.  This  is  best  guarded  against  by  careful 
preceding  localisation,  and  the  use  of  an  exploring  needle  after  the  lung 
has  been  exposed. 

(4)  Getting  as  the  result  of  the  operation,  diffuse  broncho-pneumonia 
in  the  lung  operated  on  or  its  fellow. 

(5)  Severe  haemorrhage,  causing  much  trouble,  owing  to  haemoptysis 
with  the  anaesthetic,  or  later  on  setting  up  broncho -pneumonia. 

(6)  Finding  a  large  branching  cavity,  difiicult  or  impossible  to  drain. 

(7)  A  cavity  near  the  large  vessels  at  the  root  of  the  lung. 

(8)  Much  consolidation  of  the  lung  tissue  over  the  cavity. 

(9)  Septic  infection  of  the  pleura  leading  to  empyema.  Serous 
pleural  effusion  may  occur,  independent  of  infection,  and  call  for 
aspiration. 

(10)  Post-operative  pneumothorax,  possibly  of  a  valvular  nature. 

(11)  Emphysema  of  the  cellular  tissue,  or  more  serious,  emphysema 
of  the  mediastinum.  The  latter  will  probably  be  due  to  leakage  after 
incision  or  division  of  a  main  bronchus. 

Operations  on  the  Mediastinum.  These  nmst  be  conducted  on  similar 
lines  and  with  similar  precautions  as  with  operations  on  the  lung.  They 
may  be  called  for  under  the  following  circumstances.  (1)  For  the 
drainage  of  collections  of  pus.  Such  abscesses  may  be  due  to  breaking 
down  lymphatic  glands,  to  spinal  caries,  or  to  perforations  of  the 
bronchi  or  the  oesophagus.  (2)  For  the  removal  of  growths.  These 
can  often  only  be  distinguished  with  difficulty  from  growths  of  the 
lung.  Indeed,  it  is  not  infrequently  impossible  to  say  exactly  where  the 
growth  started.  The  following  growths  may  occur.  Dermoid  cysts  or 
teratomata.^  These  are  especially  likely  to  be  present  in  the  anterior 
mediastinum.     Other  simple  tumours  are  lipomata,  fibromata,  gummata, 

1  A  paper  by  Dr.  Christian  {Med.  Surg.  Rep.  of  the  Boston  City  Hospital,  1901,  p.  114), 
in  which  he  has  collected  forty  cases,  may  be  referred  to  for  information  as  to  these  tumours. 


OPERATIONS  ON  THE  LUNG  AND  MEDIASTINUM    791 

simple  cysts,  and  hydatid  cysts.  Enlargement  of  the  lymphatic  glands 
may  be  due  to  tubercle,  Hodgkin's  disease,  to  secondary  deposits  of 
carcinoma  or  to  primary  lympho-sarcoma.  Primary  sarcoma  of  the  lung 
is  extremely  rare  but  metastatic  growths  are  very  common.  Primary 
carcinoma  of  the  bronchi  may  occur  and  also  fibrosarcomata  and  myxo- 
sarconiata  of  the  pleura,  the  latter  though  reaching  an  enormous  size  not 
being  very  malignant  growths.  The  non-malignant  growths  are  alone 
likely  to  be  suitable  for  operative  treatment,  though  successful  cases  of 
removal  of  growths  of  the  pleura  have  been  reported.  (3)  Operation 
through  the  mediastinum  may  also  be  indicated  for  some  growths  of  the 
oesophagus  and  also  for  some  cases  of  foreign  bodies  in  the  oesophagus 
or  bronchi,  when  attempts  at  extraction  by  other  means  have  failed. 

Operation  on  the  anterior  Mediastinum.     In  the  case  of  suppuration, 
if  there  be  any  sinus  or  evidence  of  pointing  at  the  side  of  the  sternum, 


Fig.  320.  Anterior  mediastinal  thoracotomy,  by  an  osteoplastic  flap  consisting 
of  soft  parts  and  sternum  corresponding  with  third,  fourth,  and  fifth  costal 
cartilages.  A,  Osteoplastic  flap  turned  to  left.  B,  Pectoralis  major  muscle. 
C  C,  intercostal  arteries.  D,  Costal  cartilage  divided.  E,  Costal  cartilage 
partly  broken  in  hinging  back  the  flap.  F  F,  Drill-holes  for  wiring.  G,  Tri- 
angularis sterni  muscle.  H  H,  Lungs  and  pleurse,  the  latter  extending  further 
toward  the  middle  line.     I,  Heart  and  pericardium.     (Bickham.) 

the  deep  opening  is  enlarged  with  a  finger  as  a  guide,  by  removal  of  as 
ranch  of  the  sternum  and  ribs  as  is  needful.  The  field  of  operation  must 
be  exposed  by  a  long  incision  or  flap  appropriate  to  the  conditions  found  in 
each  case.  Drainage  should  be  secured  by  a  large  tube  or  by  gauze. 
For  thorough  exposure  for  exploration  and  for  the  removal  of  growths 
further  steps  are  necessary,  (a)  The  manubrium  may  be  trephined  and 
sufficient  bone  then  removed  by  means  of  Hoffmann's  forceps.  A  single 
trephine  opening  will  not  give  sufficient  room,  (b)  Milton's  operation, 
in  which  the  whole  length  of  the  sternum  is  divided  vertically  by  saw  and 
bone  forceps,  the  ensiform  cartilage  being  removed.  By  retraction  of  the 
two  halves  of  the  sternum  a  space  of  two  to  two  and  a  half  inches  may  be 
obtained,  (c)  By  means  of  an  cesteoplastic  flap  (Fig.  320).  Kocher  recom- 
mends a  rectangular  incision  commencing  over  the  sternal  end  of  the 
right  clavicle,  passing  across  to  the  left  sterno-clavicular  joint,  then  ex- 
tending down  the  left  border  of  the  sternum  to  the  lower  border  of  the 


792 


OPERATIONS  OX  THE  THORAX 


manubrium  from  whence  it  is  continued  transversely  to  the  right  side 
(Fig.  322).  The  periosteum  with  the  attachments  of  muscles  is  stripped 
from  both  surfaces  of  the  bone.  The  left  sterno-clavicular  joint  is  opened, 
the  first  and  second  costal  cartilages  are  di\'ided,  and  the  manubrium  is 
divided  transversely  at  its  lower  border.  The  whole  manubrium  is  then 
turned  over  to  the  right  as  an  osteoplastic  flap,  the  right  costal  cartilages 
being  partially  divided.     In  this  way  the  anterior  mediastinum,  inno- 


FiG.  321.  Posterior  mediastinal  thoracotomy,  b}-  thoracoplastic  flap.  A,  Skin 
and  muscle  flap  turned  horizontally  backward.  B,  Flap  of  part  of  fourth  rib 
and  intercostal  muscles  turned  upward.  C,  Flap  of  part  of  sixth  rib  and  inter- 
costal muscles  turned  downward.  D  D,  Vertebral  ends  of  fourth  and  sixth  ribs, 
drilled  for  wiring.  E,  Intercostal  artery,  vein,  and  nerve.  F  F  F,  Fourth,  fifth, 
and  sixth  dorsal  nerves  exposed  and  retracted.  G,  Pleura  and  lung.  H,  Broad 
retractor  displacing  pleura  and  lung.  I,  Thoracic  aorta.  J,  Left  bronchus. 
K.  (Esophagus  protruded  into  wound  by  a  sound  introduced  through  the  mouth. 
The  operations  of  bronchotomy  and  thoracic  CBSophagotomy  are  shown  at  J  and 
K  respectively.     The  pulmonary  and  bronchial  ves-sels  are  omitted,  for  clearness. 

(Bickham.) 

minate  artery,  and  auricles  can  be  satisfactorily  exposed.  Or  the  manu- 
brium may  be  divided  transversely  below,  the  first  and  second  costal 
cartilages  divided  on  each  side  and  the  manubrium  turned  upwards. 

Operations  on  the  middle  Mediastinum.  These  will  be  described 
in  the  chapter  on  operations  on  the  heart  and  pericardium. 

Operations  on  the  posterior  Mediastinum.  The  patient  is  placed  in  the 
semi-prone  position,  and  the  scapula  is  dra'mi  outwards.  The  thick 
sldn  in  this  neighbourhood  requires  very  careful  sterilisation.  All  pre- 
parations must  be  made  for  deahng  with  a  pneumothorax  as  the  pleural 


OPERATIONS  ON  THE  LUNG  AND  MEDIASTINUM   793 

cavity  is  very  likely  to  be  opened.  An  incision,  four  inches  long,  is  made 
parallel  to  the  vertebral  column  and  about  three  inches  from  it,  over 
the  ribs  from  the  third  to  the  sixth,  and  at  each  end  transverse  incisions 
are  carried  inwards.  The  musculo-cutaneous  flap  thus  marked  out  is 
turned  inwards.  The  subjacent  portions  of  three  or  four  ribs  are  now 
resected  subperiosteally.  To  obtain  sufficient  access,  the  resection  must 
be  carried  with  the  help  of  bone  forceps  as  near  the  spine  as  possible, 
the  transverse  processes  being  also  removed.  Especial  care  must  be 
taken  to  avoid  opening  the  pleura  ;  any  such  opening  should  be  tempor- 
arily plugged  with  gauze  and  then  sutured.  All  bleeding  being  arrested, 
the  pleura  should  be  detached  with  the  fingers  and,  with  the  lung,  pushed 
forwards  (Fig.  321 ).  If  the  operation  is  undertaken  for  a  foreign  body  in  the 
esophagus  the  presence  of  a  bougie  will  facilitate  its  identification.  This 
is  carefully  separated  from  its  surroundings,  and  the  bougie  being  partially 
withdrawal,  the  oesophagus  is  drawn  into  the  wo  mid,  opened,  and  the 
foreign  body  withdrawn.  During  the  manipulations  of  the  oesophagus, 
the  trunks  of  the  vagi  must  be  carefully  protected  from  injury,  and  the 
vena  azygos,  if  met  with,  must  be  either  drawn  aside  wdth  a  blunt  hook, 
or  secured  between  double  ligatures.  The  question  of  complete  suture  of 
the  oesophagus  must  depend  on  the  character  of  the  foreign  body  and  the 
amomit  of  damage  inflicted  by  this  and  by  the  necessary  manipulations. 
Sufficient  drainage  of  the  mediastinum  is  imperative.  The  oesophagus 
is  best  approached  from  the  left  side  in  the  upper  part  of  its  course  through 
the  mediastinum  and  from  the  right  side  below. 

Those  interested  in  trans -thoracic  resection  of  the  oesophagus  should  refer  to  a 
paper  by  Dr.  Willy  Meyer,^  with  its  accounts  of  the  work  done  in  this  direction  by 
Sauerbruch  and  the  late  v.  Miculicz. 

Jaboulay  has  exposed  the  oesophagus  through  the  pericardium.  The  middle 
mediastinum  is  exposed  by  an  osteoplastic  flap  of  sternum  and  costal  cartilages,  the 
pericardium  is  opened,  the  heart  di"awn  aside,  and  the  oesophagus  reached  hy  in- 
cising the  posterior  wall  of  the  pericardium. 

Transpleural  CEsopliacjotomy.  Sauerbruch  employs  an  incision  through  the 
third  right  intercostal  space,  and  reaches  the  oesojihagus  on  the  right  side  above  the 
root  of  the  lung,  and  as  low  as  the  azygos  vein.  The  lower  part  of  the  oesophagus 
is  reached  through  the  fourth  or  fifth  left  intercostal  space.  An  incision  of  the 
desired  length  is  made  by  slichng  doAvn  the  skin  and  cutting  firmly  down  on  to 
the  rib  and  cartilage.  A  portion  of  the  rib  is  then  excised  subperiosteally  and 
the  underlying  periosteum,  endothoracic  fascia,  triangularis  sterni  and  pleura,  are 
incised,  without  appreciable  bleeding,  and  without  the  risk  of  entering  the  plem'al 
cavity  too  soon.  By  forcibly  separating  the  ribs  (by  Miculicz's  retractors),  the  lung 
can  be  pushed  aside  by  a  special  spatula,  and  the  oesophagus  identified  by  the  intro- 
duction of  a  bougie.  The  pleura  covering  it  is  then  incised,  and  the  whole  thickness 
of  the  oesophagus,  from  which  the  nerves  and  vessels  have  been  freed,  is  grasjDcd 
with  forceps  and  pulled  forwards.  The  surrounding  parts  are  packed  off  with 
gauze  and  the  oesophagus  may  then  be  opened  in  its  long  axis  and  the  foreign  body 
extracted.  The  mucous  membrane  is  seized  with  forceps  so  that  it  may  subsequently 
be  recognised  and  invaginated  with  Lembert's  sutures.  The  muscular  coat  of  the 
oesophagus  is  sutm-ed  with  silk  and  the  wound  closed  or  if  necessary  ckained. 

1  Ann.  of  Surg.,  May  190.5. 


CHAPTER  XXXVII 

TAPPING  OR  INCISING  THE  PERICARDIUM.     SUTURE 
OF  WOUNDS  OF  THE  HEART 

TAPPING  OR  INCISING  THE  PERICARDIUM 

Indications.     (1)  When  a  pericardial  effusion  has  resisted  previous  treat- 
ment, and  signs  of  cardiac  distress  are  increasing. 

(2)  When  there  is  a  steady  increase  of  prsecordial  dulness. 

(3)  When  the  heart-beat  and  pulse  are  becoming  feeble. 

(4)  When  cyanosis,  dyspnoea,  and  epigastric  distress  are  present. 

(5)  When  the  effusion  persists,  when  it  is  accompanied  by  oedema, 
rigors,  and  pysemia,  e.g.  in  cases  of  osteomyelitis  ;  when  it  occurs  in  a 
much  weakened  patient,  the  fluid  is  probably  purulent. 

The  spot  usually  chosen  for  puncture  is  the  fifth  or  fourth  space, 
about  one  inch  from  the  sternum,  so  as  to  avoid  the  internal  mammary 
vessels,  and,  if  possible,  the  pleura,  which  varies  greatly  in  the  extent 
to  which  it  lies  under  the  cover  of  the  inner  ends  of  the  fifth  and  sixth 
cartilages  and  even  of  the  sternum.  Mr.  Rowlands  ^  writes  on  this  point  : 
"  From  anatomical  considerations  and  experiments  on  the  cadaver  it  is 
certain  that  the  safest  point  to  tap  or  to  insert  the  needle  of  the  exploring 
syringe  is  the  left  costo-xiphoid  angle  as  suggested  by  Roberts  years  ago. 
The  instrument  should  touch  the  lower  end  of  the  gladiolus  and  should 
pass  backwards,  upwards,  and  a  little  inwards  behind  the  sternum,  until 
it  is  felt  to  enter  the  cavity  of  the  pericardium  at  a  distance  of  not  more 
than  two  inches  and  a  half  from  the  skin.  The  pleura  and  internal 
mammary  vessels  are  too  far  out  to  be  injured,  and  the  peritoneum  too 
low,  and  the  heart,  unless  adherent  in  front,  lies  too  far  back  in  its  dis- 
tended sac  to  be  reached  if  the  above  precautions  are  taken.  The  inner 
extremity  of  the  fifth  space  is  probably  the  next  best  situation,  where 
the  needle  should  be  passed  backwards  and  inwards  in  close  contact  with 
the  sternal  edge  ;  but  though  the  internal  mammary  vessels  are  quite 
safe,  the  pleura  will  certainly  be  pierced  occasionally.  The  sixth  left 
space  is  to  be  preferred,  if  wide  enough  at  its  sternal  end,  which  is  not 
often  the  case." 

Whichever  site  is  chosen  for  puncture,  strict  aseptic  precautions  must 
be  taken,  and  the  following  risks  of  paracentesis  must  be  remembered, 
viz.  pleurisy,  empyema,  and  injury  to  the  heart.  While  upwards  of  a 
pint  of  serum  has  been  removed  in  some  cases,  the  withdrawal  of  only 
three  or  five  ounces  has  been  followed  by  recovery  in  others. ^ 

1  Loc.  infra  cit.,  p.  796. 

2  With  regard  to  the  amount  to  be  withdrawn,  Dr.  Stewart  {Edin.  Med.  Journ., 
August  1885)  thinks  that,  if  serous  fluid  is  found,  aspiration  should  be  made  use  of,  but 
only  enough  withdrawn  to  give  relief.  He  points  out  that  it  is  a  sound  rule,  in  dealing 
with  vital  organs,  that  only  a  minimum  amount  of  interference  should  be  had  recourse 
to,  and  that  this  is  especially  necessary  in  cases  which  threaten  pulse-failure.  The 
tapping  should  be  repeated  rather  than  too  much  fluid  be  drawn  off  at  once. 

794 


TAPPING  OR  INCISING  THE  PERICARDIUM       795 

On  tlie  fluid  ceasing  to  flow,  the  puncture  should  be  closed  with 
sterilised  gauze  and  collodion. 

Thaytn*  ^  found  no  fluid  on  aspiration,  though  the  area  of  dulness  was 
large.  At  the  necropsy,  1200  cc.  of  fluid  were  found  in  the  pericardium. 
Though  the  heart  was  not  fixed  by  adhesions  it  lay  in  front  of  the  effusion, 
and  the  needle  had  come  in  contact  with  this  viscus.  In  such  cases,  to 
obtain  better  access,  a  rib  must  be  resected.     In  some  cases,  the  co- 


Fig.   322.     A,    Incision  for   osteoplastic   resection   of   the   manubrium   sterni. 

B,  Incision  for  an  osteoplastic  flap  containing  the  third,  fourth,  and  fifth  costal 

cartilages  for  exposing  the   heart.     C,    Incision  for  ligature   of  the  internal 

mammary  artery.     D,  Incision  for  drainage  of  the  pericardium. 

existence  of  effusion  into  the  pleural  and  peritoneal  sacs  must  be  re- 
membered. 

If  pus  is  present  ^  the  case  must  be  treated  by  free  incision.  An 
anaesthetic  having  been  given,  the  trocar  is  taken  as  a  guiding  director, 
and  a  narrow,  sharp-pointed  bistoury  carefully  thrust  in  by  its  side  ;  the 
opening  is  then  further  dilated  with  dressing-forceps  or  a  blmit-pointed 
bistoury,  care  being  taken  to  keep  the  internal  opening  iiito  the  pericardial 
sac  free.  A  soft  drainage-tube  should  next  be  inserted,  and  when  all 
the  pus  that  wiU  come  away  has  escaped  antiseptic  gauze  dressings  should 
be  applied. 

As,  however,  the  proximity  of  the  costal  cartilages  to  one  another 
will  only  allow  of  the  introduction  of  a  small-sized  drainage-tube,  and  as 
flocculent  matter  may  be  present,  e.g.  where  the  pneumococcus  is  present 
(p.  764),  it  is  wiser  to  resect  part  of  the  fifth  costal  cartilage  (Fig.  323),  or 
the  seventh  (Rowlands,  vide  infra).  This,  while  increasing  the  length  of 
time  occupied  by  the  operation,  wiU  allow  of  the  insertion  of  a  large 
drainage-tube,  and  thus  of  free  and  efficient  drainage.  An  incision  is 
made  from  the  sternum  outwards  over  the  fifth  costal  cartilage  to  its 

1  Johns  Hopkins  Hasp.  Bull.,  1904.  p.  149. 

2  For  the  signs,  symptoms  and  diagnosis  of  Pyopericardium  reference  should  be  made  to 
a  standard  textbook  of  medicine. 


796  OPERATIONS  ON  THE  THORAX 

junction  with  the  rib.  The  soft  parts  are  carefully  separated  as  at  p.  766, 
care  being  taken  not  to  wound  the  pleura.  The  cartilage  is  then  divided 
with  a  narrow  saw  and  sharp  bone-forceps  at  its  junction  with  the  rib 
and  sternum.  The  internal  mammary  vessels  now  exposed  are  divided 
between  two  ligatm'es  or  drawn  aside.  The  triangularis  sterni  is  detached 
from  the  sternum  and  drawn  inwards.  The  pleura,  the  relation  of  which 
to  the  chest- wall  and  pericardium  varies  greatly,  is  peeled  aside  and  drawn 
outwards.     It  is  much  thinner  than  the  pericardium  and  its  border  may 


Fig.  323.  Exposure  of  pericardium  and  heart  by  partial  excision  of  left  fifth 
costal  cartilage.  A,  Pectoralis  major  muscle  retracted,  overlying  the  retracted 
intercostal  muscles  and  membrane.  B,  Internal  mammary  vessels.  C,  Inter- 
costal vessels.  D,  Sternum  and  part  of  fifth  costal  cartilage.  E,  Pleura  and 
lung  retracted.  F,  Pericardium,  incised  and  margins  retracted.  G,  Heart, 
showing  incised  wound  being  sutured.     (Bickham.) 

contain  fat.  If  there  be  difficulty  in  displacing  the  pleura  outwards,  the 
adjacent  part  of  the  sternum  should  be  removed  (Rowlands).  In  children, 
owing  to  its  cartilaginous  nature,  this  is  readily  effected  with  a  gouge.  A 
Httle  further  use  of  a  director  will  now  expose  the  pericardium.  Before 
this  is  incised  it  is  well  again  to  use  an  exploring  needle.  The  incision 
into  this  sac  should  be  made  downwards  and  outwards,  and  if  time  admits, 
the  cut  edges  should  be  sutured  to  the  lips  of  the  womid.  Any  opening  in 
the  pleura  should  be  closed  with  a  stitch,  or  gauze  secured  with  silk. 

If,  as  is  not  uncommon,  an  empyema  be  present,  the  critical  condition 
of  the  patient  will  usually  render  it  advisable  to  defer  further  operation 
for  a  day  or  two. 

On  the  subject  of  the  best  incision  for  drainage  of  the  pericardium 
two  very  instructive  papers  by  Mr.  R.  P.  Rowlands  ^  should  be  consulted.^ 
The  cases,  aged  2|  years  and  1  year  8  months  respectively,  were  under 
the  care  of  Dr.  Coutts  at  the  East  London  Hospital  for  Children  :  his 
remarks  on  purulent  pericarditis  and  the  complications  which  may,  as 
in  these  cases,  be  present,  will  repay  careful  study.  In  the  second  of  the 
two  papers  mentioned  above,  Mr,  Rowlands  is  of  opinion  that  removal 

1  Brit.  Med.  Journ.,  January  2,  1904,  and  April  15.  1905. 

2  See  al.so  a  case  shown  by  Mr.  Douglas  Drew  and  the  discussion  thereon  (Proc.  Roy. 
Soc.  Med.,  Sec.  for  Study  of  Diseases  in  Children,  April  1912,  p.  161). 


TAPPING  OR  INCISING  THE  PERICARDIUM       797 

of  the  seventh  left  costal  cartilage  from  near  its  costo-chondral  junction 
to  within  an  inch  of  the  sternum,  together  with  a  portion  of  this  bone, 
if  needful,  gives  the  easiest,  wndest,  safest  mode  of  access  and  the  best 
drainage.  Wiion  the  thorax  is  opened  the  diaphragm  is  pushed  down- 
wards, and  never  need  be  separated  or  pierced.  The  pleural  margin  can 
be  pushed  upwards  and  outwards,  and  the  pericardium  opened  and  drained 
at  its  lowest  and  outermost  point,  so  that  when  the  patient  is  turned  on 
one  side  the  pus  drains  away  better  than  with  an  incision  close  to  the 
mid-line,  which  is  also  more  liable  to  trespass  on  the  abdomen  and  the 
deep  epigastric  artery.  It  is  also  possible  to  pass  a  finger  into  the  various 
recesses  of  the  pericardium,  and  to  introduce  a  tube  behind  the  heart 
into  the  oblique  sinus  with  ease.  This  space  cannot  be  satisfactorily 
drained  if  a  portion  of  the  fifth  costal  cartilage  be  excised. 

Epigastric  Route.  This  method,  first  brought  forward  by  Larrey,  was 
strongly  recommended  by  the  late  !Mr.  H.  W.  AJlingham,^  on  the  ground  that  the 
])ericardium  is  thas  incised  at  the  lowest  part  of  its  anterior  wall.  Stated  very 
briefl3%  this  operation  consists  in  incising  the  left  rectus  abdominis,  and,  after 
avoiding  the  peritoneum.  oi:)ening  up  the  cellular  interval  between  the  sternal  and 
costal  fibres  of  the  diaphragm  (in  which  lies  the  superior  epigastric  artery),  and 
thus  exposing  the  lowest  part  of  the  pericardium.  A  good  account  of  this  method  of 
reaching  the  pericardium  is  given  by  Mr.  Pendlebury,-  with  a  successful  case.  The 
collection  here  was  serous.  IVIr.  Rowlands  '  considers  that  the  above  ingenious 
operation  has  the  following  drawbacks  :  (o)  The  little  room  available  in  most  adults, 
who  have  wide,  firm,  or  even  ossified  ensiform  cartilages  and  rigid  costal  cartilages  ; 
the  costo-xiphoid  space  is  too  narrow  in  these  cases,  (b)  The  operation  is  neces- 
sarily performed  somewhat  in  the  dark  and  under  cover  of  the  sternum  and  seventh 
costal  cartilage,  and  it  is  not  easy  to  ensure  whether  the  exploring  finger  is  above  or 
below  the  diai^liragm,  especially  by  an  operator  not  quite  familiar  with  the  anatomy 
of  this  region.  For  these  reasons  a  portion  of  the  seventh,  or  even  of  the  sixth,  costal 
cartilage,  may  have  to  be  removed  in  order  to  provide  the  necessary  room,  as 
practised  by  Mr.  Allingham  and  ]\Ir.  Pendlebury.  (c)  The  superior  epigastric 
artery  may  be  wounded  as  it  comes  through  the  diaphragm,  and  cause  troublesome 
haemorrhage  in  the  depth  of  the  wound,  {d)  The  jjericardium  may  be  separated  by 
the  finger  from  the  parietes,  and  pus  may  then  leak  into  the  loose  connective  tissue 
and  set  up  a  fatal  mediastinitis.  When  the  pericardium  is  very  distended  these 
dangers  and  difficulties  are  much  diminished  ;  the  reverse  will  be  the  case  where  the 
collection  of  pus  is  small.  In  the  second  case  related  by  Dr.  Coutts  and  ]VIr.  Rowlands 
the  amoimt  was  between  one  and  two  ounces. 

During  the  first  few  days  after  the  operation  the  drainage  of  the  cavity 
may  be  materially  assisted  by  keeping  the  patient  propped  up,  and  turned 
on  to  his  face  at  intervals. 

Causes  of  failure.  (1)  The  tissue  of  the  heart  may  be  degenerated,  or 
the  organ  dilated.     These  changes  may  come  on  very  rapidly. 

(2)  Toxaemia,  septicaemia,  and  pyaemia. 

(3)  Co-existing  effusions  into  the  pleura  and  peritoneal  sacs,  or  into 
joints,  or  pneumonia.  During  the  after-treatment  measles  and  bronchitis 
may  cut  short  a  case  that  otherwise  promises  well,  as  occurred  in  one  of 
the  children  under  the  care  of  Dr.  Coutts  and  Mr.  Rowlands  {vide  supra). 

(4)  (Edema  of  lung.  Evidence  of  this  should  be  most  carefully 
watched  for.  It  proved  fatal  in  the  case  of  a  patient  of  Sir  James 
Goodhart's,  a  girl  of  14. 

(5)  Co-existing  diseases — e.g.  phthisis,  or  renal  disease. 

1  Lancet,  June  1900. 

2  Lancet.  March  10,  1900,  p.  693. 

'  Brit.  Med.  Journ.,  January  2,  1904. 


798 


OPERATIONS  ON  THE  THORAX 
SUTURE  OF  WOUNDS  OF  THE  HEART 


Apart  from  the  recoveries  that  have  taken  place  after  suture,  severe 
wounds  of  the  heart  have  been  almost  invariably  fatal.  Surgical  inter- 
vention has,  however,  undoubtedly  saved  a  considerable  number  of  lives, 
as  may  be  gathered  from  the  following  figures  :  Loison  ^  collected  90 
cases  of  wounds  of  the  heart  by  cutting  instruments.  Of  72  cases  not 
operated  upon,  71  died  ;   of  18  cases  treated  by  operation,  10  recovered. 


Fig.   324.     Long  intercostal  incision  in  fifth  space,   with  division  of  fourth, 

fifth  and  sixth  cartilages  at  their  sternal  attachments,  forming  two  triangular 

flaps.     Pleura  freely  opened. 

Hill  -  gives  seventeen  cases  of  heart  suture,  seven  of  which,  or  41  per  cent., 
recovered.  Dr.  Charles  Peck  ^  in  a  most  interesting  paper  on  the  operative 
treatment  of  heart  wounds  has  collected  158  cases  of  sutured  heart  wounds 
of  which  58  recovered. 

A  large  proportion  of  wounds  of  the  heart  are  either  immediately  or 
very  quickly  fatal,  but  a  certain  number  survive  long  enough  for  operative 
treatment,  which  alone  offers  a  chance  of  recovery.  Wounds  of  the  heart 
may  be  either  penetrating  or  non-penetrating — the  great  majority  of 
them  belonging  to  the  former  class.  The  ventricles  are  more  often  injured 
than  the  aiu-icles,  and  the  right  ventricle  more  commonly  than  the  left. 
It  has  been  sho^^^l,  both  by  experiments  upon  animals  and  by  the  opera- 
tions that  have  been  performed  on  man,  that  interrupted  sutures,  passed 
deeply  into  the  myo-cardium,  produce  perfect  hsemostasis.  The  sutures 
should  be  passed  during  diastole,  since  the  heart  sinks  back  during  systole 
into  the  pericardial  space.  Wounds  of  the  auricle  are  stated  to  be  more 
serious  than  those  of  the  ventricle,  while  the  prognosis  is  stated  to  be 
better  in  the  case  of  operations  for  bullet  wounds  than  for  stabs. 

1  Revue  de  Chirurgie,  1891,  Nos.  1,  2,  6. 

2  New  York  Med.  Record,  December  15,  1900. 

3  Ann.  of  Surg.,  1909,  vol.  xl,  p.  100. 


SUTURE  OF  WOUNDS  OF  THE  HEART 


709 


After  wounds  of  the  heart  death  may  occur  from  external  liaemorrhage, 
or  from  internal  bleeding,  e.g.  into  the  pleural  cavity  with  little  or  no 
external  hsomorrhagc.  A  fatal  result  may  also  be  brought  about  from 
the  so-called  "  heart  tamponade,"  that  is  distension  of  the  pericardium 
with  blood,  so  that  the  large  veins  and  the  auricles  are  compressed,  pre- 
venting entrance  of  blood  to  the  ventricles.  It  is  in  this  latter  group  of 
cases  that  operative  treatment  is  most  likely  to  be  successful.^ 


% 


Fig.  325.  Quadrangular  flap  of  third,  fourth  and  fifth  ribs,  hinge  external. 
The  drawing  represents  in  addition  the  removal  of  parts  of  the  sternum,  addi- 
tional transverse  incision  in  pericardium,  accidental  tear  of  pleura,  and  wound 
of  auricle — author's  case.  ^Vith  care  in  elevating  the  flap,  the  pleura  may  be 
jjushed  back  without  injury. 

Generally  speaking,  an  anaesthetic  should  be  given,  though  in  several  of 
Dr.  Peck's  collected  cases  it  is  noted  that  either  local  anaesthesia  or  no 
anaesthetic  was  employed. 

Reference  to  Dr.  Peck's  tabulated  list  of  cases  shows  the  frequency  of 
septic  comphcations  such  as  pericarditis,  pleurisy,  empyema,  and  wound 
infection.  Hence,  though  rapidity  is  essential,  all  possible  aseptic  pre- 
cautions should  be  taken.  It  is  also  desirable  to  commence  infusion 
during  the  operation. 

Exposure  of  the  heart.  Rapid  and  effective  exposure  are  necessary. 
The  following  methods  have  been  employed  :  of  these  the  first  and  third 
would  seem  to  be  the  most  satisfactory. 

One  of  the  dangers  to  be  anticipated  is  an  extensive  pneumothorax 

1  In  the  series  of  cases  collected  by  Dr.  Peck  there  were  69  of  the  right  ventricle  with 
48  deaths  (69-6  per  cent) ;  74  of  the  left  ventricle  with  45  deaths  (60-8  per  cent.) ;  5  of 
the  left  auricle  with  2  deaths  (40  per  cent.)  ;  6  of  the  right  auricle  with  2  deaths  (33-3 
per  cent.)  ;  and  7  miscellaneous  cases  with  5  deaths  (71-5  per  cent. )  ;  a  total  of  102  deaths 
and  58  recoveries  (63'7  percent.).  Dr.  G.  W.  Brewster  and  Dr.  S.  Robinson  have  pub- 
lished a  paper  (/I  wti.  Surg.,  1911,  vol.  liii),  on  "  The  Operative  Treatment  of  Wounds  of  the 
Heart."  A  large  number  of  cases  have  been  collected,  and  there  will  also  be  found  much 
useful  information  about  the  diagnosis,  indications  for  operation  and  operative  technique. 


800  OPERATIONS  ON  THE  THORAX 

with  collapse  of  the  lung,  since  the  pleura  may  have  been  damaged  by  the 
original  injury,  or  may  be  more  or  less  extensively  opened  in  the  course 
of  the  operation.  On  this  accomit  the  intratracheal  method  of  inducing 
anaesthesia  should,  if  possible,  be  employed,  or  one  of  the  other  methods 
mentioned  at  pp.  780,  781. 

(1)  A  quadrilateral  flap  with  the  hinge  external  (Figs.  322, 325).  The  flap 
is  marked  out  by  horizontal  incisions  along  the  second  and  fifth  inter- 
costal spaces.  These  are  joined  at  their  inner  ends  by  a  vertical  incision  just 
internal  to  the  margin  of  the  sternum.  The  third,  fourth,  fifth,  and  sixth 
costal  cartilages  are  divided  at  their  sternal  attachments,  and  the  flap  com- 
posed of  soft  parts  and  costal  cartilages  is  carefully  raised.  If  the  pleura  is 
uninjured  it  is  carefully  pushed  outwards  away  from  the  deep  surface  of  the 
flap.  The  cartilages  are  partly  cut  through  with  bone-forceps  near  the 
costo-chondral  jmiction  and  the  flap  is  then  turned  outwards.  The 
pericardium  can  then  be  freely  incised  and  the  heart  exposed.  This 
method  has  the  advantage  of  affording  a  good  and  rapid  exposure  of  the 
heart.     Injury  to  the  pleura  is  easily  avoided. 

(2)  A  quadrilateral  flap  with  the  hinge  internal.  Here  two  horizontal 
incisions,  similar  to  those  described  above,  are  made,  and  their  outer 
extremities  are  joined  by  a  vertical  cut.  The  costal  cartilages  are  then 
divided  with  bone-forceps  and  the  flap  of  costal  cartilages  and  soft  parts 
is  turned  inwards.  The  pleura  will  probably  be  extensively  torn  and  the 
exposure  of  the  heart  is  not  as  good  as  in  the  first  method.  In  a  few 
cases  the  sternum  has  been  transversely  divided  at  the  level  of  the  upper 
and  lower  horizontal  incisions  and  has  been  included  in  the  flap.  Though 
this  gives  a  good  view  it  adds  to  the  length  and  severity  of  the  operation 
and  there  is  a  danger  of  also  wounding  the  right  pleura. 

(3)  Bi/  a  long  incision  along  the  fourth  or  fifth  intercostal  spaces  with 
division  of  one  or  more  costal  cartilages  at  their  sternal  attachment  (Fig.  324). 
Ample  room  may  be  obtained  by  strong  retraction  of  the  divided  costal 
cartilages.  This  method  has  the  advantages  of  rapidity  and  simplicity, 
though  in  all  probability  the  pleura  will  be  widely  opened. 

When  the  pericardium  is  opened  the  effused  blood,  which  is  under 
considerable  tension,  will  escape,  and  in  some  cases  this  has  been  followed 
by  an  immediate  improvement  in  the  pulse.  Clots  are  gently  wiped 
away  with  gauze  ■v\Tung  out  of  sterile  sahne  solution.  Bleeding  may  be 
temporarily  checked  by  the  introduction  of  one  or  more  fingers  into  the 
wound  in  the  heart  :  in  some  cases  the  introduction  of  two  or  three 
fingers  of  the  left  hand,  or  that  of  an  assistant,  behind  the  heart  will  help 
to  steady  it  and  draw  it  forward  into  the  wound.  Dr.  Peck  recommends 
that  one  or  two  sutures  should  be  quickly  placed  to  co-apt  the  edges  of 
the  wo  mid,  to  partly  check  the  haemorrhage,  while  others  are  subsequently 
added  more  dehberately  to  complete  the  control.  He  also  advises  that 
the  end  of  the  first  suture  should  be  left  long  to  steady  the  heart  for 
the  placing  of  others.  A  small  curved  intestinal  needle  should  be 
used,  and  though  the  stitch  should  pass  deeply  into  the  cardiac 
muscle  the  endocardium  should  not  be  included.  Either  fine  catgut 
or  silk  may  be  used :  interrupted,  continuous,  or  mattress  sutures 
may  be  employed. 

Some  irregularity  of  the  heart  has  usually  been  noticed  during  the 
manipulation  and  the  passage  of  the  sutures,  but  it  soon  disappears. 
Should  the  heart-beat  cease  in  the  com-se  of  the  operation  direct  massage 
should  be  employed. 


SUTURE  OF  WOUNDS  OF  THE  HEART  801 

Closure  of  the  Wound  and  Drainage.  The  desirability  of  drainage 
in  tiiesc  cases  is  still  an  open  question.  Dr.  Peck  says,  "  unquesti(jiiably 
the  use  of  drainage  has  in  some  instances  favoured  the  development  of 
secondary  infection  of  pleura  or  pericardium,  and  I  believe  that  chjsure 
of  both  witliout  drainage,  in  conjunction  with  systematic  careful  prepara- 
tion, is  as  a  rule  the  best  proceeding." 

If  the  pleura  contain  much  blood  and  has  been  widely  opened,  drainage 
of  the  pleura  alone  may  be  indicated  and  should  preferably  be  made 
posteriorly  by  separate  rib  resection  as  in  empyema. 

Dr.  Peck  records  the  following  case  on  wliich  he  himself  operated.  A  coloured 
girl,  24  years  of  age,  was  brought  to  hospital,  having  been  stabbed  in  the  chest  with  a 
pocket-knife  about  thirty  minutes  before.  There  was  no  radial  pulse,  but  a  weak 
pulse  could  be  felt  high  in  the  brachial  artery  and  the  carotids.  The  heart  sounds 
could  not  be  heard.  Respiration  was  faint  and  shallow,  extremities  cold,  and  the 
I)atient  in  a  condition  of  profound  shock.  There  was  a  stab  wound  at  the  left  border 
of  the  sternum  over  the  third  costal  cartilage,  which  bled  very  little.  Chloroform 
and  ether  were  at  once  administered,  and  a  quadrangular  flap  with  its  base  external, 
including  the  third,  fourth  and  fifth  cartilages,  was  rapidly  cut.  The  internal  mam- 
mary vessels  wore  ligatured  above  and  below.  The  pleura  was  pushed  away  from  its 
deep  sm-face  with  gauze  pads  without  being  injured.  There  was  a  stab  wound  in  the 
pericardium  so  close  to  the  edge  of  the  sternum  that  removal  of  a  portion  of  that 
bone  was  necessary.  Intrapericardial  tension  was  so  great  that  the  heart-beat 
could  not  be  felt  even  with  the  finger  directly  on  the  stab.  The  pericardium  was 
ojiened  by  a  three-inch  longitudinal  incision,  one  inch  to  the  left  of  the  stab  wound, 
and  about  300  cc.  of  dark  blood  escaped  with  a  gush,  the  ansesthetist  noticing  im- 
mediate retmn  of  the  radial  pulse.  The  pericardium  was  more  freely  opened  by  a 
transverse  cut  and  the  heart  lifted  forward  and  slightly  rotated  to  the  left  with  the 
left  hand.  A  wound  of  the  right  auricle  about  1  cm.  long  and  2  cm.  above  the 
auriculo  ventricular  groove  was  thus  brought  into  view.  A  suture  of  fine  catgut  was 
passed  on  a  curved  intestinal  needle  and  tied,  the  ends  left  long,  helping  to  steady  the 
heart  while  three  similar  sutures  were  inserted,  completely  controlling  the  bleeding. 
An  effort  was  made  to  avoid  piercing  the  endocardium,  but  whether  successful  or 
not,  in  the  thin  am-icular  wall,  is  doubtful.  The  pericardium  was  emptied  of  blood 
and  the  wound  closed  without  drainage.  For  the  first  six  or  seven  days  there  were 
signs  of  a  mild  pleurisy,  but  at  the  end  of  the  second  week  the  signs  had  nearly  dis- 
appeared, and  pulse  and  temperature  were  approaching  the  normal.  The  wound 
healed  by  primary  union  and  she  was  discharged  twenty-four  days  after  the  opera- 
tion.    The  heart  sounds  were  normal  and  the  signs  of  i:)leurisy  had  disappeared. 

The  following  account  of  a  successful  case  of  a  stab-wound  dealt  with  by  Parroz- 
zani,  is  given  by  Hill  ^ :  "  Parrozzani,  in  1897,  operated  upon  a  young  man  who  had 
been  stabbed.  Five  hours  after  the  injury  he  was  carried  to  the  hospital,  where  it 
was  found  that  the  dagger  had  entered  the  seventh  left  intercostal  space  in  the  mid- 
axillary  line.  His  general  condition  was  extremely  grave,  heart-beats  and  pulse 
almost  imperceptible,  and  respiration  rapid  and  superficial.  Immediate  intervention 
without  an  anaesthetic  was  decided  upon.  An  incision  through  the  soft  parts,  an 
inch  and  a  quarter  from  the  margin  of  the  sternum,  in  the  fourth  intercostal  space, 
was  carried  for  a  distance  of  five  inches  and  a  half,  then  it  descended  vertically  in  the 
mid-axillary  line  as  far  as  the  superior  margin  of  the  ninth  rib.  The  fifth,  sixth, 
seventh  and  eighth  ribs  were  cut  through  in  the  mid-axillary  line  with  the  pleura. 
The  musculo -osseous  flap  was  raised,  with  the  cartilages  of  the  ribs  acting  as  the 
hinges.  The  pleural  cavity  was  filled  with  blood,  and  an  opening  one  inch  in  length 
was  found  in  the  pericardium,  which  was  subsequently  enlarged  to  two  inches  and  a 
half.  There  was  very  little  blood  in  the  pericardium,  because  the  injury  was  in  the 
most  dependent  part,  and  the  blood  readily  escaped  into  the  pleural  cavity.  A  wound 
in  the  apex  was  observed,  three  quarters  of  an  inch  in  length,  through  which  the  little 
finger  was  passed  into  the  left  ventricle.  This  served  the  double  purpose  of  checking 
the  haemorrhage  and  steadying  the  organ  for  the  introduction  of  the  sutures.  Four 
deep  silk  stitches  were  used,  not  touching  the  endocardium.  Passing  the  needle 
caused  violent  throbbing  of  the  heart.  The  pleura  and  pericardium' were  thoroughly 
cleansed,  and  the  flap  was  sutvu-ed  in  position.     Stimulating  hypodermic  injections 

1  Loc.  supra  cit. 
SURGERY    I  51 


802  OPERATIONS  ON  THE  THORAX 

were  used,  and  hypodermoclysis  and  auto -transfusion  practised.     The  operation 
lasted  one  hotir  and  a  quarter.     Recovery  resulted. " 

Hill,  of  Montgomery,  Alaska,  records  ^  a  successful  case  of  suture  of  a  stab  wound  of 
the  left  ventricle  in  a  negro,  set.  13.  The  operation  was  performed  eight  hours  after 
the  injury,  under  chloroform,  the  wound  being  closed  with  one  catgut  suture.  The 
jjatient  made  a  good  recovery. 

The  following  are  the  conclusions  drawn  by  Hill,  together  with  others  from  the 
different  published  cases:  (1)  As  the  operation  has  reduced  the  mortality  from 
over  90  per  cent,  to  about  63  per  cent.,  every  wound  of  the  heart  should  be  operated 
upon  immediately.  (2)  Unless  the  patient  is  unconsicous,  and  corneal  reflex 
abolished,  an  an;i3sthetic,  preferably  chloroform,  should  be  given.  Struggling  is 
liable  to  cause  detachment  of  clot,  and  fresh  hoemorrhage.  (3)  The  wound  should 
never  be  probed,  for  fear  of  injiury  to  the  myocardium.  (4)  Rotter's  flap-operation 
(p.  800)  renders  access  to  the  heart  extremely  easy,  and  should  usually  be  adopted. 
(5)  Before  sutures  are  introduced  the  heart  should  be  steadied  either  by  lifting  up 
with  the  hand,  or  if  the  wound  be  large  enough,  by  introducing  the  little  finger  into  it, 
which  serves  the  fiu-ther  purpose  of  stopping  the  bleeding.  (6)  The  sutures  should  be 
of  reliable  catgut  or  fine  silk,  always  interrupted  and  introduced  with  the  smallest 
possible  needle.  They  should  not  involve  the  endocardium,  and  as  few  as  possible 
should  be  used  consistent  with  safety,  as  they  cause  a  degeneration  of  the  muscle, 
with  a  tendency  to  dilatation  and  rupture.  (7)  Suturing  or  any  other  part  of  the 
technique  should  not  be  discontinued  because  the  heart  has  ceased  to  pulsate, 
especially  if  respiration  continues.  (8)  Forcible  divulsion  of  the  sphincter  and 
squeezing  the  heart  have  been  recommended  as  means  of  resuscitation  ;  how  far 
they  are  beneficial  is  another  matter.  (9)  The  pericardium  should  be  cleansed  by 
sponging  out,  no  fluid  being  poiued  into  the  sac.  (10)  The  advice  to  close  the 
pericardium  does  not  seem  judicious. 

In  the  majority  of  cases  the  wound  was  situated  in  front,  and  the  pericardium 
was  usually  found  to  be  distended  with  blood.  The  length  of  time  between  the  injury 
and  the  operation  has  varied  considerably  :  in  a  successful  case  by  Rehn  it  was  more 
than  twenty-four  hours  ;  in  a  case  of  Giordano's,  in  which  the  left  am^icle  was 
sutured,  the  operation  was  performed  within  half  an  hour  of  the  receipt  of  the  injury. 
In  the  majority  of  cases  some  hours  elapsed  before  the  operation. 

Bullet  Wounds  of  the  Heart.  These  are  probably  less  frequently 
suitable  for  operation  than  stab  wounds,  owing  to  the  likelihood  of 
co-existent  injury  to  large  blood-vessels  or  to  other  important  thoracic 
or  abdominal  viscera.  That  many  are,  however,  in  a  state  to  recover 
after  operative  treatment  is  shown  by  a  reference  to  Dr.  Peck's  list  of  cases. 
This  contains  twenty  bullet  wounds  treated  by  operation,  of  which  no 
fewer  than  nine  recovered.     In  all  cases  the  ventricles  were  injured. 

Major  Holt  ^  says  :  "  Wounds  of  the  heart  and  the  pericardium  were 
so  seldom  met  with  in  the  hospitals  that  the  inference  is  inevitable  that 
such  injuries  caused  immediate  or  very  early  death  upon  the  field  ;  but 
fatal  wounds  of  the  pericardium  were  not  all  immediately  lethal.  ...  In 
not  a  few  instances  the  heart,  from  the  absence  of  symptoms,  must  be 
presumed  to  have  escaped  injury,  though  from  the  anatomical  tract  of  the 
bullet  one  would  infer  that  a  lesion  must  have  occurred,  unless  it  be 
admitted  that  the  heart  may  be  womided  without  any  obvious  ill  effects." 
The  following  striking  case  of  double  gunshot  wound  of  the  heart  was 
operated  upon  by  M.  Launay,  and  reported  by  M.  Peyrot.^ 

The  operation  took  place  about  three  hours  after  the  injury.  The  pulse  was  now 
uncountable,  but  the  patient  was  able  to  give  an  account  of  the  injury.  The  external 
wound  was  at  the  nipple,  and  from  it  haemorrhage  was  small  and  intermittent.  The 
heart  sounds  were  indistinct,  a  splashing  sound  could  be  heard,  and  there  was 
evidence  of  blood  in  the  pleura.  Chloroform  having  been  administered,  an  osteo- 
plastic flap  was  turned  back  with  parts  of  the  fourth,  fifth,  and  sixth  ribs.     Complete 

1  New  York  Med.  Rec,  1900,  vol.  Iviii.  p.  921. 

2  Surgical  Cases  Noted  in  the  Sovth  African  War. 

3  Bull,  de  I' Acad,  de  Med.,  January  29,  1902. 


CARDIOLYSIS  803 

pneumothorax  was  present,  with  a  largo  amount  of  blood  in  the  pleural  sac.  The 
thin  eclf^e  of  the  lung  was  {)erf()rated  by  the  bullet.  From  a  small  wound  in  the 
pericardium  the  l)l()()d  llowed  slow!}'  and  persistently.  The  wound  i)eing  enlarged,  one 
was  found  in  the  left  ventricle,  2  cm.  from  the  a])e.\'.  From  this  bleeding  took  j)lace, 
only  in  diastole.  The  wound  was  easily  closed  with  a  catgutsuture.  K.xamination 
of  the  back  of  the  heart  was  somewhat  diflicult,  but  the  wound  of  the  exit  was  found 
when  the  tinger  was  i)laced  under  the  apex,  and  the  heart  tilted  up.  It  was  situated 
near  the  base  of  the  le/t  ventricle.  A  traction-suture  was  placed  in  the  heart  nuiscio 
in  order  to  give  access  to  this  wound,  which  was  closed  with  two  catgut  sutures.  The 
pericardium  was  cleared  of  clots  and  partially  closed.  The  pleura  was  treated  in  the 
same  way.  During  the  operation  two  litres  of  salt  solution  were  injected  into  the 
subcutaneous  tissue.  The  operation  lasted  about  thirty-five  minutes.  The  pulse 
was  luicountable  throughout,  but  the  heart  had  never  ceased  to  boat.  The  next 
day  the  })atient  was  in  good  conrlit  ion.  P.  1(X)  to  120,  of  good  volume.  The  drains 
were  removed  forty-eight  hours  after  the  operation.  The  patient  made  an  excellent 
recovery. 

CARDIOLYSIS ' 

This  operation,  which  was  first  suggested  by  Braiier  in  1902,  is 
performed  in  certain  cases  of  adherent  pericardium  where  the  action 
of  the  heart  is  embarrassed  by  fixation  to  the  surrounding  parts. 
No  extensive  separation  of  adhesions  is  attempted,  but  by  removal  of 
the  overlying  ribs  and  costal  cartilages  the  precordial  part  of  the 
chest  wall  is  made  more  flexible  and  yielding  in  the  hope  that  by  this 
means  the  strain  on  the  heart  may  be  lessened. 

Indications  for  Operation.  Needless  to  say  the  cases  must  be  care- 
fully selected,  and  the  operation  only  performed  after  consultation  with 
a  physician  after  watching  thoroughly  the  effect  of  rest  and  medical 
treatment.  In  the  words  of  Dr.  Poynton  and  Mr,  Trotter,  "  Clearly,  if 
relief  of  the  overloading  of  the  heart  is  to  be  obtained  by  mobilisation 
of  the  precordium,  the  capacity  of  the  heart  to  recover  must  be  de- 
monstrable when  the  overloading  is  relieved  by  rest.  It  would  seem, 
then,  that  the  most  suitable  cases  are  those  in  which  the  heart  is  just 
inadequate  for  active  life." 

Operation.  This  is  simple  and  can  be  rapidly  carried  out.  A 
horseshoe-shaped  flap  is  cut  by  an  incision  commencing  just  internal  to 
the  left  margin  of  the  sternum  opposite  the  third  costal  cartilage.  This 
is  continued  downwards  to  the  level  of  the  seventh  costal,  curving  out- 
wards along  this,  and  then  upwards  to  terminate  at  the  third  costal 
cartilage  in  the  region  of  the  nipple  line.  All  soft  parts  superficial  to 
the  costal  cartilages  are  included  in  the  flap  which  is  turned  upwards. 
Three  or  four  inches  of  the  fourth  and  fifth  costal  arches  and,  if  necessary, 
of  the  third  and  sixth  as  well,  are  then  removed  in  the  manner  already 
described  (p.  766).  No  attempt  should  be  made  to  remove  the  internal 
periosteum,  as  there  is  little  if  any  tendency  for  this  to  form  new  bone, 
and  any  endeavour  to  do  so  may  result  in  damage  to  the  pleura  or  to  the 
cardiac  muscle  :  the  external  periosteum  should  not,  however,  be  preserved. 
After  all  haemorrhage  has  been  stopped  the  wound  is  closed  without 
drainage.  The  results  of  the  operation  appear  to  have  been  satisfactory, 
though  a  large  number  of  cases  have  not  been  recorded.  Dr.  Poynton 
and  Mr.  Trotter  mention  a  paper  by  Ernst  Venus  ^  in  which  seventeen 
cases  are  described  :   no  death  is  recorded  as  the  result  of  the  operation 

i  "  See  The  Operation  of  Cardiolysis  illustrated  by  a  Case,"  by  Dr.  F.  J.  Poynton  and 
Mr.  Wilfred  Trotter  {Proc.  Roy.,  Soc.  Med.,  Clin.  Sec,  June  1909,  p.  243). 
2  Centralbl.  /.  die  Grenzgebiete,  1908,  xi,  p.  401. 


804        OPERATIONS  ON  THE  THORAX 

and  the  results  appear  on  the  whole  to  have  been  very  good.     The 
following  is  an  account  of  Dr.  Po}Titon  and  Mr.  Trotter's  case. 

A  male  patient,  aged  16  years,  was  admitted  under  Sir  Thomas  Barlow  in 
1908  for  cedema  of  the  legs  and  face  of  three  months  duration.  He  had  steadily 
got  worse  and  was  unable  to  follow  his  occupation.  On  admission  there  was  some 
cyanosis  and  the  evening  temperature  usually  rose  to  99  deg.  The  pulse,  88,  was 
of  low  tension  and  small  calibre,  although  regular.  The  veins  in  the  neck  were  fuU 
and  pulsated  visibly.  The  impulse  was  diffuse  extending  from  the  third  to  the  sixth 
intercostal  space.  Change  of  posture  made  no  alteration  in  the  position  of  the 
impulse.  There  was  great  systolic  retraction  over  this  area  with  a  powerful  ven- 
tricular beat.  On  auscultation  there  was  a  triple  rhythm  but  no  murmur  was 
audible.  The  liver  and  spleen  were  sUghtly  enlarged  and  the  urine  was  free  from 
albumin.  A  diagnosis  of  adherent  pericardium  with  mediastinitis,  left  pleurisy 
and  perihepatitis  was  made.  He  rapidly  improved,  and  the  cedema  had  disappeared 
in  three  weeks.  After  leavmg  the  hospital  the  symptoms  at  once  returned,  and  two 
weeks  later  he  was  re-admitted  under  Dr.  Poynton,  his  condition  bemg  then  worse 
than  when  first  admitted.  He  again  rapidly  improved  with  rest,  but  the  symptoms 
immediately  reappeared  after  any  exertion.  Mr.  Trotter  operated  on  October  5.  A 
semicircular  flap  was  marked  out  in  the  precordial  region  and  was  reflected  upwards. 
It  included  aU  structures  anterior  to  the  ribs.  The  fourth  and  fifth  ribs  were  those 
which  seemed  to  move  most  with  the  movements  of  the  heart  and  three  or  four  inches 
of  each  were  removed  subperiosteally.  The  pericardium  was  much  thickened  and 
adherent  to  the  chest  wall  over  the  region  exposed.  After  removal  of  the  ribs  the 
structures  over  the  heart  accommodated  themselves  far  more  easily  to  the  cardiac 
movements.  The  flap  was  replaced  and  the  wound  completely  closed.  No  exercise 
of  any  sort  except  massage  was  allowed  for  three  months,  and  since  then  it  has  been 
graduated.  "  At  the  present  time  we  believe  that  the  operation  has  been  justified 
by  the  result  even  if  the  improvement  goes  no  further  ;  for  the  patient  can  now  go 
for  a  walk  extending  over  half  an  hour,  and  in  the  evening  there  is  only  slight  pitting 
over  the  ankles.  He  looks  more  healthy  and  is  less  breathless.  His  pulse  has  more 
power  and  is  not  so  small  in  size.  The  size  of  the  heart  is  somewhat  diminished  ; 
the  liver  and  spleen  are  smaller,  and  the  veins  in  the  neck  are  greatly  reduced  in 
size."  The  writers  point  out  the  difficulty  in  estimating  the  condition  of  the  myo- 
cardium and  the  importance  of  this  in  the  prognosis. 

Precordial  thoracostomy  has  also  been  performed  in  cases  of  valvular 
disease  of  the  heart  resulting  in  cardiac  hypertrophy,  ^vith  much  heaving 
of  the  ribs  and  costal  cartilages,  with  the  object  of  relieving  the  enlarged 
heart  of  the  labour  of  raising  the  chest  wall.  Dr.  Alexander  Morison 
has  recorded  such  a  case  which  was  attended  with  a  certain  degree  of 
success.-^ 

^  Proc.  Roy.  Soc,  Med.,  Clin.  Sec,  January  1915,  p.  21. 


PART  IV^ 

OPKIJA  I  lOXS  ON  THi:   LOWKPt 
EXTPJLMITV 

CHAPTER  XXXVIII 

OPERATIONS   ON  THE  HIP-JOINT 

AMPUTATION  AT  THE  HIP-JOINT.  EXCISION  OF  THE  HIP-JOINT. 
OPERATIVE  TREATMENT  OF  HIP-DISEASE.  INCISION  OF 
THE  JOINT 

AMPUTATION  AT  THE  HIP-JOINT 

The  numerous  methods  which  have  been  described  are  easily  simpH- 
fied.  The  indications  for  this  operation  are  tuberculous  disease,  and, 
occasionally,  osteo-myeUtis,  growths,  and  injury.  For  tuberculous  and 
other  infective  disease  the  method  of  Furneaux  Jordan,  performed  in 
two  stages  as  advised  by  Sir  H.  Howse,  for  growths  or  injury  either 
the  methods  of  Wyeth  or  Lynn  Thomas,  or,  where  these  are  not  available, 
some  modification  of  lateral  skin- flaps,  and  division  of  the  muscles 
high  up  should  be  adopted.  While  a  few  others  will  be  described, 
the  above  will  suffice  for  all  practical  purposes. 

METHODS.  I.  Furneaux  Jordan's,  performed  in  two  stages  (Sir  H. 
Howse).  II.  Lateral  Flaps.  III.  Modified  Lateral — viz.  Antero-internal 
and  Postero-external — Flaps. 

Methods  of  Controlling  Haemorrhage  during  Amputation  at  the  Hip- 
Joint.  (1)  Elastic  Compression.  This  may  be  apphed  at  the  junction 
of  the  hmb  and  trunk,  without  interfering  with  the  operator,  by  the  follow- 
ing method  :  While  the  patient  is  passing  under  the  anaesthetic,  the 
limb  is  emptied  of  blood  by  elevation  ;  the  patient  is  then  rolled  over  on 
to  his  sound  side,  and  a  strong  fiat  rubber  tourniquet,  with  slotted  metal 
grip,  is  apphed  between  the  thigh  and  trunk,  passing  between  the  anus  and 
the  tuber  ischii  over  a  narrow  pad  of  gauze.  A  sterihsed  white  roller 
bandage,  of  appropriate  size,  is  then  laid  over  the  termination  of  the 
external  ihac  artery.  The  ends  of  the  tourniquet  are  firmly  and  steadily 
drawn  in  a  direction  upwards  and  outwards,  one  in  front  of  the  groin  and 
one  over  the  buttock,  to  a  point  above  the  centre  of  the  ihac  crest,  suffi- 
cient tightness  being  employed  to  stop  all  pulsation  in  the  femorals  or 
tibials  when  the  tourniquet  is  locked.  The  front  part  of  the  band  passing 
over  the  bandage  occludes  the  external  ihac  and  runs  parallel  to  and 
above  Poupart's  hgament.  The  posterior  part  runs  across  the  great 
sacro-sciatic  notch  and  controls  the  branches  of  the  internal  ihac. 

805 


806       OPERATIONS  ON  THE  LOWER  EXTREMITY 

To  prevent  the  bands  slipping  down  in  the  way  of  the  surgeon,  two 
loops  of  tape  or  bandage  may  be  thus  employed  :  each,  about  two  feet  in 
length,  is  placed  longitudinally,  before  the  elastic  band  is  applied,  the 
one  over  the  groin,  the  other  well  behind  the  great  trochanter,  the 
centre  of  each  being  where  the  elastic  band  will  go.  When  the  band 
has  been  applied,  these  form  loops  by  means  of  which  the  band  is  kept 
well  out  of  the  operator's  way,  both  at  Poupart's  ligament  and  behind 
the  great  trochanter.^ 

(2)  Wyeth's  Bloodless  Method  of  Amputation  at  the  Hip-Joint.  I  have 
mentioned  this  in  the  account  of  amputation  at  the  shoulder-joint 
already  (p.  201).  It  has  been  largely  used  by  American  surgeons,  and 
has  given  excellent  results.  Amongst  these  Dr.  Hancock,  of  Georgia, 
records  ^  a  successful  amputation  at  the  hip- joint,  and  one  at  the  shoulder 
and  hip- joints,  for  railway  accidents.     Primary  shock  was  absent  in  each 


Fig.  326.     Wyeth's  bloodless  method  of  amputation  at  the  hip-joint. 

case  to  a  very  unusual  degree.  The  pins  must  be  passed  with  exactness, 
and,  unless  of  sufficient  strength,  will  certainly  bend  under  the  strain  of  the 
cord  above.  Their  use  is  thus  described:^  "The  hmb  to  be  ampu- 
tated should  be  emptied  of  blood  by  elevation  of  the  foot,  and  by  the 
application  of  the  Esmarch  bandage,  commencing  at  the  toes.  Under 
certain  conditions,  the  bandage  can  be  only  partially  apphed.  When  a 
growth  exists,  or  when  septic  infiltration  is  present,  pressure  should  be 
exercised  only  to  within  five  inches  of  the  diseased  portion,  for  fear  of 
driving  diseased  material  into  the  vessels.  After  injuries  wdth  great 
destruction,  crushing  or  pulpefaction,  one  must  generally  trust  to  eleva- 
tion, as  the  Esmarch  bandage  cannot  always  be  applied.  While  the 
member  is  elevated,  and  before  the  Esmarch  bandage  is  removed,  the 
rubber-tubing  constrictor  is  apphed.  The  object  of  this  constriction 
is  the  occlusion  of  every  vessel  above  the  level  of  the  hip-joint,  permitting 
the  disarticulation  to  be  completed,  and  the  vessels  secured  without 
haemorrhage  and  before  the  tourniquet  is  removed.     To  prevent  any 


^  Jordan  Lloyd,  Lancet,  1883,  vol.  i,  p.  897. 
3  Ann.  of  Surg.,  1897,  vol.  i,  p.  132. 


2  Ann  of  Surg.,  July  1906,  p.  98. 


OPERATIONS  ON  THE  HIP- JOINT 


807 


possibility  of  the  touiniciuet  slipping,  I  employ  two  large  steel  needles 
or  skewers,  three-sixteenths  of  an  inch  in  diameter  and  ten  inches  long, 
one  of  which  is  introduced  one-fourth  of  an  inch  below  the  anterior 
superior  spine  of  the  ilium  and  slightly  to  the  inner  side  of  this  prominence, 
and  is  niade  to  traverse  superficially  for  about  three  inches  the  muscles 
and  fascia  on  the  outer  side  of  the  hip,  emerging  on  a  level  with  the  point 
of  entrance  (Fig.  32(i).  The  point  of  the  second  needle  is  thrust  through 
the  skin  and  tendon  of  origin  of  the  adductor  longus  muscle  half  an  inch 
below  the  crotch,  the  point  emerging  an  inch  below  the  tuber  ischii.  The 
points  should  be  shielded  at  once  with  cork  to  prevent  injury  to  the  hands 
of  the  operator.  No  vessels  are  endangered  by  these  skewers.  A  mat  or 
compress  of  sterile  gauze,  about  two  inches  thick  and  four  inches  square, 
is  laid  over  the  femoral  artery  and  vein  as  they  cross  the  brim  of  the 
pelvis;  over  this  a  piece  of  strong  white  rubber  tubing,  half  an  inch 
in  diameter  when  unstretched,  and  long  enough  when  in  position  to  go 
five  or  six  times  around  the  thigh,  is  now  wound  very  tightly  around 
and  above  the  fixation- needles  and  tied.  Except  the  small  quantity 
of  blood  between  the  hmit  of  the  Esmarch  bandage  and  the  constricting 
tube,  the  extremity  is  bloodless  and  wall  remain  so." 


Eia.  327.     Lynn  Thomas's  forceps-tourniquet.^ 

The  Esmarch  bandage  is  now  removed  and  a  circular  incision  is 
made  six  inches  below  the  tourniquet  joined  by  a  longitudinal  incision 
commencing  at  the  tourniquet  and  passing  over  the  trochanter  major. 
A  cufl:  including  the  subcutaneous  tissue  down  to  the  deep  fascia  is 
dissected  off  to  the  level  of  the  trochanter  minor.  About  this  level  the 
remaining  soft  parts  are  divided  down  to  the  bone  with  a  circular  cut 
and  are  rapidly  dissected  from  the  femur.  The  vessels  should  now  be 
searched  for  and  both  arteries  and  veins  securely  tied.  It  is  advisable 
to  tie  all  the  vessels  that  can  be  seen  at  this  stage,  i.e.  before  disarticu- 
lation, to  prevent  their  retraction.  The  muscular  attachments  are 
separated  so  that  the  capsular  ligament  may  be  exposed  and  divided. 
The  Hnib  being  used  as  a  lever,  the  thigh  is  forcibly  elevated,  abducted 
and  adducted,  letting  in  air  and  rupturing  the  ligamentum  teres. ^  The 
tourniquet  may  now  be  carefully  loosened  and  all  bleeding-points  at  once 
seized.  In  cases  of  great  exhaustion  Dr.  Wyeth  would  do  the  operation 
in  two  stages,  securing  the  vessels,  dividing  the  femur  below  the  lesser 
trochanter,  closing  the  wound  and  turning  out  the  head  of  the  femur  about 
two  weeks  later.  While  the  633  cases  of  amputation  at  the  hip- joint 
collected  by  Ashurst  showed  a  mortahty  of  64*1  per  cent.,  of  69  cases  per- 
formed in  this  manner  only  11  died — a  mortality  of  15'9. 

^  The  most  recent  form  of  his  forceps-tourniquet,  and  the  method  of  carrying  it  in  field- 
service  are  figured  by  Mr.  Lynn  Thomas  {Brit.  Med.  Jowrn.,  October  1, 1904). 

^  ^Vhere  in  cases  of  disease,  the  femur  gives  way  high  up,  or  whei'c  it  is  extensively 
crushed,  the  required  traction  and  leverage  will  be  afforded  by  tying  a  piece  of  sterile 
gauze  round  the  neck  (Hancock,  loc  supra  cit.),  if  no  appropriate  forceps  are  at  hand. 


808       OPERATIONS  ON  THE  LOWER  EXTREMITY 

(3)  Forceps-tourniquet  of  Lynn  Thomas  (Figs.  327  and  328).^  An 
account  of  this  instrument,  with  its  advantages,  will  be  found  in  the 
Lancet,  April  23,  1898,  Brit.  Med.  Journ.,  April  20,  1901,  and  Oct.  1,  1904. 
Fig.  328  shows  the  method  of  applying  the  forceps  in  disarticulation  at 
the  hip,  or  in  any  amputation  of  the  lower  extremity.  A  small  skin 
incision  is  made  in  the  front  of  the  thigh,  one  to  three  inches  below  the 
anterior  superior  spine  according  to  the  size  of  the  limb.  The  smooth 
probe-pointed  blade  is  pushed  forcibly  through  the  skin  incision  well 
down  towards  the  neck  of  the  femur,  and  in  a  transverse  direction  towards 
the  spine  of  the  pubes,  the  serrated  blade  of  the  forceps  being  outside,  and 
when  the  tourniquet  is  driven  well  beyond  the  line  of  the  common  femoral 
vessels,  it  is  clamped  like  an  ordinary  catch-forceps.  Mr.  Griffiths,  of 
Cardiff,  gives  the  following  additional  details  as  to  the  employment  of 
this  instrument  in  a  successful  case  of  amputation  at  the  hip- joint  for  a 


Fig.  328. 


The  forceps-tourniquet   applied  for  amputation  of  the   hip-joint. 
A,  Anterior  suiJerior  spine  of  ilium.     E,  Spine  of  pubes. 


periosteal  sarcoma.  ^  The  vertical  Hmb  of  a  racket-shaped  incision  was 
commenced  about  two  inches  above  the  great  trochanter,  and  into  this 
incision,  at  its  upper  part,  was  inserted  the  smooth  blade  of  Lynn- . 
Thomas's  tourniquet-forceps.  This  having  been  pushed  on  in  the  direction 
described  above,  and  the  forceps  clamped,  the  vessels  in  the  anterior  flap 
were  secured.  To  control  the  circulation  in  the  posterior  flap,  another 
pair  of  forceps  was  used,  the  deep  blade  passing  this  time  behind  the  neck 
of  the  femur.  The  oval  part  of  the  incision  was  next  marked  out,  and  the 
skin  retracted  a  httle  way  all  round.  The  muscles  attached  to  the  great 
trochanter  and  in  front  of  the  hip- joint  were  now  divided,  the  joint  opened, 
and  the  hmb  disarticulated,  the  only  spouting  vessel  seen  at  this  stage 
being  a  tiny  artery  in  the  capsule.  All  the  vessels  which  could  be  seen 
were  next  picked  up  and  tied,  and  then  the  value  of  the  tourniquet- 
forceps  was  demonstrated  in  the  search  for  the  smaller  vessels  which  were 

^  The  use  of  this  instrument  is  also  figured  under  the  account  of  Syrae's  amputation. 
*  Brit.  Med.  Journ.,  December  19,  1903,  p.  1583. 


OPERATIONS  ON  THE  HIP-JOINT  809 

found  by  loosening  tlic  forceps  and  immediately  closing  them  when  a 
bleeding-point  showed  the  position  of  a  vessel. 

Mr.  Lynn  Thomas  gives  the  following  additional  proofs  of  the  sim- 
plicity and  efficiency  of  his  instrument.  In  a  case  which  was  believed 
to  be  one  of  central  sarcoma  of  the  lower  end  of  the  femur,  he  had  am- 
putated through  the  lower  third  of  the  thigh,  controlling  the  haemorrhage 
by  the  method  given  above.  As  after  the  ligature  of  all  visible  blood- 
vessels and  loosening  the  forceps,  unusually  free  oozing  took  place  along 
the  liuea  aspera,  close  inspection  showed  that  the  growth  had  extended 
here.  The  forceps  were  reclamped  in  a  second,  and  after  the  upper  limit 
of  the  growth  had  been  defined,  the  limb  was  amputated  in  the  upper  third 
of  the  thigh.  Primary  union  followed.  "  Though  the  tourniquet  com- 
pressed the  common  femoral  vessels  and  the  accompanying  nerves  for  fifty 
minutes,  the  only  evidence  of  vaso-motor  paresis  was  conhded  absolutely 
to  the  skin  under  the  outer  blade  of  the  forceps-tourniquet." 

The  following  are  amongst  the  cases  in  which  the  forceps- tourniquet 
has  been  successfully  used  by  Mr.  Lynn  Thomas.^  Three  amputations 
through  the  hip-joint,  with  three  recoveries  ;  three  interscapulo-thoracic 
amputati(ms  with  three  recoveries.  The  application  of  the  instrument  in 
this  operation  is  well  shown.  One  aiterio- venous  aneurysm  in  Hunter's 
canal,  which  recovered.  Here  Mr.  Lynn  Thomas  used  two  pairs,  one  to 
control  the  vessels  at  the  upper  end  of  the  skin  incision,  and  the  other  at  the 
lower  end.  "  In  this  operation  I  made  the  skin  incision  down  to  the  fascia 
lata,  but  not  injuring  it,  as  it  formed  the  outer  barrier  to  the  traumatic 
aneurysm ;  the  probe-shaped  blade  was  pushed  boldly  through  in  the 
direction  of  the  inner  aspect  of  the  femur,  and  driven  in  as  far  as  it 
would  go,  and  then  clamped  (the  flat  blade  being,  of  course,  outside 
the  skin),  and  the  other  forceps-tourniquet  was  apphed  in  a  similar 
manner  at  the  lower  border  of  the  skin  incision.  Tlie  fascia  lata  was 
then  divided  and  the  clots  turned  out,  the  partially  divided  artery  and 
veins  were  easily  found,  divided  and  hgatured.  Control  of  haemorrhage 
was  as  complete  as  if  one  had  the  vessels  divided  between  two  ordinary 
pairs  of  haemostatic  forceps." 

Mr.  Lynn  Thomas  further  points  out  that  his  instrument  will  be  found 
especially  valuable  in  injuries  to  the  femoral  vessels,  by  gunshot  or  other 
wounds,  and  especially  so  where  the  injury  hes  close  to  Poupart's  hga- 
ment,  as  here  prompt  treatment  is  especially  called  for,  and  the  control 
of  haemorrhage  is  a  matter  of  much  difficulty.  Any  wound  present  would, 
of  course,  be  enlarged,  as  needed.  The  following  are  the  advantages 
of  the  forceps- tourniquet  over  other  instruments,  especially  Esmarch's 
bandage:  (1)  It  is  not  affected  by  chmate ;  (2)  it  is  easily  sterihsed ; 
(3)  it  IS  most  useful  in  major  operations  ;  (4)  it  does  not  require  an 
assistant  to  look  after  it ;  (5)  in  no  case  has  Mr.  Lynn  Thomas  seen  its 
use  followed  by  that  oozing  which  is  so  common  after  the  employment 
of  an  Esmarch  bandage. 

(4)  Alacewen's  Method  of  Compression  of  the  Abdominal  Aortal 
Prof.  Macewen  has  used  the  following  for  many  years,  and  has  found  it 
simple,  always  ready,  easily  apphed  and  efhcient.  No  injury  has  followed 
to  the  small  intestines,  if  the  patient  vomits  or  coughs  violently,  the 
pressure  must  be  temporarily  increased.  As  the  patient  lies  on  his  back 
on  the  table,  the  assistant,  facing  the  patient's  feet,  stands  on  a  stool  at 
the  left  side  of  the  table  in  a  hue  with  the  umbihcus.     He  then  places  his 

^  Brit.  Med.  Journ.,  October  1,  1904,  ^  Ann.  oj  Surg.,  1894,  vol.  i,  p.  1. 


810        OPERATIONS  ON  THE  LOWER  EXTREMITY 

closed  right  hand  upon  the  abdomen,  a  httle  to  the  left  of  the  middle  line, 
the  knuckles  of  the  index  finger  first  touching  the  upper  border  of  the 
umbihcus  so  that  the  whole  shut  hand  will  embrace  about  three  inches 
of  the  aorta  above  its  bifurcation.  The  assistant  then  standing  upon  his 
left  foot,  his  right  foot  crossing  his  left,  leans  upon  his  right  hand,  and 
thereby  exercises  the  necessary  amount  of  pressure.  With  the  index  finger 
resting  upon  the  common  femoral  at  the  brim  of  the  pelvis,  the  assistant 
can  easily  estimate  the  weight  necessary  for  the  purpose.  In  this  way 
an  efficient  assistant  can  control  the  circulation  for  half  an  hour  without 
fatigue. 

(5)  Compressing  the  Common  Femoral  or  the  Termination  of  the  External  Iliac  by 
the  fingers  or  hands,  aided,  if  need  be,  by  a  weight.  This  is  only  possible  in  the  case 
of  a  child,  and  the  assistant  thus  employed  is  liable  to  be  in  the  way  of  the  operator. 

(6)  Ligature  of  the  Common  Femoral  Artery.  The  incision  is  utilised  afterwards  in 
shaping  lateral  or  some  modification  of  lateral  flaps.  The  surgeon  must  be  prepared 
for  the  haemorrhage  from  the  gluteal  and  other  branches  of  the  internal  iliac  artery 
(Fig.  330). 

(7)  Commanding  the  Main  Artery  during  the  operation  by  seizing  it  in  the  flap. 

Furneaux  Jordan's  Method  (Fig.  329).  By  amputating  through  the 
thigh  as  low  down  as  possible,  and  shelhng  out  and  disarticulating  the 
femur,  it  is  now  possible  to  avoid,  in  large  measure,  those  dangers  which 
were  formerly  inseparable  from  the  operation,  viz.:  (1)  Shock,  the 
Umb  being  removed  much  farther  from  the  trunk.  (2)  Haemorrhage. 
(a)  Abundant  room  is  aflorded  for  compression  of  the  common  femoral, 
and  the  vessels  behind,  (h)  The  large  vessels  can  easily  be  secured  on 
the  face  of  the  stump,  low  down,  (c)  The  gluteal  and  sciatic  arteries 
remain  untouched,  the  haemorrhage  from  these,  in  the  older  operations, 
being  a  source  of  serious  danger.  (3)  Infection.  By  the  other  methods, 
the  copious  discharge  of  bloody  serum  from  the  large  wound,^  being 
poured  out  close  to  the  anus  and  genitals,  was  very  hable  to  infection. 
By  this  operation,  both  the  end  of  the  stump  and  the  wound  on  the  outer 
side  can  be  more  easily  drained  and  kept  aseptic.  In  making  use  of 
this  amputation,  especially  for  hip  disease  or  failed  excision,  the  surgeon 
should  not  attempt  too  much  to  secure  primary  union.  (4)  The  stump 
is  a  better  one.  It  is  longer,  more  mobile,  and  occasionally,  as  in  ampu- 
tation for  acute  periostitis  or  necrosis,  it  is  possible  to  preserve  much  of 
the  periosteum  from  the  upper  half  of  the  femur,  and  a  cord  ^  will  be  left 
which  will  render  the  stump  movable. 

I.  Furneaux  Jordan's  Operation  (Fig.  329).^  The  modification  of 
Sir  H.  Howse  in  two  stages  is  given  at  p.  812.     Every  provision  must 

^  While  the  wound  in  a  Furneaux-Jordan  amputation  is  also  a  large  one,  it  is  much 
more  happily  placed  for  drainage. 

^  The  committee  of  the  Climcal  Society  appointed  to  examine  Mr.  Shuter's  case  of 
subperiosteal  amputation  of  the  hip-joint  reported  {Trans.,  vol.  xvi,  p.  89),  (1)  that, 
though  there  was  a  firm,  resisting  cord  of  considerable  size  in  the  centre,  which  afforded 
the  muscles  a  common  point  of  attachment,  there  was  not  sufficient  evidence  to  enable 
them  to  state  that  this  cord  contained  bone  ;  (2)  that  the  muscles  were  in  a  high  state 
of  nutrition,  the  patient  not  only  powerfully  flexing,  extending,  abducting,  and  adducting 
his  stump,  but  being  able  to  communicate  all  these  movements  to  the  artificial  limb. 

3  Dr.  W.  E.  Arnold,  assistant-surgeon  U.S.  Navj',  has  kindly  drawn  my  attention  to 
the  fact  that  an  amputation,  in  all  essentials  the  same  as  Furneaux  Jordan's,  was 
performed  as  long  ago  as  1806  by  Dr.  W.  Brashear  in  Bardstown,  Kentucky.  The 
following  account  taken  from  a  letter  by  Dr.  Brashear  will  be  found  in  Dr.  Mott's  edition 
of  Velpeau's  Surgery,  in  a  summary  of  hip- joint  amputations  by  Dr.  Eve,  of  Tennessee. 
The  patient  was  a  lad,  aged  17.  An  operation  on  the  thigh  in  the  ordinary  manner  was 
determined  upon,  as  remote  from  the  hip-joint  as  ciicumstances  might  justify  (in  this 
case,  about  mid-thigh).  The  amputation  was  performed  and  the  arteries  secured.  The 
next  step  was  to  make  an  incision  to  and  from  the  lower  end  of  the  bone  externally  over 


OPERATIONS  ON  THE  HIP-JOINT 


811 


be  taken  against  shock.  'I'lic  limbs  slioukl  be  bandaged  in  cotton- 
wool, the  body  well  wi'aj)i)e(i  iiji  on  a  hot- water  table,  the  head  k(!pt  low, 
ether  given,  sahne  infusion  employed  intravenously  or  into  the  cellular 
tissue,  or  by  both  means.  In  many  cases  spinal  anaesthesia  is  strongly 
indicated  as  it  reduces  shock  to  a  minimum. 

Before  connnencing  the  circular  amputation,  J  have  the  limb  elevated, 
an  Ksmarch  bandage  applied  uj)  to  the  knee,  the  thigh  emptied  of  venous 
blood  by  firm  stroking,  and  the  Hat  rubber  tourni(|Uet  is  applied  over  the 
groin  and  above  the  crest  of  the  ileum  (p.  8D5),  while  the  femur  is  shelled 
out  or,  perhaps,  disarticulated,  if  the  whole  operation  is  performed  in  one 
stage. 


Fig.  329.     Furneaux  Jordan's  amputation;     Above  is  shown  the  means  of  con- 
trolling haemorrhage  described  at  p.  805.     Lower  down  is  seen  the  method  of 
shelling  out  the  femur,  after  a  circular  amputation  has  been  performed,  and  the 
large  vessels  secured. 


The  patient's  pelvis  is  brought  to  the  edge  of  the  table  and  the  body 
rolled  a  little  on  to  the  sound  side,  the  surgeon  standing  usually  to  the 
right  of  the  diseased  Hmb — i.e.  inside  on  the  left  and  outside  on  the 
right  side — draws  up  the  soft  parts  forcibly  with  his  left  hand,  and 
makes  a  circular  incision  through  the  lower  third  of  the  thigh,  using 
his  knife  as  at  p.  849,  the  assistant  who  is  in  charge  of  the  limb  rotating 
it  so  as  to  make  the  tissues  meet  the  knife.  A  circular  cuff-like  flap 
of  skin  and  fascise  is  then  cjuickly  raised  for  about  two  inches  and  a  half, 
an  assistant,  who  stands  opposite  the  surgeon,  giving  much  help  here,  by 
seizing  and  everting  the  cut  edge  of  the  flap  as  the  surgeon  raises  it.     The 

the  great  trochanter,  to  the  head  of  the  bone  and  upper  part  of  the  socket.  The  dis- 
section of  the  bone  from  the  surrounding  muscles  was  simple  and  safe,  by  keeping  the 
edge  of  the  knife  resting  against  it.  The  bone  being  disengaged  from  its  integuments  at 
its  lower  extremity,  was  then  turned  out  at  a  right  angle  from  the  body,  so  as  to  give 
every  facility  in  the  operation  to  separate  the  capsular  ligament  and  remove  the  head 
from  its  socket.  The  patient  made  a  good  recovery.  Judging  from  a  letter  from  Prof. 
Oilier  to  Mr.  Shuter  {loc.  supra  cit.)  the  former  surgeon  had  recommended  this  method  in 
1859,  and  performed  such  an  operation  once. 


812       OPERATIONS  ON  THE  LOWER  EXTREMITY 

flap  being  drawn  upwards  out  of  the  way,  the  soft  parts  are  severed  by 
one  or  two  vigorous  circular  sweeps  down  to  the  bone,  and  the  large 
vessels  and  any  others  that  can  be  seen  are  next  secured.  Pressure  is 
now  made  with  sterihsed  pads  on  the  still  oozing  wound,  the  upper  india- 
rubber  bandage  (Fig.  329)  is  tightened,  and  the  patient  being  rolled  well 
over  on  to  his  sound  side,  the  surgeon  cuts^along  the  outer  side  of  the  thigh, 
starting  |from  the  circular  wound  and  ending  about  midway  between  the 
iliac  crest  and  top  of  the  great  trochanter.  This  incision  goes  straight 
down  to  the  bone  and  runs  into  any  excision  wound  or  sinuses  which  may 
exist  over  the  joint.  The  soft  parts  are  then  rapidly  stripped  off  the 
femur,  partly  with  the  knife,  partly  with  the  finger,  the  only  difficulty 
met  with  being  along  the  hnea  aspera.  If  an  excision  has  been  performed, 
the  operation  is  rapidly  completed,  but  if  the  head  and  neck  remain  intact, 
the  final  steps  will  be  rendered  more  difficult,  and  the  joint  must  be 
opened  from  the  outside  by  cutting  strongly  on  the  neck  of  the  bone,  this 
being  facihtated  by  the  assistant  moving  the  hmb,  in  accordance  with  the 
surgeon's  directions  as  different  parts  require  to  be  put  on  the  stretch, 
strong  outward  rotation  of  the  femur  and  dragging  of  the  head  away 
from  the  acetabulum  being  required  at  the  last. 

Free  drainage  must  be  provided,  for  it  must  be  remembered  that  the 
wound  left  by  this  method  is  a  very  large  one,  though  it  has  the  advantage 
of  being  farther  removed  from  sources  of  infection.  Thus,  especially  if 
the  tissues  are  riddled  with  sinuses,  too  much  of  the  wound  must  not  be 
closed,  and,  if  shock  is  present,  the  surgeon  must  not  wait  to  insert  many 
sutures,  but,  trusting  to  firm  bandages  over  an  aseptic  dressing,  get  his 
patient  quickly  back  to  bed.  If  disease  of  the  acetabulum  be  present  the 
surgeon  will,  if  the  patient's  condition  admit  of  it,  attend  to  this,  the  use 
of  a  sharp  spoon  and  the  insertion  of  a  drainage-tube  through  this  bone 
being  specially  required  if  pelvic  suppuration  be  present. 

Sir  H.  Howse's  Two-stage  Modification  of  the  Above.  As  in  spite 
of  its  advantages  the  Furneaux-Jordan  method  must  always  be  accom- 
panied by  shock,  and  as  in  spite  of  strenuous  use  of  elastic  compression 
the  loss  of  blood,  especially  in  adults,  may  be  too  much  for  the  patients 
when  their  usual  exhausted  vitaUty  is  remembered,  I  strongly  advise 
my  readers  to  follow  Sir  H.  Howse,  and  to  remove  the  hmb  in  two  stages 
whenever  this  is  possible,  as  in  cases  of  tuberculous  disease.  My  own 
experience  is  based  upon  four  cases,  in  which  I  superintended  its  perform- 
ance by  my  house-surgeons.  Two  of  the  patients  were  in  a  most  unfavour- 
able condition ;  all  recovered.  The  hmb  is  first  removed  by  a  circular 
amputation  through  the  lower  third  of  the  thigh,  and,  about  a  fortnight 
later,  the  rest  of  the  femur  is  taken  away.  By  the  adoption  of  this  course, 
the  shock  is  greatly  diminished.  The  blood  which  would  have  been 
circulating  in  the  rest  of  the  limb  is  returned  into  the  trunk  before  the 
first  operation.  By  the  removal  of  the  hmb  the  length  of  leverage  which 
exerts  a  disturbing  influence  on  the  diseased  joint  and  the  need  of  a  sphnt 
are  done  away  with.  The  patient  rapidly  recovers  lost  ground,  and  is,  at 
the  close  of  the  second  operation,  in  a  much  better  condition  for  the 
curetting  of  sinuses,  now  usually  needful.  These  advantages,  in  my 
experience,  outweigh  the  disadvantage  of  two  operations,  and  the  double 
anaesthetic. 

Amputation  by  Different  Flap  Methods.^The  following  will  be  given 
here,  it  being  understood  that  in  no  case  can  any  of  them  be  recommended 
if  the  above  method  is  available.     In  all,  shock  should  be  diminished  by 


OPERATIONS  ON  THE  HIP-JOINT 


813 


spinal  anaesthesia  or  by  the  injection  of  eucaine  into  the  chief  nerve 
trunks  prehminary  to  their  division,  by  the  method  of  C'rile  and  Gushing. 
Whenever  availabk>,  the  method  of  Lynn  Thomas  or  Wyeth  for  arresting 
haemorrhage  (pp.  806  and  808)  should  always  be  employed. 

II.  Lateral  Flaps.  The  met liocls  of  Larry  and  Lisfranc  need  not  be  more  than 
alluded  lo  here.  In  both,  the  flaps  were  cut  by  transfixion,  and  were  about  four 
inches  long.  Larry  tied  the  common  femoral  as  a  preliminary  step.  Flaps  made 
by  eitlier  method  are  so  bulky  as  not  to  be  recommended. 


^AKTORIUS 


ILIO-PSOAS 


\-  -  COMHOH    FEMOHAL  A\ 


V£;?i-£     TO  P££.TiNE.VS 


--ii£.£.f  /^£/*Oll/9L   A 


Fig.  330.     Amputation   at   the   hip-joint   by   modified  lateral   flaps   (anterior 
racket-shaped  incision).     A  double  ligature  has  been  placed  upon  the  common 

femoral  vessels. 

If  the  surgeon  wishes  to  use  lateral  flaps,  as  in  a  case  involved  by  growth  in  front, 
he  may  make  them,  thus,  from  without  inwards  :  Standing  on  the  right  side  of 
either  limb,  he,  e.g.  in  the  case  of  the  right  limb,  marks  out  an  inner  flap  by  means 
of  an  incision  starting  from  below  the  tuber  ischii,  carried  downwards  along  the  inner 
aspect  of  the  thigh  for  about  four  inches  and  then  curving  upwards  to  the  centre 
of  the  groin  and  ending  a  little  below  Poupart's  ligament,  to  the  outer  side  of  the 
femoral  vessels  ;  next,  without  taking  off  his  knife,  he  marks  out  an  outer  flap  by 
cutting  between  the  same  points,  but  in  the  reverse  direction.  This  incision,  as  it 
passes  downwards,  outwards,  and  backwards,  should  leave  the  front  of  the  limb 
about  a  hand's-breadth  below  the  great  trochanter.  The  flaps  having  been  dis- 
sected up,  the  soft  parts  are  cut  through  from  without  inwards,  the  femoral  vessels 
being  secured  before  they  are  cut,  and  disarticulation  performed  last. 

III.  Antero-internal  and  Postero-external  Flaps  (Figs.  330,  331). 
This  is  a  modification  of  the  last  method,  and  will  be  useful  in  cases 


814       OPERATIONS  ON  THE  LOWER  EXTREMITY 

of  growth  extending  liigh  up,  where  it  is  impossible  to  perform  a  Fur- 
neaux-Jordan  amputation.  8ome  such  flaps  as  the  above  may  be 
the  only  ones  obtainable.  They  may  be  made  as  follows  :  The  pre- 
cautions as  to  shock  given  at  p.  811  having  been  taken,  haemorrhage 
will  be  best  met  by  the  details  given  at  p.  808,  if  Mr.  Lynn  Thomas's 
forceps-tourniquet  is  available.  The  patient's  pelvis  is  then  brought 
well  down  to  the  edge  of  the  table,  and  the  opposite  limb  being  held  aside 
but  not  tied,  the  surgeon,  standing  to  the  right  of  either  limb,  reaches 


Fig.  3.31 .     The  same  operation  as  in  the  last  figure,  in  a  more  advanced  stage. 

The  capsule  has  been  opened  and  its  outer  lip  drawn  aside  by  a  retractor.     The 

other  retractor  draws  inwards  and  protects  the  vessels. 

somewhat  over  and  marks  out  (in  the  case  of  the  right  limb)  an  antero- 
internal  flap,  but  cutting  from  a  point  close  to  the  tuber  ischii  to  one  a 
little  below  and  internal  to  the  anterior  superior  iliac  spine.  The  skin 
and  fascise  having  been  dissected  up,  the  muscles  are  cut  through  till 
the  femoral  vessels  are  reached  and  secured.  Sterilised  gauze  is  now 
packed  into  this  wound,  and,  the  patient  having  been  rolled  a  little 
over,  a  postero-external  flap  is  marked  out  and  dissected  up  from  the 
gluteal  region,  passing  between  the  above  points,  but  in  the  reverse 
order.     The  gluteal  vessels    are  next  cut  through,   the  chief  vessels 


EXCISION  OF  THE  HIP  815 

being  secured  by  Spencer-Wells  forceps;   the  capsule  is  then  opened, 
the  round  ligament  severed,  and  the  limb  removed. 

EXCISION  OF  THE  HIP.     OPERATIVE  TREATMENT  OF  HIP- 
JOINT  DISEASE.     INCISION  OF  THE  JOINT 

Indications.  A.  Disease,  chielly  tuberculous.  B.  Injury,  especially 
gunshot. 

A.  Disease.  Few  will  deny  that  the  progress  in  the  treatment  of  hip 
disease  has  not  made,  of  late  years,  advances  in  accordance  with  the 
advantages  of  modern  surgery,  and  the  progress  made  in  operations  on 
other  parts  of  the  body.  While  the  immediate  mortality  after  operative 
interference  here  has  been  lessened,  the  results  as  to  real  cures  are  still 
very  poor  and  compare  very  unfavourably  with  the  results  of  careful  and 
prolonged  conservative  treatment. 

This  is  very  simple  but  tedious.  The  patient  must  be  kept  under 
observation  for  at  least  a  year  or  eighteen  months,  in  an  apparatus  such 
as  a  single  or  double  Thomas's  splint,  designed  to  keep  the  joint  at  rest 
and  prevent  deformity.  For  about  six  months  the  recumbent  position 
is  essential.  Later  the  patient  can  walk  about  on  crutches  with  hand 
supports,  the  opposite  boot  being  elevated  to  keep  the  diseased  limb  off 
the  ground.  Later  still  a  modified  Hessing's  apparatus  allows  the 
patient  to  walk,  without  transmitting  his  weight  through  the  diseased 
hip.  This  always  guards  against  deformity.  An  open-air  life  and  good 
food,  and  cod-liver  oil  and  malt  are  valuable  aids.  As  a  rule,  tuberculin 
injections  are  unnecessary — and  undesirable.  The  results  of  careful 
treatment  along  these  lines  are  extremely  good. 

As  regards  excision  of  the  joint  it  is  obvious  that  it  is  almost  impossible 
to  remove  all  the  diseased  tissues,  and  that  once  the  head  of  the  femur  is 
removed  a  normal  hip  joint  is  impossible,  and  is  replaced  by  an  unstable  or 
fixed  joint  with  permanent  shortening,  more  or  less  flexion,  adduction  and 
eversion.     In  many  cases  sinuses  persist. 

When  excision  is  performed  later  and  abscesses  are  present,  satis- 
factory deahng  ^\dth  these  is  usually  rendered  extremely  difficult  by 
their  devious  tracks,  the  risk  of  leaving  a  tuberculous  sinus,  and  of 
this  becoming,  later,  the  seat  of  mixed  infection.  Then  follow  one 
or  more  curettings,  and  the  child  is  sent  out  in  a  Thomas's  splint,  or 
perhaps  to  a  convalescent  home,  or  otherwise  lost  sight  of  ;  the  dislike 
to  having  even  mild  cases  of  suppuration  in  the  wards  of  a  general  hospital 
playing  a  large  part  in  the  interruption  in  the  treatment. 

The  truth  is  that  the  only  satisfactory  treatment  of  hip-joint  disease 
is  the  conservative  one  by  strict  adequately  prolonged  rest.  This  will 
not  be  perfectly  obtained  while  these  cases  are  treated  in  general  hospitals. 
Institutions  on  a  large  scale,  especially  adapted  to  this  class  of  case, 
are  what  is  needed. 

The  unsatisfactory  results  met  with  after  excision  of  the  hip  have 
led  surgeons  to  be  more  chary  in  its  performance,  and  to  the  employment 
of  other,  more  conservative,  steps. 

Abscesses  are  extremely  rare  under  conservative  treatment  com- 
menced as  soon  as  the  diagnosis  is  made,  but  when  an  abscess  does  appear 
it  may  be  aspirated  if  it  does  not  absorb  under  complete  rest  in  the 
recumbent  position. 

Iodoform  emulsion  may  be  injected  into  abscesses  and  the  joint  itself. 


816       OPERATIONS  ON  THE  LOWER  EXTREMITY 

as  advocated  by  the  late  v.  Mickulicz  of  Breslau  and  other  authorities. 
The  weak  points  of  this  treatment  are  obvious.  In  the  case  of  abscesses 
thickness  of  the  pus  may  prevent  anything  hke  complete  evacuation. 
The  method  makes  no  attempt  to  eradicate  the  bone  lesions  usually 
present,  but  with  rest  the  tendency  to  heal  is  strong. 

In  deahng  with  an  abscess  strict  asepsis  as  to  the  skin,  &c.,  is  need- 
ful. A  syringe  holding  two  to  three  ounces  should  be  employed,  so  as  to 
allow  of  aspiration  of  the  pus.  The  emulsion  is  then  injected,  the  syringe 
being  resterihsed.  A  spray  of  ethyl-chloride  may  be  used.  The  aspira- 
tion is  repeated  according  to  the  rate  at  which  the  abscess  re-fills.  Where 
the  process  has  to  be  repeated,  fresh  spots  should  be  selected.  If  the 
re-collection  takes  place  slowly  and  is  found  to  contain  only  blood- 
stained or  brownish-green  fluid  the  outlook  is  good.  I  need  not  enforce 
the  necessity  of  watching  these  cases.  Where  the  abscess  is  multiple, 
this  method  rarely  succeeds,  in  my  experience. 

The  joint  itself  may  be  injected  by  taking  the  line  for  opening  the 
joint  anteiioily  (p.  820),  and  introducing  the  needle  two  to  three  inches 
below  the  anterior  superior  spine,  in  a  direction  backwards,  upwards,  and 
inwards,  so  that  it  enters  the  joint  just  above  the  anterior  inter-trochan- 
teric  Hue.  From  4  to  30  c.c.  of  the  emulsion  are  injected  at  intervals  of 
from  one  to  two  weeks,  according  to  the  reaction  produced.  Any  pyrexia 
and  pain  are,  usually,  quite  temporary. 

Reference  may  here  be  made  to  an  important  contribution  to  the 
study  of  the  treatment  of  hip  disease  by  L)rs.  Gibney,  Waterman,  and 
Reynolds,  of  Xew  York.^  An  analysis  is  given  of  150  cases  treated  at  the 
New  York  Hospital  for  the  Ruptured  and  Crippled.  Of  these  25  were 
still  under  treatment,  and  deed  not  be  further  considered  ;  7  were  ad\dsed 
readmission  for  deformity,  11  died,  and  107  were  cured.  The  107  cured 
cases  were  finally  examined  at  an  interval  of  five  to  twenty  years  after 
leaving  the  hospital.  The  excellence  of  the  final  result  in  the  cured  cases, 
all  of  which  recovered  with  sound  useful  Umbs,  will  be  gathered  from  the 
following  facts.  As  regards  motion,  this  was  perfect  in  15,  good  in  22, 
Umited  in  41,  and  absent  in  only  9  cases.  Shortening  averaged  an  inch 
and  three-fifths  in  aU  the  cases,  but  was  absent  in  21  cases ;  under 
one  inch  in  71,  and  over  one  inch  in  36.  The  reiord  as  regards  flexion 
is  also  extremely  satisfactory,  as  47  cases  had  none  at  all,  and  in  77  it  was 
under  10°  ;  in  the  remaining  30  cases  it  was  under  30°.  The  treatment 
employed  consisted  essentially  in  rest  and  extension  ;  abscesses  being 
either  aspirated,  or  opened  and  curetted.  Osteotomy  of  the  femur  was 
performed  19  times  to  correct  deformity,  but  excision  was  done  in  4  cases 
only. 

Briefly  stated,  of  114  cases  examined  five  years  and  upwards  after 
leaving  the  hospital,  107  "  were  cured  and  able  to  follow  an  occupation 
without  the  shghtest  trouble,"  and  the  remaining  7  cases  were  cured 
but  suffering  from  considerable  deformity.  As  excision  was  performed 
in  only  4  of  these  cases,  it  must  be  admitted  that  these  excellent  results 
constitute  very  strong  evidence  in  favour  of  treatment  other  than  that 
by  actual  excision.  My  experience  at  a  large  children's  hospital  and  for 
years  in  charge  of  the  Orthopaedic  Department  at  Guy's  Hospital,  where 
I  watched  a  large  number  of  these  cases  for  many  years,  makes  me  strongly 
advocate  conservative  treatment.  Even  under  the  mifavourable  circum- 
stances of  South  London  the  patients  did  very  well,  and  only  a  few  excep- 

1  Ann.  of  Surg.,  vol.  ii,  1897,  p.  435. 


KX(  ISION  OF  THE  HIP  817 

tions  developed  an  abscess.     I  have  not  excised  a  tuberculous  hip  during 
the  last  ten  years. 

Prof.  Marsh  is  strongly  against  excision,  for  these  reasons  :  He  con- 
siders the  results  obtained  by  continued  rest  to  be  such  as  to  render 
excision  totally  uncalled  for.  "  The  estimate  that  T  have  been  led  to 
form  is,  (a)  that,  in  the  early  stage  of  the  disease,  although  matter  is 
developed,  the  operation  is  as  unjustitial)le  as  it  is  to  remove  a  testis,  an 
eye,  or  a  tooth  for  incipient  but  still  curable  disease  ;  (6)  that  the  opera- 
tion is  generally  uncalled  for,  even  when  sinuses  have  formed  ;  (c)  that 
if  hip  disease  has  been  allowed  to  reach  the  stage  in  which  the  bones  have 
become  extensively  carious,  in  which  matter  has  burrowed  widely,  and  in 
which  the  general  health  has  become  seriously  affected,  excision  will  be  of 
very  doubtful  benefit. 

The  following  are  the  conditions  given  by  a  committee  of  the  CHnical 
Society  as  calling  for  excision,  viz.  : 

(i)  "  Necrosis,  and  separation  of  the  entire  head  of  the  fenmr,  and  its 
conversion  into  a  loose  sequestrum."  ^ 

(ii)  ''  The  presence  of  firm  sequestra  either  in  the  head  or  neck  of  the 
femur,  or  in  the  acetabulum."'  This  question  is  a  most  important  one, 
for,  as  Prof.  Marsh  (p.  318)  writes,  "  much  difference  of  opinion  exists 
as  to  the  frequency  \^^th  which  hard  sequestra  of  any  material  size  are 
present  in  suppurative  hip  disease."  He  himself  thinks  that,  when 
present,  sequestra  usually  consist  of  porous,  friable  bone.  Their  struc- 
ture is  such  that,  should  excision  not  be  performed,  they  will  crumble 
away  and  disappear,  and  ^^^]l  not  prevent  repair.^  A -distinctly  different 
opinion  is  held  by  Mr.  Wright  ^ :  "  Here  opening  of  abscesses,  and,  still 
less,  expectant  treatment,  can  hardly  be  considered  a  satisfactory  mode 
of  getting  rid  of  sequestra,  yet  in  no  less  than  in  39  (out  of  100)  were  there 
actual  loose  sequestra,  while  in  many  others  there  were  patches  of  bone 
which  was  practically  dead,  though  not  loose.  The  possibility  of  re- 
mo\ang  sequestra  ^vithout  a  formal  excision  is  worth  trying  in  some  cases, 
but  it  is  often  impossible  to  discover  the  presence  of  the  sequestra  until 
the  end  of  the  bone  has  been  removed,^  or  to  extract  them  if  found. 
Moreover,  even  after  the  removal  of  sequestra,  others  may  exist  and  not 
be  found,  and  in  other  instances  the  disease  progresses  in  the  surrounding 
bone  and  necessitates  subsequent  excision.  There  are  often,  too,  other 
foci  of  disease  in  the  medulla,  which  are  as  great  bars  to  recovery  as  the 
sequestra  themselves."  Careful  radiographic  examination  are  very 
valuable  here. 

(iii)  "  Extensive  caries  of  the  femur,  or  the  pelvis,  leading  to  prolonged 
suppuration  and  the  formation  of  sinuses." 

(iv)  "  IntrapeMc  abscess  follo\nng  disease  of  the  acetabulum." 

^  Prof.  Marsh  {loc.  supra  cit..  Fig.  50,  p.  383)  thinks  that  these  cases  are  not  rare. 
Mr.  Hilton  {Rest  and  Pain,  Fig.  63,  p.  341)  shows  a  similar  specimen.  I  should  have 
thought  the  condition  a  very  uncommon  one. 

2  "'  This  seems  to  be  proved  by  the  fact  that  in  numerous  cases  in  which  profuse 
suppuration  has  been  going  on,  so  that  there  can  be  no  reasonable  doubt  that  extensive 
bone  disease  has  been  present,  all  the  sinuses  will  close,  although  either  no  bone  has 
worked  out  or  been  extracted.  In  these  instances  we  must  conclude  either  that  no 
sequestra  were  present,  and  in  that  case  it  would  appear  that  sequestra  are  not  so  common 
as  some  believe,  or  that  they  often  crumble  away  and  are  discharged,  so  that  operative 
interference  is  by  no  means  essential  for  their  removal  "  (Marsh,  loc.  supra  cit.,  p.  319). 

3  Loc.  supra  cit.,  p.  118. 

*  For  the  word  "  removed  "  I  should  substitute  "  displaced,"  a  step  which  I  consider 
quite  justifiable  at  the  present  day,  to  prevent  the  need  of  a  complete  excision  and  the 
flail-like  limb  which  usually  follows. 

SURGERY  I  52 


818       OPERATIONS  ON  THE  LOWER  EXTREMITY 

(v)  "  Extensive  and  old-standing  synovial  disease  and  ulceration  of 
the  articular  cartilages,  wdth  persistent  suppuration."  This  condition 
is  rarely  seen  in  the  hip-joint,  where  the  disease,  as  usually  met  with, 
starts  not  in  the  synovial  membrane,  as  in  the  knee-joint,  but  as  a 
chronic  osteo-myehtis  in  the  neighbourhood  of  the  epiphyses,  especially 
the  upper  one. 

(vi)  "  Displacement  of  the  head  of  the  femur  on  the  dorsum  ilii,  with 
chronic  sinuses  and  deformity." 

Mr.  Jacobson  performed  excision  seven  times  for  such  cases  ;  of  these 
six  recovered  with  sound  and  useful  limbs.  These  patients  seem  to 
bear  excision  well,  this  being  probably  due  to  their  having  good  vitality, 
as  shown  by  their  survival,  and  the  amount  of  repair.  Further,  in 
running  successfully  the  gauntlet  of  the  disease,  they  have  escaped 
the  dangers  of  lardaceous  and  general  tuberculous  trouble.  But  as  a 
rule,  especially  if  the  sinuses  are  few  or  closed,  osteotomy,  either  cunei- 
form of  the  neck  or  by  Gant's  method,  together  with  division  of  the 
contracted  sartorius,  tensor  fasciae,  and  adductor  longus  is  much  to 
be  preferred.  Excision  does  away  with  much  of  the  stabihty  of  the 
hmb,  already  secured.  The  surgeon  here  must,  if  he  excise,  be  prepared 
for  a  good  deal  of  trouble  in  dislodging  the  displaced  head,  after  sawing 
through  its  neck,  o^^dng  to  its  being  firmly  matted  down  by  old  adhesions. 

The  Condition  of  the  Limb.  Is  this  a  better  one  after  Excision  or 
after  a  Cure  by  Rest  ?  Prof.  Marsh  ^  is  of  opinion  that  "  the  limb  after 
excision  of  either  the  hip  or  the  knee  is  usually  very  inferior  to  the  average 
Hmb  that  is  obtained  after  recovery  has  followed  the  treatment  by  rest." 
The  Clinical  Society's  Committee  reported  on  this  subject  that,  after 
excision,  "  movement  is  more  frequently  present,  and  is  also  more  exten- 
sive, but  that  patients  often  walk  more  insecurely  and  with  a  considerable 
limp,  while  the  Hmb,  after  treatment  by  rest  and  extension  though 
frequently  more  or  less  fixed,  is  more  firm  and  useful  for  the  purposes 
of  progression."  In  a  very  large  proportion  complete  recovery  results 
from  careful  conservative  treatment,  in  many  cases  not  treated  from  the 
first  or  continuously.  Limitation  of  movement  with  flexion  and  adduc- 
tion develop  ;  but  even  these  results  are  better  than  those  of  excision, 
where  much  shortening,  instability,  and  chronic  sinuses  are  common. 

Conditions  of  Success  in  Excision  of  the  Hip.  Amongst  these  are  : 
(1)  Age.  I  consider  the  best  six  to  fourteen.  After  fifteen  the  results 
have  not  been  so  good.  (2)  Absence  of  lardaceous  disease.  Excision 
should  be  performed,  in  my  opinion,  only  before  the  appearance  of 
lardaceous  disease.  When  there  is  evidence  of  this  condition  having 
set  in,  especially  in  the  kidneys  or  intestine,  amputation  is  to  be  pre- 
ferred. (3)  Absence  of  advancing  mischief  in  other  joints,  or  of  tuber- 
culous lesions  in  the  viscera,  e.q.  the  lungs.  (4)  The  disease  must 
be  removed  as  entirely  as  possible.  Thus,  in  the  femur  at  least,  the 
section  must  pass  below  all  foci  of  disease  (p.  823).  All  sinuses  should 
also  be  scraped  out.  (5)  Adequate  drainage.  (6)  Careful  after-treat- 
ment, the  wound,  including  the  adjacent  skin,  being  kept  aseptic.  The 
patient  must  not  be  kept  too  long  on  his  back  in  ordinary  hospital 
air  but  must  lead  an  open-air  Hfe.  These  words  must  not  be  taken  to 
encourage  getting  the  patient  up,  and  allowing  him  to  bear  any  weight 
on  the  Hmb,  even  if  primary  union  has  been  secured,  eight  weeks  or  so 
after  the  operation.     After  this  time  the  patient  may  get  about  on 

^  Loc.  supra  cit.,  p.  308. 


EXCISION  OF  TIIK  HIP  81«.) 

crutches  with  hand  supports,  the  opposite  boot  being  elevated  at  least  an 
inch.  The  weight  of  tlie  limb  is  beneficial  and  limits  shortening.  Later 
a  calliper  or  Hessing  splint  enables  the  patient  to  walk  without  detri- 
ment. 

B.  Gunshot  Injuries. 

Excision  oi  the  Hip-joint  lor  Gunshot  Injuries,  contrasted  with  Conservative 
Treatment,  and  Amputation  at  the  Hip-joint.  For  llic  sake  of  coiivcniciicc 
it  will  Ih'  well  to  taUi>  tlic  above;  llini'  plans  of  tifalincnt  of  gunshot  injuries  of  tlio 
iiip  lofj;(.>llicT.  As  before,  I  siiall  avail  niy«clf  of  tho  hiborious  researches  and  the 
unrivalled  authoritj'  on  this  subject  of  Dr.  Otis.  He  writes  ^  that  the  evidence 
colleeted  during  the  American  War  shows  that  "expectant  treatment  is  to  be  con- 
demned in  all  cases  in  which  the  diagnosis  of  direct  injury  to  the  articulation  can  be 
clearly  establisheil  "  ;  that  "  primary  excisions  of  the  head  or  upper  extremity  of 
the  femur  should  be  performed  in  all  uncomplicated  cases  of  shot  fracture  of  the 
head  or  neck";  that  "intermediary  excisions  are  indicated  in  similar  cases  where 
the  diagnosis  is  not  made  out  till  late  "  ;  that  "  secondary  excisions  are  demanded 
by  caries  of  the  head  of  the  femur  or  secondary  involvement  of  the  joint  "  ;  that 
amputation  should  be  performed  :  "  (1)  When  the  thigh  is  torn  off,  or  the  upper 
extremity  of  the  femur  comminuted  with  great  laceration  of  the  soft  parts,  in  such 
proximity  to  the  trunk  that  amputation  in  continuity  is  impracticable.  (2)  When 
a  fracture  of  the  head,  neck,  or  trochanters  of  the  femur  is  comj)licated  with  a  wound 
of  the  femoral  vessels.  It  may  be  possible  to  restore  the  circulation  by  vascular 
suture  or  anastomosis.  (3)  When  a  gunshot  fracture  involving  the  hip-joint  is 
complicated  by  a  severe  compound  fracture  of  the  limb  lower  down,  or  by  a  wound 
of  the  knee-joint." 

Other  authorities  have  differed  from  Dr.  Otis's  opinion  as  to  the  uselessness  of 
expectant  treatment  in  gunshot  injuries  of  the  hip-joint.  Prof.  Langenbeck,^  from 
his  experience  in  the  Franco-German  War,  considered  that  the  expectant  treatment 
gave  a  larger  proportion  of  recoveries  than  excision,  and  still  more  than  amputation, 
and  advised  that  the  expectant  method  should  always  be  resorted  to  save  when  dis- 
articulation is  rendered  inevitable  by  the  destruction  and  shattering  of  the  limb. 
Sir  T.  Longmore,*  thought  that  this  question  must  be  held  to  be  still  "  stib  jiidice, 
and  surgeons  must  wait  for  still  more  extended  experience  under  modern  improved 
methods  of  treatment,  before  any  rule  can  be  accepted  as  having  yet  been  established 
on  this  grave  question." 

Dr.  Otis  shows  that  "  intermediary  operations  offer  the  least  chance  of  recovery." 

The  experience  of  the  Boer  campaign,  one  where  the  proportion  of 
shell  wounds  was  very  small,  was  widely  different. 

Mr.  G.  H.  Makins,  C.B./  saw  no  case  of  perforation  of  the  head  or  neck 
of  the  femur,  nor  of  injury  to  the  hip-joint.  Occasionally  excision  of  the 
head  of  the  femur  is  indicated  in  poor  patients  suffering  severe  pain  from 
intracapsular  fracture. 

Operation.  Two  will  be  described  here  :  A.  By  Anterior  Incision  ; 
B.  By  Posterior  Incision. 

A.  Mr.  A.  E.  Barker,^  in  his  Hunterian  Lectures,^  advocated  the  use  of 
the  anterior  method  in  the  early  stage  of  hip  disease.  In  later  papers  '  he 
published  some  cases  thus  treated  in  later  stages,  where  other  means  had 
failed,  and  abscesses  were  threatening  to  burst.  The  following  are  the 
chief  advantages  :  (1)  the  interference  with  the  muscles  is  practically  nil  ; 

1  Med.  and  Surg.  Hist,  of  the  War  of  the  Rebellion,  pt.  iii,  p.  165. 

2  Arch.  f.  Klin.  Ghir.,  1874,  Bd.  xvi,  S.  309-316.  The  recoveries  seem  to  have  been 
twenty-five  out  of  eighty-eight  cases  so  treated. 

'  Syst.  of  Surg.,  vol.  i,  p.  561. 

*  Loc.  supra  cit.,  pp.  193  and  238. 

*  Mr.  R.  W.  Parker  {Clin.  Soc.  Trans.,  vol.  viii,  p.  108)  recommended  this  method  as 
interfering  less  with  the  muscles  and  the  blood-supply  of  the  joint.  Hiiter  was,  I  believe, 
really  the  first  to  use  this  incision,  draining  the  joint  by  a  counter-puncture  at  the  back. 

«  Brit.  Med.  Journ..  1888,  vol.  i,  p.  1326. 

'  Ibid.,  1888,  vol.  ii,  p.  1337,  and  1890,  vol.  ii,  p.  1009, 


820       OPERATIONS  ON  THE  LOWER  EXTREMITY 


(2)  the  patient  can  thus  be  treated  and  his  wound  dressed  much  more 
conveniently,  e.g.  with  a  Thomas's  splint ;  (3)  primary  union  will 
follow  if  the  following  most  essential  points  can  be  secured  :  {a)  the 
whole  of  the  diseased  structures  must  be  removed  ;  (b)  perfect  asepsis 
must  be  secured  ;  (c)  all  oozing  must  be  checked,  and  the  wound  kept 
dry  by  well-applied  dressings  ;  [d]  absolute  rest  must  be  maintained 
during  healing.  With  regard  to  the  objection  which  has  usually  been 
considered   to   be   fatal   to   the   anterior  incision,   ^^z.   the   insufficient 

drainage  which  it  gives,  Mr.  Barker 
replies  that  the  incision,  though 
anterior,  is  perfectly  adequate  for 
drainage,  (1)  because  the  discharges 
are,  if  the  above  given  precautions  are 
duly  followed,  very  small  in  quantity, 
"  little  more  than  odourless  serum, 
which  ought  never  to  become  truly 
purulent";  (2)  "if  all  the tubercidar 
tissue  is  removed,  a  clean- walled 
cavity  is  left,  most  of  which  is  quite 
capable  of  healing  by  first  intention, 
when  its  dift'erent  surfaces  are  brought 
into  close  contact  by  firm  pressure. 
And,  in  these  cases,  the  head  of  the 
bone  being  removed,  and  the  aceta- 
bulum quite  clean,  the  cut  surface  of 
the  neck  of  the  femur  can  be  brought 
close  up  to  the  latter,  so  that  al- 
though there  is  potentially  a  large 
space  in  the  field  of  operation,  there 
ought  to  be  actually  little  or  no  cavity 
left  if  pressure  has  been  properly 
apphed  from  the  first." 

G.  A.  Wright,^  speaking  at  the 
discussion  on  one  of  Mr.  Barker's 
papers,  said  that  he  had  found  the 
entire  removal  of  the  morbid  tissues 
practically  impossible  either  by  the 
anterior  incision  which  he  used  occa- 
sionally, or  by  the  posterior.  Only 
little  foci  of  disease  might  be  left, 
but  they  were  apt  to  suppurate  when 
some  fall  or  accident  gave  them  the 
opportunity.  And  this  will  be  the 
experience  of  most,  particularly  with 
regard  to  the  acetabulum,  and  syno- 
vial membrane  at  the  back  of  the 
capsule. 

Operation. — The  patient  being  on  his  back,  with  the  limb  extended, 
and  the  parts  duly  sterilised,  the  surgeon  makes  an  incision  three  to  four 
inches  long,  starting  half  an  inch  below  the  anterior  superior  spine,  down- 
wards and  slightly  inwards,  between  the  tensor  vaginae  and  gluteei 
externally  and  the  sartorius  and  rectus  internally.  The  upper  part  of  this 
1  Brit.  Med.  Journ.,  1888,  vol.  ii,  p.  1338. 


Fig.  332.  (1)  R.  Jones's  line  of  section 
through  trochanter.  By  this  trans- 
trochanteric osteotomj',  followed  by 
traction  and  abduction,  Mr.  R.  Jones 
has  been  able  to  obliterate  or  very 
greatly  lessen  the  shortening  in  a  very 
large  number  of  cases  of  bony  anky- 
losis. (2)  Cuneiform  osteotomy  for 
coxa  vara.  (3)  Anterior  incision  for 
excision  of  the  hip.    (MacCormac.) 


EXCISION  OB^  THE  HIP  821 

incision  sliould  pass  down  to  the  capsule  at  once,  the  lower  third  should 
divide  skin  only.  The  interval  betw'een  the  above-named  muscles  is 
next  thorougiily  opened  up  and  the  wound  retracted,  so  that  the  anterior 
surface  of  the  capsule  is  exposed.  A  branch  of  the  external  circumflex 
artery  will  now,  probably,  be  divided.  The  capsule  now  being  freely 
opened,  and  the  limb  flexed,  the  left  index  finger  is  passed  into  the 
joint.  As  the  difliculty  wiiich  is  sometimes  experienced  in  removing 
the  head  is  usually  due  to  an  insufticient  division  of  the  capsule,  this 
is  now  further  incised  with  scissors,  the  left  index  finger  being  used  as  a 
guide.  An  aseptic  finger  now  examines  the  condition  of  the  joint.  The 
wound  being  opened  by  retractors,  a  narrow-bladed  saw,  guided  by  a 
finger,  is  introduced  into  the  upper  part  of  the  wound  in  the  direction  of 
this,  and  with  as  little  damage  to  the  soft  parts  as  possible,  and  the  femur 
sawn  through  the  neck,  or  across  the  top  of  the  great  trochanter. 

The  advantages  and  disadvantages  of  these  sections  are  given  below 
at  p.  823.  In  a  case  at  all  advanced  there  will  always  be  a  risk  that  a 
section  through  the  neck  will  expose  diseased  bone.  The  head  of  the 
femur  is  now  extracted  and  the  acetabulum  treated  by  the  means  given 
at  p.  823.  Owing  to  the  depth  at  which  it  lies  there  is  usually  difficulty 
in  dislodging  the  head  of  the  femur.  Its  direction  must  be  remembered, 
and  the  narrow  interval  between  its  articular  surface  and  the  acetabulum 
detected.  A  free  opening  in  the  capsule  will  facilitate  its  extraction. 
In  the  use  of  elevator  or  forceps  care  must  be  taken  not  to  damage  the 
sawn  edge  of  the  femur  (p.  823).  Every  atom  of  diseased  structure, 
including  all  the  synovial  membrane  that  is  accessible,  must  now  be 
removed,  especial  care  being  taken  to  clear  out  any  caseating  abscesses 
communicating  with  the  joint.  All  this  should  be  done  with  as  little 
violence  as  possible  to  the  surrounding  tissues,  the  lowered  vitality  of 
these  being  remembered,  so  that  none  of  the  tuberculous  debris  be 
forced  into  the  fresh-cut  surfaces.  The  best  instrument  for  remov- 
ing the  disease  thoroughly  is  Mr.  Barker's  "  flushing  gouge."  This 
has  a  cutting  scooplike  edge,  is  perforated,  and  to  its  belt  is  attached 
tubing  which  communicates  with  an  irrigating  can.  By  this  means 
boiled  water  (F.  105°)  is  kept  flowing  through  the  area  of  operation, 
carrying  away  the  debris  of  disease  whether  from  abscess  cavities,  the 
joint,  or  the  surface  of  the  acetabulum,  if  diseased,  and  wdth  it  all  blood, 
while  at  the  same  time  it  arrests  haemorrhage.  When  every  part  of  the 
field  of  operation  has  been  gouged  and  scraped  clear  of  all  tuberculous 
material,  and  the  water  runs  clear,  the  cavity  is  dried  out  with  sterihsed 
pads,  and  the  wound  closed  with  interrupted  salmon-gut  sutures.  Gradu- 
ated even  pressure  is  then  applied  by  the  dressing  and  bandages,  so  that 
the  walls  of  the  cavity  are  brought  into  apposition,  and  the  remainder 
of  the  neck  of  the  femur  secured  in  the  acetabulum.  The  patient  is  then 
placed  in  a  double  Thomas's  splint.  If  sinuses  are  present,  and  the 
joint  infected,  the  wound  must  not  be  closed,  but  drainage  must  be 
provided.  All  sinuses,  having  been  thoroughly  opened  up  and  curetted, 
must  be  plugged  by  means  of  strips  of  iodoform  gauze  passing  down 
to  the  bottom. 

With  regard  to  the  after-treatment  I  would  urge  that  cases  of  hip 
excision  should  be  got  up  as  early  as  possible,  i.e.  at  the  end  of  six 
or  eight  weeks.  A  double  Thomas's  splint  should  be  applied  immediately 
after  the  operation,  and  worn  for  a  period  of  from  six  to  eight  months. 
After  this  the  child  should  get  about  on  a  patten  and  crutches,  sw^inging 


822       OPERATIONS  ON  THE  LOWER  EXTREMITY 

the  affected  limb.  He  should  not  be  allowed  to  bear  any  weight  on  this 
for  a  year  after  the  operation.  If  w^eight  is  borne  on  the  limb  earher,  the 
end  of  the  femur  is  pushed  upwards  on  to  the  dorsum  ihi,  and  much 
shortening  is  the  result.  A  modified  Hessing's  splint  or,  in  poor  patients,  a 
Thomas's  calliper  sphnt,  designed  to  take  the  weight  from  the  tuber 
ischii,  enables  the  patient  to  walk  earher  and  with,  less  fear  of  shortening, 
adduction  or  flexion.  Mr.  Barker  has  allowed  some  of  his  cases  to  get  up 
and  dispense  with  a  sphnt  at  a  much  earher  period.  I  think  the  above- 
given  dates  better  suited  to  these  cases  of  excision  of  the  hip,  when  we 
remember  the  risks  to  which  they  are  exposed  by  their  rough-and-tumble 
Ufe  when  they  leave  the  hospital. 


frrfi/iftio^L 


GLUTEUS  M^}^lMUb 


Fig.  333. 


Resection  of  the  head  of  the  femur  by  the  posterior  incision. 
is  flexed  to  an  angle  of  45°. 


The  thigh 


B.  Posterior  Incision  (Fig.  333).  The  chief  advantage  of  this  is  its 
better  drainage,  a  point  which  is  of  less  importance  nowadays,  and 
which  no  longer  outweighs,  in  my  opinion,  the  smaller  interference  with 
muscles  entailed  by  the  incision  in  front  (p.  819). 

While  the  patient  is  being  brought  under  ether,  a  stirrup  is  applied  if  weight- 
exteiTsion  is  to  be  made.  The  child  being  rolled  over  on  to  his  sound  side,  and  the 
parts  thoroughly  cleansed,  the  surgeon  stands  usually  outside  the  limb,  the  patient's 
body  being  in  either  case  placed  conveniently  at  the  edge  of  the  table,  one  assistant 
supporting  the  limb,  wliile  another  is  opposite  to  the  surgeon.  An  incision,  about 
three  and  a  half  inches  long,^  is  now  made  over  the  middle  ^  of  the  great  trochanter, 
commencing  about  midway  between  the  top  of  this  bone  and  the  posterior  superior 
spine,  and  ending  over  the  shaft,  just  below  the  trochanter.  The  incision  should 
curve  slightly  forwards  and  pass  down  to  bone  or  cartilage,  as  the  case  may  be,  at 

1  It  must  be  always  remembered  that  a  sn  all  wound,  by  giving  insufficient  room,  leads 
to  bruising  and  difficulty. 

^  The  advantage  of  going  so  far  forward  as  this  is,  that  the  fleshy  and  vascular  parts 
of  the  muscles  attached  to  the  great  trochanter  are  better  avoided. 


EXCISION  OF  THE  HIP  823 

once.  Any  blicding  vessels  having  been  secured,  the  exact  position  of  the  head  and 
neck  is  now  made  out  by  Ihe  finger,  aided  by  an  assistant  rotating  flio  limb.  A 
second  incision  opens  the  capsule  freely.  With  a  periosteal  elevator,  aided  by  a 
knife,  the  muscles  attached  to  tlie  great  trochanter  are  detached,  the  cartilage  in 
young  subjeits  peeling  off  with  them  in  one  or  more  pieces.  The  finger  is  now 
passed  roinid  tlio  neck  of  the  femur  and  the  soft  j)arts,  iuc^luding  the  ])eri()st(Him, 
detached  as  much  as  ])ossible  on  f  lie  inner  side.  The  linger  now  feeling  that  the 
u])per  j)art  of  the  trochanter  and  the  neck  of  the  bone  are  free,  and  protecting  the 
soft  parts  on  the  inner  side,  the  bone  is  sawn  through  just  below  the  toii  of  the  tro- 
chanter with  an  osteotomy,  metacarpal,  or  keyhole  saw.^  This  division  should 
be  thoroughly  and  cleanly  eifected  witliout  splintering.  If  it  be  preferred,  in 
addition  to  the  ])rotection  of  the  finger  on  the  inner  side,  a  blunt  dissector  may  be 
})assed  behind  the  bone,  but  this  is  not  essential:  retraction  will  protect  the  lijis 
of  the  wound  from  the  saw.  With  the  aid  of  tlie  finger  and  an  elevator,  or  with  a 
lion-forceps,  the  head  and  neck  of  the  bone  are  levered  out  of  the  acetabulum,  this 
being  often  attended  with  difhculty.  Free  opening  of  the  cajjsule  will  aid  this  step. 
But  great  care  is  now  needed  to  avoid  infliction  of  damage  on  the  sawn  femur.  Such 
damage  is  very  likely  indeed  to  lead  to  tuberculous  infection  of  the  bony  section. 
This  must  be  left  clean  cut  and  uninjured.  Any  instrument  used  must  be  directed 
to  the  head  itself.  The  ligamentum  teres  is  probably  destroyed  ;  if  not,  it  must  be 
divided.  The  acetabulum  is  then  examined,  and,  if  merely  roughened,  left  alone  ; 
if  pitting  or  erosion  be  j)resent,  gouging  must  be  resorted  to.  Any  sequestra  present 
must  be  removed.  If  the  acetabulum  is  perforated,  and  pus  present  on  its  pelvic 
aspect,  free  exit  must  be  provided  by  means  of  a  gouge  or  small  trephine,  and  a 
drainage-tube  passed  tlu'ough. 

The  inner  surface  of  tlie  capsule  and  all  abscess  cavities  must  now  be  thoroughly 
curetted  and  irrigated  by  means  of  a  flushing  spoon,  as  described  above,  until  all 
granulation  tissue  and  caseous  debris  have  been  removed.  If  sinuses  are  present, 
these  must  be  carefully  curetted  and  treated  with  pure  carbolic  acid.  Haemor- 
rhage is  usually  very  slight,  and  with  the  exception  of  a  few  vessels,  which  may 
be  caught  with  forceps,  usually  consists  of  a  general  oozing,  This  will  usually  be 
stopped  by  the  hot  irrigating  fluid  ;  if,  however,  it  is  troublesome,  the  cavity  may 
be  jmcked  with  gauze. 

Drainage,  either  by  means  of  iodoform  gauze  or  a  tube,  will  be  necessary  in  nearly 
all  cases.  In  a  very  few,  however,  where  no  sinuses  exist,  where  all  disease  in  bone 
and  soft  jiarts  alike  has  been  removed,  and  where  all  oozing  has  been  arrested,  a  little 
sterilised  iodoform  emulsion  may  be  rubbed  in  and  the  wound  partially  closed  with 
sutures.  The  dressings  must  be  carefully  applied  and  firm  pressure  used  to  prevent 
oozing. 

Site  of  Section  of  the  Femur.  Section  through  the  root  of  the  neck 
of  the  femur  has  the  great  advantages  of  disturbing  and  damaging  the 
attachments  of  muscles  much  less,  and  thus  leads  to  more  rapid  healing 
and  far  greater  mobility  of  the  Hmb.  These,  however,  are  outweighed  by 
the  disadvantage  which  leaving  such  a  large  piece  of  bone  as  the  trochanter 
entails,  viz.  that,  after  heahng,  this  process  gets  drawn  up  against  the 
scar  and  may  constantly  fret  it.  It  is  also  said  to  check  the  escape  of 
discharges,  and  to  render  the  patient  liable  to  persistence  or  recur- 
rence of  the  disease.  I  am  doubtful  as  to  the  last  two,  but  the 
first  is  absolutely  certain,  unless  prolonged  rest  is  enforced.  Where 
the  section  is  made  through  the  neck,  the  surface  must  be  carefully 
scrutinised. 

Usual  Causes  of  Failure  after  Excision  of  the  Hip.  (1)  Persistent 
pelvic  disease.     (2)  Chronic  osteomyehtis  of  sawn  end  of  femur  [vide 

^  It  is  usually  advised  that  the  section  of  the  femur  be  mads  while  the  bone  is  in  situ. 
owing  to  the  risks  of  fracturing  a  wasted  shaft,  inflicting  damage  on  weak  epiphysial 
lines  and  strijaping  otT  the  periosteum.  But  these  accidents  will  be  very  exceptional  in 
careful  hands.,  and  there  is  no  doubt  that  displacement  of  the  head  (by  adducting  the 
limb)  facilitates  complete  removal  of  the  synovial  membrane,  especially  its  posterior  and 
less  accessible  portion.  Finally,  careful  dislocation  of  the  head  does  away  with  the 
difficulty,  often  present,  of  turning  it  out  of  its  socket  after  the  bone  section  has  been 
made  in  situ,  and  the  resulting  damage  so  easily  inflicted  on  the  upper  end  of  the  shaft  of 
the  femur  {vide  infra). 


824       OPERATIONS  ON  THE  LOWER  EXTREMITY 

supra).  (3)  Suppuration  and  hectic.  (4)  Lardaceous  disease.  (5)  Tu- 
berculous conditions  elsewhere.  General  outbreak  of  tuberculosis. 
(G)  Disease  of  the  opposite  femur. 

Operations  for  Rectifying  Deformities  in  the  Later  Stages  of  Hip-Joint 
Disease,  such  as  a  cuneiform  osteotomy  of  the  neck,  or  Gant's  sub- 
trochanteric operation,  are  described  below  in  the  chapter  on  Osteotomy. 

The  anterior  incision  should  be  used  to  open  the  joint  in  cases  of 
infective  arthritis  and  epiphysitis  occasionally  met  with  here.  Owing  to 
the  gravity  of  these  cases,  and  the  difficulty  of  flushing  out  the  joint 
and  establishing  drainage,  the  capsule  should  be  very  freely  opened  and 
drainage  should,  in  every  case,  be  provided  behind  by  a  counter-puncture 
in  the  buttock,  made  with  a  pair  of  stout  forceps  thrust  through  the  back 
of  the  capsule  from  the  wound  in  front. 

I  only  mention  the  subject  of  excision  in  osteoarthritis  to  condemn 
it,  owing  to  its  severity  in  patients  of  the  usual  age  at  which  this 
disease  appears,  and  the  impossibility  of  preventing  re-appearance  of 
osteophytes.  I  can  imagine  the  operation  being  justified  in  patients 
who  are  crippled  at  an  unusually  early  age,  in  whom  both  joints  are 
affected,  the  operation  being  performed  in  the  hope  of  enabling  them 
to  bend  one  hip-joint.  Handley's  operation  for  the  removal  of  osteo- 
phytes from  the  acetabular  rim  and  the  neck  of  the  femur  is  to  be 
preferred. 

In  some  cases  when  only  one  hip-joint  is  affected  with  painful  osteo- 
arthritis a  partial  arthrectomy  with  the  object  of  securing  painless  bony 
ankylosis  is  desirable. 


SACRO-ILIAC  JOINT 

ARTHRECTOMY 

It  has  been  show  that  the  prognosis  in  tuberculous  disease  of  this  joint, 
usually  looked  upon  as  so  grave,  is  much  better  if  the  same  radical  methods 
of  treatment,  which  have  proved  so  satisfactory  in  other  joints,  are 
applied  to  the  sacro-iliac  synchondrosis  after  conservative  treatment  has 
failed. 

Mr.  Collier  first  drew  attention  to  the  above  fact  with  a  case  success- 
fully treated  by  trephining,^  and  Sir  George  Makins  and  Mr.  Golding  Bird 
followed,  each  surgeon  publishing  three  successful  cases. ^  The  following 
points  are  taken  from  these  papers  : 

Operation.  The  joint  is  exposed  by  a  crucial  incision  (Makins),  or 
by  a  flap  (Collier,  Golding  Bird).  In  the  words  of  the  last-named  surgeon, 
"  a  semicircular  flap  of  skin  and  subcutaneous  tissue  over  the  iliac  area 
of  the  joint,  and  having  its  convexity  corresponding  to  the  posterior 
edge  of  the  ilium,  is  dissected  upwards  and  forwards,  and  the  underlying 
glutei  are  detached.  The  bone  being  thus  freely  exposed,  a  large  trephine 
is  applied  at  the  root  of  the  posterior  inferior  iliac  spine,  and  in  a  line  drawn 
from  the  top  of  that  spine  to  the  junction  of  the  anterior  with  the  middle 
third  of  the  iliac  crest.  .  .  .  The  ilium  at  the  seat  of  the  operation  is 
very  thick,  but  the  disc  of  bone  removed  should  reach  quite  down  to  the 
joint."     The  trephine-opening  is  then  sufficiently  enlarged,  the  articular 

1  Lancet,  1889,  vol.  ii,  p.  787. 

^  Clin.  Soc.  Trans.,  vol.  xxvi,  p.  127,  and  vol.  xxviii,  p.  186. 


ARTHRECTOMY  825 

surfaces  cut  away  with  a  gouge  or  forceps  sufficiently  to  enable  the 
surgeon  to  explore  the  pelvic  surface  of  the  joint,  and  to  liberate  any  pus 
lying  on  this  aspect.  The  sharp  spoon,  or  Baiker's  flushing  gouge, 
is  then  thoroughly  used,  all  fragments  of  bone,  granulation  tissue,  or 
loosened  cartilage  removed,  and  any  sinuses  present  laid  open.  Sterilised 
iodoform  having  been  next  applied  the  wound  is  closed,  a  drainage-tube 
being  left  in  for  twenty-four  hours  only.  Rest  for  some  weeks  in  the 
supine  position,  to  be  followed  by  a  Thomas's  hip-splint  with  crutches 
and  elevation  of  the  opposite  boot  for  many  months,  are  essential  in  the 
after-treatment. 


CHAPTER  XXXIX 

OPERATIVE  INTERFERENCE  IN  DISLOCATION  OF 
THE  HIP.     COXA  VARA 

Heke  three  varieties  of  cases  have  to  be  considered  :  I.  Traumatic  Disloca- 
tions. II.  Dislocation  from  Disease  (this  is  rather  a  partial  dislocation, 
or  a  subluxation).     III.  Congenital  Dislocations. 

I.  Traumatic  Dislocation.  The  great  deformity,  permanent  crippling,  and 
often  great  suffering  resulting  occasionally  from  old  unreduced  dislocations  of  the 
hip,  abundantly  justify  resort  to  operation,  nowadays,  as  long  as  it  is  understood 
that  the  operation  will  be  a  severe  one,  and  the  after-treatment  one  requiring  great 
vigilance  on  the  jmrt  of  the  surgeon. 

In  an  excellent  paper  ^  Dr.  M.  L.  Harris,  of  Chicago,  publishes  an  instructive 
oase  of  his  own  and  twenty-four  others  which  he  has  collected.  From  these  he 
draws  the  following  conclusions  :  (1)  Owing  to  the  danger  of  fracturing  the  neck 
of  the  femur  ;  "-  of  laceration  of  the  great  vessels  of  the  thigh ^ — h^ere,  in  an  attempt  to 
reduce  by  manipulation  an  obturator  dislocation  of  thirteen  weeks'  duration  in  an 
adult,  a  fatal  tear  was  produced  at  the  junction  of  the  superficial  and  deep  femoral 
veins  ;  or' of  shock  and  death,''  the  application  of  great  force  to  reduce  old  disloca- 
tions of  the  hip  should  be  discontinued  in  favour  of  freely  opening  the  joint  and 
reducing  the  head  of  the  bone,  after  the  method  used  by  Dr.  Harris  {vide  infra). 
(2)  Subcutaneous  operations  in  old  dislocations  arc  without  benefit.  (3)  As 
osteotomy  below  the  great  trochanter  leaves  the  head  in  its  abnormal  jiosition,  and 
thus  fails  to  relieve  the  pain  which  so  frequently  accompanies  these  old  dislocations, 
and  as  it  cannot  improve  the  limited  mobility  which  is  always  present,  it  is  not  to  be 
considered  in  any  way  an  operation  of  choice.  (4)  Resection  is  only  to  be  thought 
of  when  reduction  after  free  arthrotomy  fails. 

The  following  are  the  steps  of  the  operation  performed  by  Dr.  Harris  in  his 
case  of  dorsal  cUslocation  of  nearly  four  months'  standing,  in  which  rej^eated  and 
prolonged  attempts  at  reduction  had  been  made  : 

A  free  incision  was  made  between  the  tensor  vaginae  femoris  and  the  gluteus 
medius,  thus  leading  directly  down  to  the  acetabulum  and  anterior  surface  of  the 
head  and  neck  of  the  femur.  As  was  expected,  the  acetabulum  was  found  filled  with 
a  tough,  adherent  comiective  tissue  proliferation  ^  from  the  anterior  portion  of  the 
capsular  ligament,  which,  in  falling  over  the  cavity,  completely  closed  it.  On 
cutting  through  the  capsular  ligament,  the  head  of  the  bone  was  found  resting 
on  the  posterior  and  superior  edge  of  the  acetabulum  in  a  shallow  depression,  the 
lining  of  which  had  a  smooth  cartilaginous  feel.  Immediately  in  front  of  the  head 
and  helping  to  fill  the  cotyloid  cavity  was  a  small  piece  of  bone,  curved  in  shape, 
which  had  been  detached  from  the  posterior  wall  of  the  acetabulum.  This  may  have 
been  an  obstacle  to  the  early  reduction  of  the  case.  The  head  of  the  bone  was  still 
covered  with  smooth  cartilage,  while  the  neck  had  acquired  new  firm  adhesion  to 
all  the  surrounding  parts,  thus  producing  a  new  capsular  ligament. 

1  Ann.  of  Surg.,  September  1894,  p.  319. 

2  Arch.f  hlin.  Ckir.,  1885,  Bd.  xxxii,  S.  440. 

3  Ann.  of  Surg.,  June  1892,  p.  425. 
«  Rev.  cCOrthop.,  September  1890. 

^  In  a  case  of  traumatic  dorsal  dislocation  in  a  boy,  aged  7,  reduced  after  five  months 
by  the  open  method,  and  brought  by  Mr.  Spencer  before  the  Clinical  Society.  Febuary  8, 
1895,  a  long  anterior  incision  showed  the  acetabulum  to  be  filled  with  dense  fibrous 
tissue.  It  is  stated  that  the  acetabuhim  could  not  have  been  reached  by  a  posterior 
incision  without  resecting  the  head  of  the  bone. 

826 


DISLOCATIONS  OF  THE  HIP  827 

Only  a  small  pDi'tioii  of  the  ligainciitiiiii  teres  was  present  in  the  dcjuession  in  tlie 
head  when  lliis  was  turned  out  of  its  uvw  joint.  The  adhesions  to  the  neck  were 
divided,  and  all  tlie  nuiseular  atlaelnuents  to  the  groat  troehanter  and  shaft  as  far 
down  as  tlu^  hvsser  trochanter  were;  separated  sid)j)eriosteally  from  the  bone,  thus 
liberating  tlie  entire  uj)])er  end  of  the  fennu'.  Atfi-ntion  was  tlien  directed  to  the 
acetabulum,  which,  by  means  of  the  gouge  and  shar])  sj)oon,  was  freed  of  capsular 
ligament  and  th(>  new  connective-tissue  format  ion.  The  (cartilage  lining  tlio  bottom 
of  the  cavity  was  found  to  be  still  smooth.  The  head  of  the  bone,  however,  could 
not  be  made  to  enter  the  acetabulum,  whuih  seemed  too  small.  The  cavity  was 
consequently  enlarged  somewhat  ])osteriorly  with  the  gouge  and  mallet,  after  which, 
by  considerable  exertion  and  nianijndation,  the  head  was  finally  returned  to  its 
place,  and  the  leg  assumed  its  normal  position.  Tlie  wound  was  partly  stitched,  and 
the  rest  jiat'ked  with  iodoform  gauze.  The  limb  was  placed  in  the  extended  position, 
plaster  of  Paris  j)ut  on,  and  extension  applied.  The  o})eration  was  a  very  severe  one, 
occupying  fully  two  hours.  The  patient  suffered  considerably  from  shock,  although 
the  loss  of  blood  was  not  great.  Reaction  came  on  promptly,  and  the  progress  of  the 
case  was  favourable  from  the  start.  There  was  considerable  serous  drainage  from 
the  wound  during  the  first  few  days,  necessitating  rather  frequent  renewals  of  the 
dressings.  In  three  weeks  the  wound  was  closed,  but  in  another  week  a  small 
collection  of  sero-pus  required  evacuation  by  a  counter-puncture.  The  extension 
was  continued  three  weeks.  Six  weeks  from  the  time  of  the  operation  the  patient 
was  allowed  up  on  crutches.  In  three  months  he  could  walk  with  a  cane  without 
pain  in  the  hip.  Active  motion  was  possible  in  all  directions — flexion,  alxluction, 
adduction,  and  rotation  ;  these,  though  limited,  were  daily  increasing. 

II.  Dislocation  from  Disease.     This  has  been  referred  to  at  p.  818. 

III.  Congenital  Dislocations.  Lorenz's  Manipulative  Method.  There 
is  no  doubt  that  Lorenz's  bloodless  method  gives  very  satisfactory  results 
in  the  majority  of  children  under  eight  years  of  age.  The  younger  the 
child  the  more  easy  the  replacement,  the  less  the  danger,  and  the  better 
the  result.  Even  when  the  head  of  the  femur  cannot  be  reduced  or  main- 
tained in  the  acetabulum,  a  posterior  dislocation  is  converted  into  a 
subspinous  one,  and  the  functional  result,  although  not  perfect,  is  much 
improved.  The  gliding  is  much  diminished  and  the  balance  is  improved. 
The  pelvis  and  the  thighs  are  thoroughly  washed,  dried,  and  then  powdered 
with  boracic  acid  and  zinc  oxide,  and  the  hands  of  the  surgeon  are  treated 
in  a  similar  way.  While  an  assistant  thoroughly  fixes  the  opposite  side 
of  the  pelvis  and  the  opposite  thigh,  the  surgeon  grasps  the  knee  with 
one  hand  and  flexes  and  abducts  the  thigh,  while  with  the  ulnar  border  of 
the  other  hand  he  presses  against  and  tears  the  tight  adductors  just  below 
the  pelvis.  The  muscles  gradually  yield  to  the  firm  pressure  combined 
with  traction,  and  when  they  no  longer  offer  any  appreciable  resistance 
the  hip  is  gradually  hyperextended  in  order  to  stretch  the  shortened 
structures,  if  any,  in  front  and  to  the  outer  side  of  the  hip,  especially  the 
tensor  fasciae  femoris  and  the  fascia  lata.  Then  the  surgeon  places  one 
fist  with  its  ulnar  border  on  the  table  and  the  child's  trochanter  lying  in 
the  hollow  between  the  index  finger  and  the  thumb.  The  fist  thus 
placed  acts  as  a  splendid  fulcrum,  while  with  the  other  hand  the  thigh  is 
flexed,  abducted,  and  rotated  until  the  head  of  the  femur  can  be  felt  to 
enter  the  acetabulum  with  a  distinct  thud  or  click.  When  the  head  has 
been  reduced  an  effort  is  made  to  stretch  the  anterior  part  of  the  capsule 
by  rotation  of  the  femur  but  care  must  be  taken  to  avoid  external  rotation, 
which  may  possibly  produce  a  subspinous  dislocation.  The  pelvis  and 
the  thigh  are  surrounded  with  gamgee  tissue  and  several  plaster  bandages 
are  applied,  while  the  hip  is  maintained  in  the  corrected  position  ab- 
ducted at  right  angles  to  the  pelvis,  and  with  the  knee  farther  back  than 
the  })lane  of  the  symphysis  pubis.  The  plaster  spica  extends  to  the  lower 
third  of  the  thigh,  the  knee  being  left  free.     Great  care  is  taken  to  avoid 


828        OPERATIONS  ON  THE  LOWER  EXTREMITY 

undue  pressure  upon  any  part,  and  especially  by  the  edges  of  the  spica. 
This  can  be  avoided  by  making  the  plaster  less  extensive  than  the  gamgee 
protection.  No  plaster  is  applied  directly  in  front  of  the  reduced  head 
of  the  femur,  for  it  is  a  great  advantage  to  be  able  to  prove  that  the 
correction  is  maintained,  by  feeling  the  head  of  the  femur  and  by  means  of 
an  X-ray  examination,  while  the  plaster  is  still  on.  When  the  displace- 
ment is  double,  both  hips  are  reduced  at  the  same  sitting,  and  then  fixed 
in  a  double  plaster  spica.  The  plaster  is  changed  at  once  if  the  correc- 
tion is  not  maintained,  as  shown  by  repeated  examinations  ;  but,  as 
a  rule,  it  is  not  necessary  to  change  it  for  about  three  months,  and  then 
the  flexion  and  abduction  may  be  shghtly  diminished  in  most  cases.  At 
the  end  of  six  months  the  limb  is  brought  still  farther  down  so  that  the 
child  can  walk  upon  the  foot  with  the  aid  of  a  high  boot. 

If  carefully  carried  out,  Lorenz's  bloodless  method  gives  very  satis- 
factory results  in  the  majority  of  cases.  In  about  80  per  cent,  the  head 
of  the  femur  can  be  reduced  into  the  acetabulum  ;  and  though  in  a  few 
redislocation  may  occur  from  failure  of  after-treatment,  it  may  be 
estimated  that  in  at  least  60  per  cent,  of  cases  a  good  permanent  ana- 
tomical reduction  can  be  obtained,  and  that  in  another  30  per  cent, 
anterior  transposition  with  improved  function  may  result. 

There  are  certain  dangers  associated  with  the  method,  and  these 
should  never  be  overlooked.  The  anaesthetic  mortality  has  been  high, 
probably  owing  to  the  severity  of  the  manipulation  and  consequent  shock. 
The  neck  of  the  femur  and  even  the  pelvis  have  been  fractured.  Paralysis 
of  the  external  popliteal,  the  sciatic,  or  the  anterior  crural  nerve  has 
also  occurred.  The  femoral  artery  has  been  ruptured,  and  gangrene  of 
the  leg  has  occurred.  Suppuration  or  sloughing  of  the  skin  in  the  soft 
parts  about  the  pelvis  has  also  taken  place.  But  with  care  and  early 
operation  there  is  very  little  risk  of  these  complications  at  the  present 
time. 

Indications  for  Operation.  Operative  interference  in  this  condition 
should  not  be  undertaken  unless  the  bloodless  method  of  reposition  by 
manipulation  has  been  given  a  fair  trial,  and  has  failed.  Even  then 
the  advisabiUty  of  operative  interference  here  is  still  much  disputed. 
When  we  consider  the  condition  of  the  parts  affected,  especially  the 
shallow,  ill-developed  acetabulum  and  the  altered  flattened  head,  we  can 
easily  understand  the  difficulty  which  has  been  met  with  in  getting  the 
head  into,  and  retaining  it  in,  a  satisfactory  position. 

Mr.  Jackson  Clarke,  whose  book  on  "  Congenital  Dislocation  of  the 
Hip,"  2nd  ed.,  1905,  contains  the  clearest  account  of  Lorenz's  manipu- 
lative method  with  which  I  am  acquainted,  and  one  based  on  much 
personal  experience,  goes  farther  than  the  above  statement  and  sums  up 
the  position  of  the  open  operation  as  follows  (p.  x.) :  "It  should  not  be 
performed  in  any  case  in  which  manipulative  reposition  is  impossible, 
and,  where  the  latter  can  be  done,  it  is  safer,  and  alone  gives  far  better 
functional  results  than  the  open  operation.  Therefore  the  open  opera- 
tion is  no  longer  a  legitimate  surgical  procedure."  Later  in  his  work 
Mr.  J.  Clarke  is  inclined  to  allow  a  little  more  latitude,  implying  that 
there  may  be  a  few  cases  in  which  an  open  operation  is  justificable. 
Thus  he  writes  at  p.  21  :  "  Lorenz's  manipulative  method  in  a  con- 
siderable proportion  of  cases  gives  a  perfect  anatomical  and  physio- 
logical result  {i.e.  it  cures  a  condition  hitherto  deemed  incurable)  ;  in 
a  still  greater  number  of  cases  it  affords  a  permanent  functional  im- 


DISLOCATIONS  OF  THE  HIP  829 

proveiiiont  that  relievos  the  patient  of  the  j^jrievous  disahlHties  which 
the  deformity  entails  if  unti-eated.  In  the  reniaininj^  cases  in  which 
this  method  fails  to  give  a  firm  articulation  placed  anteriorly,  the  manipu- 
lative operation  of  Lorenz  is  a  necessary  preliminary  to  any  subsequent 
treatment  by  open  operation  that  may  be  undertaken." 

No  one  who  studies  the  results  which  have  been  progressively  attained 
will  feel  any  doubt  that  with  increasing  experience  and  careful  attention 
to  the  details  of  Lorenz's  techni([ue,  not  only  at  the  time,  but  during  the 
nine  or  twelve  months  which  follow,  the  number  of  perfect  results  will 
increase.^  Where  a  perfect  result,  i.e.  an  actual  replacement  of  the 
head  within  the  acetabulum  and  its  retention  there,  as  proved  by  skia- 
graphy, six  months  after  the  removal  of  all  casing,  is  not  secured,  but 
merely  an  improved  position,  e.g.  an  anterior  transposition,  not  a  true 
reposition,  if  this  transposition  has  brought  the  head  of  the  femur  near 
the  acetabulum,  and  if  this  new  resting-place  is  made  secure  by  atten- 
tion to  the  after-treatment  insisted  upon  by  Lorenz  so  as  to  secure 
sound  healing  of  the  torn  structures  and  to  prevent  a  relapse,  either 
anterior  or  supracotyloid,  or  still  more  a  posterior  or  dorsal  one,  the 
result  will  be  a  great  improvement.-  Thus  many  of  the  chief  deformities 
characteristic  of  congenital  dislocation,  viz.  the  shortening,  the  lordosis, 
and  the  insecurity  will  be  largely  removed,  and  a  good  functional  result 
will  be  secured. 

Operation.  In  those  cases  where  it  has  been  found  impossible  to 
secure  or  to  maintain  a  sufficiently  improved  position,  where  the  child  is 
over  five  or  six  years  and  therefore  more  easily  kept  clean,  but  not  of  such 
an  age  that  the  structures  have  become  so  rigid  that  the  head  cannot 
be  brought  near  the  acetabulum,  the  following  method  may  be  em- 
ployed ;  the  chief  changes  in  the  structures  and  the  difficulties  that 
may  be  met  with  will  be  manifest.  If  the  adductors  and  hamstrings 
are  very  rigid  these  must  be  dealt  with  at  a  preliminary  stage.  By 
extension  the  head  is  drawn  down  to  the  level  of  the  hip-joint.  The 
incision  given  at  p.  820  is  made  and  its  upper  part  prolonged  along  the 
crest  of  the  ilium  in  order  to  detach  the  origin  of  the  tensor  fasciae  and 
the  deep  fascia.^  The  tensor  is  retracted  and  the  extended  limb  rotated 
outwards.  The  capsule  is  next  freely  incised  parallel  with  the  anterior 
inter- trochanteric  line  and  the  head  protruded.  If  the  ligamentum  teres 
interfere  with  this,  it  should  be  divided.  With  a  sterile  finger  the  condi- 
tion of  the  acetabulum  is  investigated.  I  shall  suppose  that  one  exists 
though  small,  and  I  would  here  point  out  that  the  safety  of  the  operation 
largely  turns  on  the  degree  to  which  the  acetabulum  and  head  of  the 
femur  are  developed  ;  the  difficulties  and  dangers  of  the  operation 
increase  greatly  when  this  is  not  the  case.  The  obstacles  to  the  re- 
entrance  of  the  head  may  now  be  found  to  rec[uire  division  of  the  ilio- 
psoas at  its  insertion  (Burghard),  the  straight  head  of  the  rectus  at  its 
origin,^  or  to  be  due  to  resistance  of  the  capsule  and  a  narrow  slit-hke 

^  Mr.  J.  Clarke  is  of  opinion  that  those  who  speak  of  the  perfect  results  attained  by 
Lorenz'smethod  being  few  and  isolated  have  not  really  mastered  the  details  of  his  technique. 

2  The  diiferent  results  which  may  be  attained  short  of  a  perfect  one  and  the  necessary 
treatment,  exercises,  &c.,  to  secure  further  improvement  are  given  in  detail  by  Mr.  J. 
Clarke  (loc.  supra  cit.).  On  this  subject  my  readers  should  also  refer  to  a  paper  by  Dr.  J. 
Ridlon,  of  Chicago  (Journ.  Amer.  Med.  Assoc,  1904.  pp.  1011  and  1063).  The  paper  is  a 
very  helpful  one  from  its  straightforward  candour,  and  from  the  fact  that  Dr.  Ridlon,  like 
Mr.  Clarke,  has  been  associated  with  Lorenz. 

3  Burghard.  Brit.  Med.  Journ.,  October  19,  1901,  p.  1157. 
*  Keetley,  Orthopaedic  Surgery,  j).  297. 


830       OPERATIONS  ON  THE  LOWER  EXTREMITY 

condition  of  the  cotyloid  Ugament.  With  regard  to  the  capsule,  any- 
unnecessary  division  must  be  avoided,  as  it  is  one  of  the  chief  means  of 
restraining  and  steadying  the  head  later,  and  the  introduction  of  sutures 
is  a  possible  source  of  infection.  If  it  be  a  slit-like  condition  of  the 
cotyloid  ligament  which  cannot  be  sufficiently  dilated  by  the  pressure 
of  the  head,  this  structure,  with  the  anterior  attachment  of  the  capsule 
to  the  acetabulum,  together  with  the  straight  head  of  the  rectus,  must 
be  carefully  detached  with  a  periosteal  elevator.  The  head  can  usually 
now  be  placed  in  its  proper  position  by  the  manipulations  of  Lorenz. 
It  remains  to  replace  the  separated  capsule  and  to  tighten  this  by  sutures 
of  sterihsed  catgut  or  silk.  The  question  of  drainage  must  depend  upon 
the  extent  to  which  the  parts  have  been  disturbed,  and  the  dryness  of 
the  wound.  The  hmb  is  then  put  up  in  plaster  of  Paris  in  the  abducted, 
outwardly  rotated,  and  slightly  flexed  position.  To  provide  inspection  of 
the  wound,  Mr.  Burghard  employs  a  form  of  Croft's  splint,  consisting  of 
a  posterior  portion  embracing  the  posterior  two-thirds  of  the  buttocks, 
pelvis,  thigh,  and  leg  ;  the  other  half  embraces  the  anterior  portions, 
and  can  be  taken  off  for  inspection  of  the  wound.  The  knee,  in  the 
flexed  position,  is  included  in  the  plaster.  At  the  end  of  a  month  a 
large  plaster  spica  is  substituted,  and  the  abduction  slightly  diminished. 
An  X-ray  photograph  is  taken  at  the  same  time. 

Up  to  this  point  the  conditions  met  with  have  been  comparatively 
simple  and  easy  to  deal  with.  But  there  are  other  cases  which  present 
an  entirely  different  aspect.  To  take  those  where  the  acetabulum  and 
head  of  the  femur  are  totally  inadequate.  With  regard  to  the  first,  and 
deepening  or  making  a  new  acetabulum,  it  should  be  superfluous  to 
point  out  how  the  difficulties  and  dangers  of  the  operation,  especially 
shock,  haemorrhage,  and  infection,  are  increased.  And  if  these  are 
satisfactorily  met,  the  ultimate  after-result  is  liable  to  be  very  dis- 
appointing. On  this  point  Mr.  Burghard's  opinion  on  the  results  of 
Sir  Arbuthnot  Lane's  operation,  the  object  of  which  is  to  make  a  secure 
joint  below  the  anterior  inferior  spine,  deserves  careful  attention.  "  I 
have  tried  it  in  five  cases  and  have  been  invariably  disappointed  with  the 
results.  The  space  available  for  the  formation  of  a  new  acetabulum  is 
extremely  small,  and  in  order  to  get  a  stable  joint  it  is  necessary  so  to 
whittle  down  the  head  of  the  bone  that  it  becomes  a  mere  point  and  firm 
ankylosis  is  likely  to  result.  If  not,  the  joint  becomes  gradually  unstable, 
and  the  final  condition  is  no  better  than  before  operation."  Every 
surgeon  of  experience  will  confirm  Mr.  Burghard's  opinion.  Hoffa 
himself,  in  his  article  in  v.  Bergmann's  Surgery,^  dismisses  the  formation 
of  a  new  acetabulum  in  four  and  a  half  lines,  as  if  it  were  a  simple  and 
easy  matter.  It  is  a  matter  of  great  difficulty  to  ensure  that  "  the  new 
cavity  be  deep  and  broad  and  the  walls  fairly  steep,  especially  above,  to 
give  good  support  to  the  head."  It  requires  most  careful  and  arduous 
work  with  gouge  and  burrs  to  form  a  new  cavity  even  large  enough  to 
bury  the  last  joint  of  an  adult  thumb.  One  operator  has  b3en  candid 
enough  to  record  a  case  in  which  perforation  of  the  bone  took  place  at 
this  stage  with  fatal  peritonitis.  When  the  head  and  neck  of  the  femur  are 
faulty  in  direction  rather  than  in  development,  i.e.  directed  forwards 
instead  of  inwards,  this  may  be  first  corrected  and  the  dislocation  reduced 
later.  When  the  head  and  neck  are  practically  absent  it  is  extremely 
doubtful  if  any  operation  will  be  of  real  permanent  value.  Our  experience 
^  Amer.  Trans.,  vol.  iii,  p.  413. 


CURVATURES  OF  THE  NECK  OF  THE  FEMUR   831 

up  to  the  present  time  justifies  the  following  conclusions.  Between  the 
ages  of  about  two  and  six — I  repeat  that  the  amount  of  rigidity  present 
is  a  more  important  factor  than  the  luimber  of  years—  one  or  more- 
attempts  should  always  be  made  to  secure  a  peifect  or  nuich  improved 
result  by  the  manipulative  method  perfected  by  Lorenz.  If  the  details 
insisted  upon  by  this  authority  are  followed  at  the  time  and  during  the 
needful  after-treatment,  good  results  will  be  increasingly  secured.  If 
the  surgeon  fail,  and  also  in  the  case  of  rather  older  children,  i.e.  from 
the  ages  of  six  to  about  eight,  it  will  be  justifiable  to  operate  on  the 
lines  given  above.  When  the  acetabulum  and  upper  extremity  of  the 
femur  are  sufficiently  developed  and  normal  in  direction  and  position 
to  admit  of  their  being  refitted,  the  result  will  often  be  good.  In  other 
cases,  it  is  very  doubtful  if  the  results  ultimately  attained  are  worth 
the  risks  which  are  necessarily  run. 

Risks  and  Causes  of  Failure.  The  chief  of  these  are  :  (1)  Shock. 
(2)  Haemorrhage.  (3  and  4)  In  children  the  effects  of  a  prolonged 
anaesthetic  and  of  iodoform  intoxication  irmst  also  be  remembered. 
(5)  Infection.  (6)  Prolonged  suppuration  increasing  the  risk  of  (7)  anky- 
losis. (8)  Relapse  into  a  faulty  position.  Other  rarer  but  possible 
accidents,  such  as  that  of  peritonitis,  have  been  already  mentioned. 
Finally,  in  cases  where  much  difficulty  is  present,  it  is  obvious  that  the 
dangers  which  have  been  met  with  in  the  manipulative  method  must 
be  remembered  here  also.  I  refer,  especially,  to  injury  to  the  dehcate 
epiphyses  and  shaft  and  neck  of  the  femur.  These,  and  many  others, 
are  mentioned  by  Dr.  Ridlon  and  Mr.  J.  Clarke,  especially  the  former.^ 

CURVATURES  OF  THE  NECK  OF  THE  FEMUR.     COXA  VARA  ^ 

Indications  for  Operation.  These  are,  chiefly,  a  degree  of  deformity 
in  which  such  shortening,  fatigue  after  walking,  stiffness  in  stooping 
and  sitting  are  present  that  rest  will  not  permanently  relieve  the  pain, 
or  exercises,  active  and  passive,  increase  the  range  of  movement.  No 
operation  should  be  undertaken  in  children  or  adolescents  while  there 
is  any  reason  to  believe  that  the  bones  are  still  soft,^  and  if  the  patient 
operated  on  be  rapidly  growing  with  poor  development  of  muscles  and 
joints,  prolonged  rest  and  general  treatment  will  be  required  if  a  satis- 
factory result  is  to  be  attained.  An  occupation  involving  hard  work, 
or  carrying  heavy  weights  is,  in  my  opinion,  an  indication  for  operation, 
if  the  above-mentioned  condition  can  be  secured. 

Operation.  Two  groups  may  be  made  here  :  A.  On  the  neck.  B.  Sub- 
trochanteric. Owing  to  the  healthy  condition  of  the  joint,  excision 
may  be  set  aside,  though  still  highly  thought  of  by  some  German  autho- 
rities.^   Contrasting   these   two   methods   briefly,    I   consider   that   the 

^  Loc.  supra  cit. 

^  This  term  is  convenient,  but  only  correct  when  one  curve  is  spoken  of.  IMore  than 
one  curve  may  be  met  with. 

3  Mr.  Keetley,  to  whom  belongs  the  credit  of  first  performing  osteotomy  (subtrochan- 
teric), in  a  case  due  to  rachitis  adolescentium,  and  proving  this-  by  examination  of  the 
wedge  removed  (/Wi*.s.  Med.  Neivs.  September  29,  1888),  gives  the  following  important  hint 
{OrthopcBdic  Surgery,  p.  312)  :  "  Adolescents  attacked  with  rickets  do  not  present  the 
same  clinical  picture  as  infants.  .  .  .  The  older  a  person  is  when  attacked  with  rickets 
the  more  limited  and  localised  are  his  deformities  likely  to  be." 

*  Prof.  Hoffa  (v.  Bergmann's Surgery,  Amer.  Trayis.,  vol.  iii,  p.  517)  writes :  "  Resection 
of  the  joint  is  best  for  the  severe  cases.  The  improvement  in  the  gait  and  general  con- 
dition in  the  majority  of  cases  of  resection  verify  its  value  (Miiller,  Hoffa,  Kocher,  Maydl, 
Sprenger,  and  others).     In  the  case  which  the  author  resected  the  shortening  was  reduced 


832       OPERATIONS  ON  THE  LOWER  EXTREMITY 

younger  the  patient  the  more  is  a  subtrochanteric  operation  indicated. 
In  children  the  parts  are  too  small  to  admit  of  easily  meeting  the  necessity 
of  so  arranging  the  wedge  that  when  the  gap  is  brought  together  the 
proper  position  of  the  femur  is  restored.  In  older  patients,  where  the 
parts  are  larger  and  the  elongation  of  the  upper  margin  of  the  neck  more 
pronounced,  it  is  easier  to  secure  the  above  object,  but  in  these  patients 
opening  the  joint,  which  it  is  difficult  to  avoid,  is  more  hkely  to  be 
followed  by  stiffness.  In  my  opinion  a  subtrochanteric  operation  is 
always  to  be  preferred.  Certainly  osteotomy  of  the  neck  should  never 
be  employed  unless  a  skiagram  shows  that  the  lengthening  of  the  neck 
is  enough  pronounced  to  render  removal  of  a  wedge  likely  to  be  sufficient. 
Linear  osteotomy  alone  is  not  likely  to  be  satisfactory  in  cases  of  sufficient 
severity  to  call  for  operation. 

A.  Cuneiform  osteotomy  of  the  neck  (Fig.  332).  The  parts  are 
exposed  by  the  anterior  incision  already  described  (p.  820).  The  upper 
margin  of  the  neck  is  the  spot  to  which  attention  must  be  directed,  and 
in  separation  of  the  periosteum  and  other  structures  care  must  be  taken 
not  to  inflict  needless  damage  on  the  epiphysial  structures  or  the  joint. 
It  will  be  remembered  that  the  epiphyses  here  are  late  in  joining,  and 
that  rachitic  changes  may  be  more  or  less  active  up  to  certainly  as  late 
as  eighteen  years.  The  base  of  the  wedge  should  be  upwards  and 
usually  forwards ;  according  to  the  degree  of  the  deformity  it  will 
measure  from  one  to  two  inches.  The  wedge  must  be  cut  cleanly  with  a 
chisel,  and  through  to  the  inner  border,  which  is  always  short.  In 
removing  it  the  above  given  precautions  as  to  injury  to  adjacent  parts 
must  be  remembered. 

Before  the  necessary  correction  into  the  abducted,  everted  and 
rotated  inwards  position  can  be  satisfactorily  secured,  division  of  the 
adductors  and  hamstrings  may  be  needful,  now,  or  as  a  preliminary 
measure. 

B.  Subtrochanteric  osteotomy  (Fig.  334).  Here  the  osteotomy  has 
been  linear,  transverse,  oblique  from  without  inwards,  or  cuneiform. 
Theoretically,  as  the  neck  is  the  part  primarily  affected,  interference 
here  is  the  more  scientific  course,  but  on  account  of  its  greater  sim- 
plicity, and  for  the  reasons  given  above,  I  recommend  subtrochanteric 
osteotomy.  I  shall  mention  two  methods,  both  of  which  give  good 
results.     I  prefer  the  first  as  rather  the  simpler. 

I.  Cuneiform  Subtrochanteric  Osteotomy.  Here  a  wedge  is  removed 
below  the  great  trochanter,  the  apex  being  inwards  and  forming  a  hinge  ; 
on  this,  when  the  cut  surfaces  of  the  bone  are  brought  into  contact  by 
abducting  the  limb,  not  only  is  the  position  of  the  limb  rectified  but  the 
restoration  of  a  more  normal  angle  and  direction  of  the  neck  is  com- 
menced, the  after-treatment  continuing  this  object. 

R.  Whitman's  method  ^  will  be  found  comparatively  easy  and  efficient 

from  2|  to  If  inches.  The  importance  of  gymnastics  and  massage  after  the  extension 
is  removed  is  self-understood."  It  is  difficult  to  understand  the  above  statement  with 
regard  to  the  shortening  if  the  case  had  been  watched  for  any  length  of  time.  With 
regard  to  the  adoption  of  this  step,  Mr.  Keetley  writes  in  his  usual  terse  and  vigorous 
stj'le  :  "  What  is  to  be  thought  of  reports  like  the  following  (reference  to  one  of  Schneider's 
cases)  :  '  Patient  limps,  but  has  no  pain.  Treatment :  Resection  of  the  hip-joint.  The 
patient  was  discharged  cured.'  Cured  I  What  of  ?  Not  of  the  limp,  we  may  be  sure  ; 
not  of  the  adduction  either,  unless  bony  ankylosis  ensued  ;  nor  of  the  shortening.  In- 
creased mobility  may  have  been  obtained,  but  at  the  expense  of  increased  weakness 
and  diminished  length." 

1  Ann.  of  Surg.,  1900,  vol.  i,  p.  145,  and  Med.  Eec,  March  19,  1904. 


CURVATURES  OF  THE  NECK  OF  THE  FEMUR  833 


(Fig.  334).  It  is  especially  indicated  in  adolescents  (about  twelve  to 
seventeen  years  of  age).^  In  Dr.  Whitman's  words:  "  The  ha.se  of  the 
wedge  should  be  about  three-quarters  of  an  inch  in  breadth,  directly 
opposite  to  the  trochanter  minor  ;  the  upper  section  should  be  practically 
at  a  right  angle  with  the  shaft,  the  lower  one  being  more  oblique.  The 
cortical  substance  on  the  inner  aspect  of  the  bone  should  not  be  divided, 
but,  reinforced  by  the  cartilaginous  trochanter  minor,  should  serve  as  a 
hinge  on  which  the  shaft  of  the  femur  is  gently  forced  out  until  the  opening 
is  closed  by  the  apposition  of  the  fragments  after  the  upper  segment 
has  been  fixed  by  contact  with  the  margin  of  the  acetabulum  ;    thus 


Fig.  334.  A.  A  normal  fenmr.  B.  A  femur  with  coxa  vara.  a.  A  sub- 
trochanteric wedge  has  been  removed.  C.  Abduction  fir.st  fixes  the  upper 
segment  by  contact  with  the  acetabulum,  and  then  closes  the  opening  in  the 
bone.  D.  Replacement  of  the  limb,  after  union  is  completed,  elevates  the 
neck  to  its  former  position.     (\y hitman.) 

the  continuity  of  the  bone  is  preserved.  The  leg  is  then  held  in  the  atti- 
tude of  extreme  abduction  by  a  plaster  spica  bandage,  which  should 
include  the  foot  also,  until  the  union  is  firm." 

Here  also  any  contracted  adductors  or  hamstrings  must  be  rectified, 
either  at  the  time,  or  beforehand  by  manipulation  or  tenotomy. 

^  In  children  Mr.  Barnard  finds  it  possible  to  produce  a  subcutaneous  rectification  of 
the  neck  of  the  femur  by  simply  abducting  the  femur  under  an  ansesthetic,  to  a  similar 
degree  to  the  normal  side  and  then  putting  the  limb  up  in  plaster  (Clin.  Journ.,  January  G, 
1904). 

SURGERY  I  '  S3 


834       OPERATIONS  OX  THE  LOWER  EXTREMITY 

II.  Mr.  Watson  Cheyne,  C.B.,  divides  the  femur  below  the  trochanters, 
and,  having  rotated  the  hmb  inwards  until  in  the  position  of  extreme 
internal  rotation,  holds  the  fragments  together  by  perforated  aluminium 
plates  secured  with  tin-tacks. 

When  both  limbs  require  operation,  they  should,  if  possible,  be  dealt 
with  at  the  same  time.  In  a  young  adult  the  time  required  for  adequate 
rest  and  after  exercises,  if  the  result  is  to  be  satisfactory,  is  consider- 
able. Mr.  AVatson  Cheyne  gives  another  reason  which  affects  younger 
patients.  In  a  case  seen  some  years  after  the  operation,  the  limb 
operated  on  was  found  to  be  a  good  deal  longer  than  its  fellow,  which, 
not  rectified  and  still  incapacitated,  had  not  grown  so  well. 


CHAPTER  XL 
LIGATURE  OF  ARTERIES  IN  THE  BUTTOCK  AND  THIGH 

LIGATURE  OF  THE  GLUTEAL  ARTERY 

Indications.     (I)  Stab.     (2)  Aneurysm.     (3)  Hwraorrhage  after  opening 
an  abscess.     All  aie  rare,  especially  the  last. 

( 1 )  Stdb.  The  source  of  the  bleeding  from  a  stab  in  the  buttock  may  be 
very  difficult  to  tell  exactly.  The  surgeon  may  be  guided  by  the  position 
of  the  exit  of  the  gluteal  and  sciatic  vessels  (Fig.  335)  ;  he  will  remember 
the  outhne  of  the  gluteus  maximus,  the  lower  border  of  this  muscle 
forming  the  fold  of  the  buttock,  the  upper  starting  from  the  crest  about 
two  inches  in  front  of  the  posterior  superior  spine,  and  running  down- 
wards and  forwards  to  the  greater  trochanter.  Haemorrhage  from  a  stab 
in  the  upper  part  of  this  muscle  will  probably  come  from  the  gluteal ;  if 
from  the  lower  part,  from  the  gluteal  or  sciatic. 

(2)  Aneurysm.  When  it  is  entirely  outside  the  pelvis.  When  this 
point  is  uncertain  it  is  better  to  tie  the  internal  iliac. 

Surgical  Anatomy  of  the  Gluteal  Artery.  A  short,  thick  branch 
from  the  posterior  division  of  the  internal  iliac,  this  leaves  the  pelvis 
above  the  pyriformis,  through  the  sacro-sciatic  notch.  Immediately 
after  its  exit  it  divides  into  a  superficial  and  a  deep  portion.  The  super- 
ficial is  mainly  distributed  to  the  gluteus  maximus  ;  the  deep  lies  between 
the  gluteus  medius  and  minimus,  and  divides  into  two,  the  upper  branch 
running  along  the  origin  of  the  gluteus  minimus,  and  the  lower  running 
obliquely  across  this  muscle  towards  the  trochanter  major.  The 
superior  gluteal  nerve  emerges  just  below  the  artery,  and  sends  branches 
with  the  deeper  portion. 

Line  and  Guide.  "  If  a  line  be  drawn  from  the  posterior  superior 
spine  to  the  great  trochanter,  the  Hmb  being  sHghtly  flexed  and  rotated 
inwards,  the  point  of  emergence  of  the  gluteal  artery  from  the  upper 
part  of  the  sciatic  notch  will  correspond  with  the  junction  of  the  upper 
with  the  middle  third  of  this  line  "  ^ 

Operation  (Fig.  335).  The  patient  being  rolled  two-thirds  over  on  to 
his  face,  the  part  well  exposed  and  cleansed,  the  limb  hanging  over  the 
edge  of  the  table,  an  incision,  five  inches  long,  is  made  in  a  hue  running 
from  the  posterior  superior  spine  to  the  upper  and  inner  part  of  the 
great  trochanter.  The  incision  should  run  almost  parallel  with  the 
gluteus  maximus.  The  fibres  of  this  muscle  being  separated,  between 
adjacent  fascicuh,  with  a  director,  a  muscular  branch  should  be  found 
and  traced  down  to  the  exit  of  the  artery.  The  gluteus  maximus  having 
been  relaxed,  and  the  contiguous  margins  of  the  gluteus  medius  and 
pyriformis  separated  with  retractors,  the  surgeon,  taking  as  his  guide 

^  MacCormac,  Lig.  of  Arts.,  p.  1£G,  Figs.  10,  11. 
835 


83G       OPERATIONS  ON  THE  LOWER  EXTREMITY 

the  above  line  and  the  aperture  of  the  great  sacro-sciatic  notch,  clears 
the  artery  as  high  np  as  possible,  avoiding  the  nerve  and  the  veins,  and 
dividing  the  adjacent  muscles  if  needful.  The  hgature  should  be  applied 
as  far  within  the  notch  as  possible,  almost  within  the  pelvis,  as  the  artery 
divides  immediately  after  its  exit.  If  in  the  case  of  a  stab,  bleeding 
continues  after  the  ligature  has  been  carefully  applied,  and  the  gluteal 
has  evidently  been  punctured  within  the  pelvis,  the  internal  iliac  must  be 
tied  after  the  wound  in  the  buttock  has  been  firmly  plugged  with  sterilised 
game. 


Fig  335.    Position  and  direction  of  the  superfu  lal  incisions  which  must  be  made  to 
secure  the  gluteal   sciatic,  or  pudic  arteries. 

A.  Posterior  superior  iliac  spine.  C.  Tuberosity  of  ischium. 

B.  Great  trochanter.  D.  Anterior  superior  iliac  spine. 

AB.  Ilio-trochanteric  line,  divided  into  thirds.  This  line  corresponds  in 
direction  with  the  line  of  the  fibres  of  the  gluteus  maximus.  The  incision  to 
reach  the  gluteal  artery  is  indicated  by  the  darker  portion  of  the  line.  Its  centre 
is  at  the  junction  of  the  upper  and  middle  thirds  of  the  ilio-trochanteric  line,  and 
exactly  corresponds  with  the  point  of  emergence  of  the  gluteal  artery  from  the 
great  sciatic  notch. 

AC.  Ilio-ischiatic  line.  The  incision  to  reach  the  sciatic  or  internal  pudic 
arteries  is  indicated  by  the  lower  dark  line.  It  is  also  to  be  made  in  the  direction 
of  the  fibres  of  the  gluteus  maximus.  The  centre  of  the  wound  corresponds 
to  the  junction  of  the  lower  and  middle  thirds  of  the  ilio  ischiatic  line. 
(MacCormac.) 

LIGATURE  OF  THE  SCIATIC  ARTERY 

Indications.  Stab.  This  operation  is  so  rarely  required  that  it  may 
be  very  briefly  described  here. 

Surgical  Anatomy.  The  sciatic  artery  emerges,  together  with  the 
sciatic  nerve  and  the  pudic  artery,  from  the  lower  part  of  the  great 
sacro-sciatic  notch  below  the  pyriformis. 


LUiATUKK  OF   J'lIK  COMMON  FEMORAL  837 

Guide  and  Line.  The  limb  being  rotated  inwards,  a  line  is  drawn 
from  the  posterior  superior  spine  to  the  ischial  tuberosity.  The  exit  of 
the  sciatic  and  pudic  arteries  corresponds  to  the  junction  of  the  middle 
and  lower  thirds  of  this  line. 

Operation  (Fig.  335).  The  sciatic  artery  may  be  found  by  one  of  two 
imi.sions  (it)  by  a  lioiizontal  one,  about  five  inches  long,  made  about 
an  inch  and  a  half  })olow  that  for  the  gluteal  artery,  and,  like  that, 
parallel  with  the  fibres  of  the  gluteus  maximus  ;  (6)  by  one  made  vertically 
in  the  above  given  line. 

LIGATURE  OF  THE  COMMON  FEMORAL 

Though  this  operation  is  not  regarded  with  much  favour,  especially  for 
aneurysm,  it  will  be  described  here,  as  the  question  of  tying  it  arises 
from  time  to  time,  and  as  it  should  always  be  performed,  for  the  sake 
of  practice,  on  the  dead  body. 

Indications.  (I)  Wounds.  These  are  rare,  here,  compared  with  those 
affecting  the  vessels  lower  down.  The  wound  must  always  be  explored 
and  the  bleeding- point  sought,  for  several  reasons :  (a)  Ligature  of  the 
external  iliac  will  usually  fail  to  arrest  bleeding  from  the  common  femoral. 
(6)  The  source  of  the  bleeding  may  easily  be  mistaken  here  ;  thus, 
Mr.  Liston,^  in  a  case  of  pistol-shot  w^ound  of  the  groin,  tied  the  external 
iliac  for  what  was  proved,  at  the  necropsy,  to  be  a  wound  of  "  one  of  the 
superficial  branches  of  the  common  femoral,  about  half  an  inch  below 
Poupart's  ligament."  (c)  Vascular  suture  may  be  practicable  and  wise, 
so  that  the  continuity  of  the  artery  or  vein  is  maintained  or  restored. 

The  very  important  subject  of  ligature  of  the  femoral  artery  or  vein, 
or  both,  in  cases  of  wounds,  will  be  referred  to  here,  though  briefly. 
Such  cases  will  arise  most  frequently  in  removal  of  growths — e.g.  epithe- 
liomata,  lymphomata,  sarcomata — less  often  in  cases  of  stabs. 

(2)  Ulceration  into  the  Artery  by  Growths.  From  the  frequency  of  growths  here 
tliis  indication  will  occasionally  arise.  I  have  met  with  one  case.  A  man  was 
admitted  under  my  care  who  had  been  ojierated  on  elsewhere  for  the  removal  of 
sarcomatous  glands  in  the  groin.  The  application  of  zinc  chloride  paste  had  led  to 
detachment  of  sloughs  and  exposure  of  the  common  femoral,  which  gave  way, 
leading  to  profuse  haemorrhage.  I  tied  the  common  femoral  immediately  above 
the  bleeding-point  ;  this  was  slowly  followed  by  typical  dry  gangrene,  necessitating 
amputation  through  the  lower  third  of  the  thigh. 

(3)  Ulceration  of  the  Femoral  Vessels  in  Inguinal  Bubo.  Mr.  Shield  has  drawn 
attention  to  this  most  dangerous  condition.^  Though  in  his  case  ulceration  occurred 
in  the  superficial  femoral  vessels,  I  have  alluded  to  it  here,  in  association  with  the 
previous  two  headings.  Owing  to  haemorrhage  from  sloughing  sinuses  in  Scarpa's 
triangle,  Mr.  Shield  was  obliged  to  tie  both  artery  and  vein,  using  two  ligatures 
in  each  case.  There  was  no  return  of  haemorrhage,  and  gangrene  did  not  occur, 
but  the  patient  sank  exhausted  on  the  eleventh  day  with  a  large  pysemic  abscess 
in  the  opposite  liip-joint.  When  once  bleeding  has  occurred  and  recurred,  as  pressure, 
owing  to  the  condition  of  the  soft  parts,  is  likely  to  fail,  a  free  incision  and  ligature 
of  the  vessels  above  and  below  the  point  of  ulceration  is  the  wisest  course. 

(4)  Aneurysm.  There  has  been  much  difference  of  opinion  as  to 
whether  it  is  Aviser,  when  dealing  with  an  aneurysm  of  the  superficial 

1  Med.-Chir.  Trans.,  vol.  xxix,  p.  107.  The  flow  of  the  blood  here  is  said  to  have 
been  "  most  impetuous  and  profuse."  In  Mr.  Listen's  words:  "  The  division  of  even  a 
small  branch  close  to  the  principal  vessel,  it  is  well  known,  pours  out  blood  furiously,  as 
much  so,  in  fact,  as  if  an  opening  in  the  coats  of  the  artery  itself  were,  so  to  say,  punched 
out,  corresponding  in  size  to  the  area  of  the  branch." 

-  Med.  Soc.  Proc,  vol.  x,  p.  261. 
SURGERY    I  53 


838        OPERATIONS  ON  THE  LOWER  EXTREMITY 

femoral  high  up,  to  tie  the  common  femoral  or  the  external  iUac.  English 
surgeons  have  rejected  hgature  of  the  common  femoral  for  these  reasons  : 
(1)  The  risk  of  gangrene,  as  the  ligature  is  placed  above  both  the  great 
nutrient  arteries  of  the  hmb.  (2)  The  probability  of  firm  clotting 
taking  place  after  the  ligature  is  rendered  doubtful,  owing  to  the  number 
of  small  vessels  given  off  here,  viz.  the  superficial  epigastric,  and  circum- 
flex iliac,  the  superior  and  inferior  external  pudic,  and  very  commonly 
one  of  the  circumflex  arteries,  and  also  by  the  proximity  of  the  profunda. 
(3)  The  uncertainty  of  the  origin  of  the  profunda,  and  thus  of  the  length 
of  the  common  femoral.  (4)  I  would  add  to  the  above  that  hgature 
of  the  common  femoral  for  aneurysm  approximates  the  treatment  to  that 
of  Anel  rather  than  to  that  of  Hunter.  Sir  J.  E.  Erichsen  ^  went  so 
far  as  to  say,  "  It  may  be  laid  down  as  a  rule  in  surgery,  that  in  all 
those  cases  of  aneurysm  which  are  situated  above  the  middle  of  the 
thigh,  in  which  compression  has  failed  and  sufficient  space  does  not 
intervene  between  the  origin  of  the  deep  femoral  and  the  upper  part  of 
the  sac  for  the  application  of  a  ligature  to  the  superficial  femoral,  the 
external  iliac  should  be  tied." 

(5)  As  a  Preparaiorij  Step  to  Amfutation  at  the  Hip-joint.  The  need 
of  this  has  been  largely  done  away  with  by  the  adoption  of  other 
preferable  steps  (p.  805). 

Li7ie  mid  Guide.  From  a  point  midway  between  the  anterior  superior 
spine  of  the  ilium  and  symphysis  pubis  to  the  adductor  tubercle,  and 
the  inner  margin  of  the  internal  condyle. 

Relations  : 

In  Front 
Skin  ;  fascia? ;  lymphatic  glands. 
Crural  branch  of  genito-crural.     Sheath. 

Outside  Inside 

Anterior  crural.  Common  femoral.  Septum  of  sheath. 

Femoral  vein. 
Behind 
Sheath. 
Psoas. 

It  is  important  to  note  that  the  common  femoral  is  usually  only  an 
inch  and  a  half  long,  and  that  from  it  come  off  not  only  the  superficial 
epigastric,  circumflex  iliac,  and  superior  and  inferior  external  pudic 
but  occasionally  one  of  the  circumflex  arteries  as  well. 

Collateral  Circulation  (Fig.  336). 

Above  Below 

Gluteal  and  sciatic,  with        Superior  perforating  and  cir- 

cumflex arteries. 

Superficial  circumflex  ihac,  with         Ascending   branch   of   exter- 

nal circumflex. 

Obturator,  with         Internal  circumflex. 

Comes  nervi  ischiadici,  with         Perforating  of  profunda  and 

articular  of  pophteal. 

Operation.  The  groin  having  been  shaved  and  cleansed,  the  hip 
find  knee  semiflexed,   and  the  limb  abducted  and  rotated  somewhat 

*  iSurgery,  vol.  ii,  p.  244. 


LTGATITRK  OF  TIIK  SUPKKFTCTAL  FEMORAI.      839 

outwards,  an  incision  about  two  and  a  half  inclics  long  is  made  in  the 
line  of  the  artery,  coinniencinfj;  just  above  P()U])art"s  ligament.  The 
skin  and  supeifieial  fascia  having  been  divided,  and  any  overlying  glands 
displaced  or  removed,  any  veins  which  may  be  met  with  descending 
to  join  the  internal  saphena  are  either  drawn  aside  or  tied  between  double 
ligatures.  The  fascia  lata  having  been  opened  just  below  Poupart's 
ligament,  the  artery  or  its  pulsation  is  felt  for,  the  vessel  exposed  here, 
and  the  needle  passed  from  within  outwards,  care  being  taken  to  avoid 
the  crural  branch  of  the  genito-crural  nerve,  which  lies  superficial  to  the 
artery.  The  neighbourhood  of  any  branch  is,  if  possible,  avoided.  The 
ligature  of  strong  catgut  is  tied  and  the  wound  closed. 


LIGATURE  OF  THE  SUPERFICIAL  FEMORAL  IN 
SCARPA'S  TRIANGLE 

Indications.  (1)  Certain  Cases  of  Aneurysm  of  the  Popliteal  Artery 
or  the  Femoral  lotv  down.  Thus  the  ligature  will  probably  be  indicated  : 
(a)  where  a  popHteal  aneurysm  is  rapidly  growing,  especially  when  (6)  it 
is  on  the  anterior  aspect  of  the  artery  instead  of  behind  or  at  one  side  of  it, 
as  in  the  former  case  the  knee-joint  may  become  involved  after  very 
obscure  symptoms  ;  (c)  when  the  aneurysm  is  fusiform  rather  than 
saccular ;  {d)  when  it  has  very  thin  walls  ;  (e)  when  it  threatens  to 
burst,  or  when  this  has  already  happened,  unless  other  symptoms — 
e.g.  gangrene — call  for  amputation ;  (/)  if  visceral  disease — cardiac, 
renal,  hepatic — or  an  atheromatous  condition  of  the  vessels  is  present, 
the  surgeon  must  weigh  carefully  the  question  of  operative  interference  : 
I  should  prefer  in  most  cases  a  trial  of  the  ligature  as  likely,  with  the 
aid  of  antiseptic  precautions,  a  modern  ligature  and  primary  union,  to 
entail  less  taxing  of  the  patient's  powers.  On  this  point,  so  difficult 
of  wise  decision,  I  may  say  that  of  the  seven  cases  in  which  I  have 
hgatured  the  superficial  femoral  for  popliteal  aneurysm  the  only  one 
that  ended  in  failure  was  that  of  a  man  set.  65,  with  diseased  arteries 
and  interstitial  nephritis.  Owing  to  the  restlessness  and  want  of  amen- 
abihty  of  the  patient  I  decided  against  a  trial  of  pressure.  The  greatest 
difficulty  was  met  with  in  keeping  the  patient  still,  and  gangrene  followed, 
fatal  on  the  fifth  day  ;  (g)  where  a  trial  of  pressure  has  failed,  or  is  certain 
to  fail  from  the  irritability  of  the  patient.  Matas's  operation  is  given  at 
p.  839. 

(2)  Wounds. 

(3)  For  Hcemorrhage  low  down,  e.g.  after  amputation  in  the  middle 
of  the  thigh,  when  other  means  fail  and  the  wound  is  nearly  united. 
Two  other  instances  are  given  by  Mr.  Bryant. '^ 

One  was  "  a  case  of  Mr.  Brans  by  Cooper's  in  which  a  compound  fracture  of  the 
leg  was  complicated  with  a  laceration  of  the  femoral  artery.  The  artery  was  secured 
at  the  seat  of  injurj^  and  repair  went  on  well  in  all  respects.  Mr.  Brans  by  Cooper 
has  also  recorded  in  his  Surgical  Essays  a  case  of  fracture  of  the  femur  in  which  the 
femoral  artery  was  ligatured  for  a  ruptured  popliteal  artery,  and  in  which  recovery 
took  place  in  six  weeks." 

Each  of  such  cases   must  be  considered  on  its  own  merits,  but  the 

above  shows  what  ligature  of  the  femoral  artery  will  do  in  appropriate 

cases. 

^  Surgery,  vol.  ii,  p.  417. 


840       OPERATIONS  ON  THE  LOWER  EXTREMITY 

(4)  For  Elephantiasis.  Cases  in  which  the  superficial  femoral  has 
been  tied  will  be  found  in  the  Lancet  for  is7i),  vol.  i,  p.  44  ;  and  Ranking's 
Abstract  for  1860,  vol.  ii,  p.  193.  The  subject  of  ligature  of  the  main 
artery  of  the  limb  for  this  affection  is  considered  at  p.  893,  vol.  ii. 

Line.     That  above  given,  p.  838. 

Guide.  The  above  Une  and  the  inner  border  of  the  sartorius  at  the 
apex  of  the  triangle. 

Relations : 

In  Front 

Skin  ;  superficial  fascia  ;  glands  ;  crural 
branch  of  genito-crural  nerve  ;  middle 
cutaneous  and  branch  of  internal  cu- 
taneous ;   fascia  lata  ;   sartorius. 

Outside  Inside 

Femoral    vein    (below).      Ante-  Femoral  vein  (above), 

rior  crural  nerve,  and  some 
of  its  branches,  viz.  the 
nerve  to  the  vastus  internus, 
and  long  saphenous  nerve. 

Behind 

Psoas  ;  pectineus  ;  adductor  longus  ;  fe- 
moral vein  (below)  ;  profunda  artery 
and  vein  ;   nerves  to  pectineus. 

Collateral  Circulation. 

Above  Below 

Perforating  of  profunda,  with    Lower  muscular  and  anastomotic 

of  femoral,  articular  of  popli- 
teal, and  anterior  tibial  recur- 
rent. 
External    circumflex    of 

profunda,  with  Ditto  ditto. 

Comes  nervi  ischiadici,  with     Perforating    of    profunda    and 

articular  of  poj^liteal. 

Operation.  The  parts  having  been  sterilised,  the  knee  and  hip 
slightly  flexed,  the  thigh  abducted  and  somewhat  everted,  and  the  leg 
resting  on  a  pillow,  the  surgeon,  seated  or  standing  to  the  right  of  the 
affected  limb,  makes  an  incision  three  inches  long  in  the  line  of  the 
artery  (p.  838).  This  should  begin  about  two  inches  and  a  half  below 
Poupart's  ligament,  and  run  down  to,  and  somewhat  below,  the  apex  of 
Scarpa's  triangle,  which  lies  usually  four  to  five  inches  below  Poupart's 
ligament.  The  skin  and  superficial  fascia  having  been  divided,  any  small 
vessels  are  secured,  and  branches  of  the  saphena  vein  drawn  aside  with 
a  strabismus  hook  or  secured  with  double  ligatures.  The  deep  fascia  is 
now  slit  up  for  the  whole  length  of  the  wound,  and  the  inner  margin  of 
the  sartorius,  which  crosses  the  lower  part  of  the  incision,  identified. 
This  is  then  held  outwards,  while  the  artery  or  its  pulsation  is  felt  for. 
The  wound  being  now  well  opened  out  with  retractors  and  carefully  wiped 
out,  the  sheath  is  opened  to  the  outer  side,  care  being  taken  to  avoid 
the  nerves  in  contact  with  it,  viz.  the  long  saphenous,  and  the   nerve 


D£EP    CIRCUMFLEX    ILI^C 


COMMON    FEMOt^l. 

PROFUNDA 

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Flu.  336.     Ana.stomotic  circulation  of  the  iliac  and  femoral  arteries. 


842       OPERATIONS  ON  THE  LOWER  EXTREMITY 

to  the  vastus  internus  {see  Fig.  337).  The  artery  having  been  cleaned, 
thoroughly  but  most  carefully,  on  either  side  and  behind,  the  needle  is 
passed  from  within  outwards,  being  kept  very  close  to  the  vessel  so  as  to 
avoid  the  vein  which  lies  behind  and  internally.^  The  artery  having  been 
tied,  the  ligature  is  cut  short,  drainage  provided  according  to  the  amount 
of  disturbance  of  the  parts,  &c.,  and  the  wound  closed.  The  precautions 
given  in  vol.  ii,  p.  890  for  the  prevention  of  gangrene  must  be  taken. 


-COMMOhl  Ft^Ofl/ti. 


-f'SL/PEK/OJi  F£HO>i^L. 


FlQ.  337.     Ligature  of  the  superficial  femoral  artery. 


Difficulties  and  Mistakes.  (1)  Wounding  the  SapJienaVeiti.  This  may 
occur  if  the  incision  is  made  too  internal.  It  is  always  to  be  avoided  if 
possible,  owing  to  the  troublesome  oedema  which  may  follow.  (2)  A 
very  broad  sartorius.     (3)  Injury  to  the  Femoral  Vein.     This  may  easily 

1  The  vein  is  so  frequently  damaged  here  especially  on  the  dead  subject,  that  a  few 
precautions  may  be  given  as  to  the  best  way  of  avoiding  it.  First,  the  sheath  must  be 
identified  exactly,  and  sufficiently  opened  at  its  outer  part.  It  will  be  found  of  much 
heliJ  in  cleaning  the  vessel  if  one  edge  of  the  cut  sheath  is  held  by  an  assistant,  while  the 
surgeon  has  hold  of  the  other  ;  the  opening  in  the  sheath  is  thus  made  sure  of  and  retained. 
There  must  be  no  needless  disturbance,  or  lifting  up  of  the  vessel  upon  the  needle,  which, 
with  the  director,  must  be  used  with  the  utmost  carefulness.  As  soon  as  the  eye  (and  this 
should  be  at  the  very  end  of  the  needle)  is  seen  to  have  passed  round  the  vessel  the  ligature 
should  be  at  once  seized,  and  the  needle  withdrawn.  On  the  dead  body  the  apparent 
thickness  due  to  the  solid  thrombosis  in  the  vein,  in  subjects  prepared  with  formalin,  must 
not  lead,  here  or  elsewhere,  to  this  vessel  being  mistaken  for  the  artery. 


LIGATURE  OF  THE  FEMORAL  ARTERA^  813 

take  place  if  force  is  used  in  pushing  the  needle  round  an  imperfectly 
cleaned  artery,  or  if  the  needle  is  not  kept  close  to  the  vessel.  If  the 
accident  occur,  the  surgeon  must  not  persist  in  his  attempt  to  tie  the 
artery  at  this  spot,  a  course  which  will  only  end  in  his  inflicting  more 
injury  in  the  vein,  but  finger-pressure  being  made  in  the  lower  angle  of 
the  wound,  the  artery  is  tied  either  above  or  below  the  spot  where  the  vein 
has  been  injured.  As  soon  as  the  artery  is  secured,  no  further  hainior- 
rhage  will  take  place,  but  pressure  may  be  kept  up  by  means  of  sterilised 
dressings  over  the  wound  for  a  day  or  two.^  The  patient  will  do  well  to 
wear  a  Martin's  bandage  or  an  elastic  stocking  for  some  time  after  getting 
up.  (4)  Including  one  of  the  nerves.  (5)  A  matted  condition  of  the 
parts  due  to  a  previous  trial  of  compression. 

Abnormalities  of  the  Femoral  Artery.  (1)  A  double  superficial  femoral,  flio 
(wo  trunks  uniting  I)clo\v  to  form  the  popliteal.  More  than  one  case  of  this  kind 
is  recorded.  The  persistence  of  jjulsation  in  the  aneurysm  after  the  first  ligature 
would  load  to  a  suspicion  of  this  condition.  (2)  The  vessel  may  run  down  at  the 
back  of  the  limb. 


LIGATURE  OF  THE  FEMORAL  ARTERY  IN  HUNTER'S  CANAL 
TREATMENT  OF  A  STAB  IN  MID-THIGH 

Indications  for  Ligature  of  the  Femoral   Artery  in  Hunter's  Canal. 

(1)  Woimds.     These  may  be  {a)  incised  ;   (b)  punctured. 

(a)  The  artery  above  is  controlled  by  a  tourniquet  or  the  hands 
of  an  assistant  or  provisionally  secured  by  a  loop  of  silk  immediately 
above  the  wound  in  it,  or  clamps,  if  these  are  at  hand.  The  wound 
is  then  enlarged  and  the  vessel  dealt  with  according  to  the  directions 
given  at  p.  53,  if  possible.  Only  if  the  conditions  do  not  admit  of  this  is 
the  artery  to  be  tied  above  and  below  the  wound  in  it.  If  the  vein  is  in- 
jured also,  suture  is  still  more  strongly  indicated  ;  if  ligatures  are  applied, 
the  patient  or  the  friends  must  be  prepared  for  the  possibility  of  im- 
minent need  of  amputation.  The  Umb  should  be  secured  on  a  splint, 
and  the  foot  of  the  bed  raised. 

(b)  If  a  punctured  wound  hes  in  the  line  of  the  artery,  and  if 
much  blood  has  been  lost,  the  main  trunk  is  probably  injured,  and  the 
question  will  arise,  if  the  bleeding  has  ceased,  whether  to  cut  down  upon 
the  artery  or  to  trust  to  pressure.  Mr.  Cripps  ^  advises  that,  if  the  wound 
be  in  the  upper  part  of  the  thigh,  "  the  surgeon  may  enlarge  the  wound 
with  a  good  prospect  of  finding  the  wounded  vessel  without  an  extensive 
or  prolonged  operation.  If  the  wound  be  in  the  lower  half  of  the  thigh, 
owing  to  the  greater  depth  of  the  artery  and  the  possibihty  of  its  being 
the  pophteal  which  is  wounded,  the  search  is  rendered  far  more  severe  and 
hazardous,  and  it  should  not  be  taken  until  a  thorough  trial  of  pressure 
has  proved  ineffectual." 

The  following  mode  of  applying  pressure  is  taken  from  Mr.  Cripps.^ 
I  would  also  refer  my  readers  to  the  account  of  punctured  wound  of  the 
palm  given  in  vol.  i  of  this  work. 

^  Jf  venous  hsemorrhage  persist,  the  opening  in  the  vessel  should  be  secured  by  suture 

*  Diet,  of  Surg.,  vol.  i,  p.  525. 

3  Loc  su-pra  cit.  Mr.  Cripps  draws  attention  to  the  instructiveness  of  the  literature  of 
this  subject,  as  it  proves  not  only  that  many  cases  have  been  successfully  treated  by 
pressure  from  the  first,  but  that  both  life  and  limb  have  been  saved  by  pressure  after 
the  surgeon  has  failed  to  find  the  artery  in  the  wound,  or  after  the  iliac  has  been  tied  in 
vain. 


844       OPERATIONS  ON  THE  LOWER  EXTREMITY 

The  main  vessel  having  been  controlled  above,  the  foot  and  leg  should 
be  carefully  strapped  from  the  toes  to  the  knee,  and  a  bandage  then 
carried  from  the  toes  up  to  the  wound,  and  then,  avoiding  this,  up  to 
the  groin,  where  it  is  secured,  spica-fashion,  over  a  pad  on  the  main 
artery.  The  hmb  is  then  laid  on  a  long  back  splint  with  a  foot-piece 
and  secured  to  this  in  an  elevated  position.  The  wound  having  been 
sterilised,  a  graduated  gauze  compress  is  then  fastened  over  it.  Two 
sterilised  rectal  bougies  are  then  applied  in  the  course  of  the  artery, 
above  and  below  the  wound,  outside  the  bandage  which  surrounds  the 
limb,  so  as  to  keep  these  segments  of  vessel  empty.  Two  well-padded 
lateral  sphnts  are  then  secured  with  straps  and  buckles  to  the  thigh. 
The  toes  should  be  left  exposed  that  their  condition  may  be  watched. 
Morphia  must  be  given  as  freely  as  is  judicious. 


ti  si^firoK/ijs 


FMMOfL^i.  /^. 


Fig.  .338.     Ligature  of  the  femoral  artery  in  Hunter's  canal. 


(2)  Hoemorrhaije  from  a  Stump  after  Amputation  in  the  Lower  Third 
of  Thigh  or  Knee.  If  clearing  away  the  clots,  followed  by  well-adjusted 
pressure,  and,  this  failing,  trying  to  find  the  bleeding-point  in  the  flaps, 
do  not  suffice,  the  artery  must  be  tied  above. 

Line  and  Guide  (p.  838). 
Relations  : 

In  Front 

Saphena  vein. 

Skin ;  fasciae  ;  sartorius ;  aponeurosis  between 
vastus  internus  and  adductors  ;  internal  saphe- 
nous nerve. 

Outside  Inside 

Vastus  internus  ;    vein  (slightly).  Adductor  longus  and  magnus. 

Femoral  artery  in  Hunter's  canal. 

Behind 
Femoral  vein  (especially  above) 


LIGATURE   OF  TIIK   FEMORAL   ARTERY  845 

Operation  (Fig.  .'538).  The  knee  and  hip  having  been  flexed,  and 
the  hnil)  alxUicted  and  rotated  outwards,  the  surgeon,  ssated  comfortably 
on  the  inner  side  of  the  limb,  makes  an  incision  three. inches  and  a  half 
long  in  the  line  of  the  artery  in  the  middle  tliird  of  the  thigh.  The  skin, 
superficial  and  deep  fascia\  having  been  divided,  and  the  saphena  vein, 
if  seen,  drawn  to  one  side  with  a  strabismus  hook,  or  any  of  its  branches 
divided  between  double  ligatures,  the  sartorius  is  identified  by  the 
direction  of  its  fibres  and  drawn  to  the  inner  side.  The  canal  is  next 
opened  by  dividing  the  aponeurotic  roof,  and  the  artery  or  its  pulsation 
felt  for.  The  vessel  will  be  found  closely  connected  to  its  vein,  which 
lies  behind  it,  while  the  saphenous  nerve  crosses  it  from  without  inwards. 
The  artery  having  been  most  carefully  cleaned  all  round,  the  ligature 
may  be  passed  from  either  side,  as  is  found  most  convenient.^ 

Causes  of  Failure  after  Ligature  of  the  Femoral.  (1)  Gangrene, 
(2)  Secondarij  Haemorrhage.  If  pressure  fail,  an  attempt  must  be  made 
to  re-tie  the  vessel,  and  this  not  succeeding,  the  limb  must  be  ampu- 
tated. (3)  Suppiiration  of  the  Sac  of  an  Aneurysm.  This  is  very  rare. 
(4)  Recurrent  Pulsatio7i  in  the  Aneurysm.  The  premature  softening  of 
the  ligature,  especially  in  an  infected  wound,  must  always  be  remembered 
as  a  possible  cause  of  this.  Pressure  faihng,  the  artery  may  be  tied  lower 
down.  (5)  A  very  rare  complication  is  the  formation  of  an  aneurysm  at 
the  seat  of  ligature. 

^  Much  difficnlty  will  be  met  with  ii  tyi  ig  the  femoral  artery  in  Hunter's  canal 
unless  the  line  of  the  artery  is  strictly  followed.  A  common  mistake  is  to  make  the 
incision  too  far  out,  thus  exposing  the  fibres  of  the  vastus  internus,  which  run  downwards 
and  outwards,  instead  of  those  of  the  sartorius,  which  run  downwards  and  inwards  (Smith 
and  Walsham,  Man.  of  0 per.  Surg.,  p.  83).  Sir  J.  E.  Erichsen  (Surgery,  vol.  ii,  p.  250), 
who  gives  as  the  line  of  the  artery,  one  drawn  from  a  point  exactly  midway  between  the 
anterior  superior  spine  and  the  symphysis  pubis  to  the  most  prominent  part  of  the  internal 
condyle,  insists  on  the  need  of  making  the  incision  a  finger's- breadth  internal  to  this. 
The  line  which  I  have  given  above  will  be  found  sufficiently  internal. 


CHAPTER  XLI 

AMPUTATION  THROUGH  THE  THIGH.     REMOVAL  OF 
EXOSTOSIS.     FRACTURES  OF  THE  FEMUR 

AMPUTATION  THROUGH  THE  THIGH 

Practical  Points  in  Amputation  of  the  Thigh.  The  operation  should 
always  be  performed  as  low  down  as  possible,  not  only  to  avoid  shock 
and  to  secure  as  long  a  stump  as  possible  for  the  artificial  limb,  but 
also  to  secure  as  much  as  possible  of  the  rectus  femoris.  This  muscle 
is  a  most  important  agent  by  which  the  thigh  is  put  forward  in  stepping. 
Its  division  does  not  preclude  the  retention  of  its  office,  as  it  acquires 
a  sufficient  adhesion  to  the  material  of  the  stump  to  answer  every  useful 
purpose,  as  an  agent  in  the  flexion  of  the  thigh  on  the  pelvis,  though 
that  of  extension  of  the  leg  be  destroyed. 

Different  Methods.  The  following  five,  which  will  give  ample  choice, 
will  alone  be  described  here  ;   the  first  is  especially  recommended  : 

I.  Mixed  Antero-posterior  Flaps  and  Circular  Division  of  the  Muscles. 
II.  Antero-posterior  Flaps  by  Transfixion.  III.  The  Circular  Method. 
IV.  Rectangular  Flaps.     V.  Lateral  Flaps. 

I.  Mixed  Antero-posterior  Flaps  and  Circular  Division  of  the  Muscles 
(Fig.  339).  By  the  term  mixed  is  meant  an  anterior  flap  of  skin  and 
fasciae  raised  from  without,  and  a  posterior  one  made  by  transfixion.  The 
anterior  is,  wherever  practicable,  made  the  longer  of  the  two. 

This  method  has  the  following  great  advantages  :  (1)  The  longer 
anterior  flap  falls  well  over  the  bone,  and  thus  keeps  the  scar  behind  ; 
(2)  being  raised  from  without  inwards,  it  can  be  taken  from  the  neigh- 
bourhood of  the  knee-joint  and  patella  ;  (3)  it  is  a  most  expeditious 
method, 1  almost  as  quick  as  that  by  double  transfixion-flaps  ;  (4)  it  is 
suited  to  all  cases,  save  perhaps  those  of  very  muscular  thighs,  where 
the  surgeon  should  be  careful  to  take  only  part  of  the  muscles  behind 
as  he  transfixes,  or  else  should  raise  his  posterior  flap  also  from  without 
inwards  ;   (5)  it  gives  good  drainage. 

While  amputation  by  anterior  and  posterior  flaps  is  given  in  detail, 
the  surgeon  will  not  tie  himself  to  this  method,  but  use  such  modifica- 
tions as  that  by  antero- external  and  postero-internal  flaps.  Save  in 
cases  of  mahgnant  disease,  the  chief  object  is  to  save  as  much  of  the 
femur  as  possible  and  also  of  the  adductors.  The  length  of  the  leverage 
on  the  artificial  limb  is  thus  increased,  and  the  action  of  the  abductors 
better  counter-balanced. 

Operation.  The  femoral  artery  having  been  controlled  with  a 
tourniquet,  the  limb,  a  sterile  towel  having  been  first  bandaged  on,  being 
brought  over  the  edge  of  the  table,  and  supported  by  an  assistant ;   the 

^  As  in  railway  and  other  accidents. 
846 


AMPUTATION  THROUGH  THE  THTGII  847 

Opposite  ankle  heinij;  tied  to  the  table,  and  the  parts  duly  cleansed,  the 
surgeon  staniling  to  the  right  side  of  the  limb  to  be  removed,  places  his 
left  index  tinger  and  thumb  on  either  side  of  the  limb,  at  the  level  where  he 
intends  to  saw  the  bone,i  and  sinking  the  point  of  his  knife  through  the 
skin  just  below  the  former  and  rather  below  the  centre  of  the  outer  or 
inner  aspect  of  the  limb,  as  the  case  may  be,  carries  it  rapidly  down 
for  about  four  and  a  half  inches,  and  then  sweeps  it  across  the  limb  with 
a  broad,  not  pointed,  convexity,  and  carries  it  up  along  the  side  nearest 
to  him  as  far  as  his  thumb.  A  flap  of  skin  and  fascia?,  muscle  being 
taken  up  increasingly  towards  its  base,  is  then  (piickly  dissected  up,  and 
the  knife,  being  sent  across  the  limb,  behind  the  bone,  cuts  a  posterior 
flap,  the  knife  being  used  with  a  rapid  sawing  movement,  and  driven  at 
first  straight  down  parallel  with  the  bone,  and  then  sharply  brought  out 
through  the  skin. 

The  flaps,  covered  with  gauze,  being  held  out  of  the  way  by  the 
surgeon's  left  hand,'-  the  soft  parts  around  the  femur  are  next  severed 


Fig.  339.     Amputation  through  the  thigh.     The  posterior  flap  may  be  cut  by 
transfixion  if  desired. 

with  circular  sweeps  ^  till  the  bone  is  exposed,  when  one  more  firm 
sweep  di\4des  the  periosteum.^ 

The  saw  is  now  placed  with  its  heel  on  the  bone  and  drawn  towards 
the  operator  once  or  twice  ^vith  firm  pressure  so  as  to  make  one  groove, 
and  one  only.  With  a  few  sharp  sweeps  the  bone  is  next  severed,  care 
being  taken  to  use  the  saw  lightly  for  fear  of  splintering  the  linea  aspera, 
and  to  use  the  whole  length  of  the  instrument.  At  this  time  the  limb 
must  be  kept  steady  and  straight,  the  assistant  neither  raising  it,  which 
will  lock  the  saw,  nor  depressing  it,  which  will  splinter  the  femur  when 
this  is  partly  di\aded. 

If  the  surgeon  decide  to  make  his  posterior  flap  also  of  skin  and 
fasciae,  he  must  have  the  hmb  raised,  and  first  looking  over  and  then 
stooping  down,  he  marks  out  a  skin  flap,  about  two- thirds  the  length  of 

1  The  finger  and  thumb  should  not  be  shifted  till  the  anterior  flap  is  marked  out. 

2  And  also  pressed  firmly  upwards,  so  as  to  enable  the  saw  to  be  applied  as  high  up  as 
possible.     If  the  limb  is  bulky  an  assistant  must  help  here. 

'  This  requires  really  forcible  use  of  the  knife,  the  muscles  behind  the  bone  tending 
to  be  pushed  before  the  knife  rather  than  divided  by  it. 

*  This  final  cut  should  be  a  little  above  the  base  of  the  flaps,  in  order  that  the  sawn 
femur  may  lie  well  buried  in  soft  parts. 


848       OPERATIONS  ON  THE  LOWER  EXTREMITY 

the  anterior  ;  this  is  then  dissected  up,  and  the  operation  completed 
as  before. 

In  addition  to  the  femoral  vessels,  the  anastomotica,  and  descending 
branch  of  the  external  circumflex,  some  muscular  branches  will  require 
attention  ;  and  one  of  these  last  may  give  some  trouble  from  its  position 
close  to  the  bone,  in  contact  with  the  linea  aspera. 

The  following  points  deserve  attention  in  tying  the  femoral  vessels  : 
(1)  Not  to  include  the  saphenous  nerve  ;  (2)  the  tendency  of  the  vessels 
to  slip  up  if  the  point  of  their  division  passes  through  Hunter's  canal  ; 
(3)  if  the  vessels  are  atheromatous,  they  must  not  be  tied  too  tightly. 
A  catgut  hgature,  not  too  fine,  should  be  employed  now,  and  care  should 
be  taken  to  include  a  little  of  the  soft  parts  so  as  to  prevent  the  hgature 
cutting  through.  The  muscles  are  brought  together  over  the  bone  end 
with  catgut  sutures.  The  cavity  in  the  stump  is  thus  obliterated  and 
oozing  prevented,  so  that  clots  and  serum  do  not  accumulate. 

In  amputations  of  the  thigh  accompanied  by  grave  shock  (p.  811),  no 
time  should  be  lost  in  looking  for  vessels,  save  the  femoral  and  any  other 
large  branch  which  can  be  seen.  Firm  bandaging  and  raising  the  stump 
will  suffice.  It  is  well  partially  to  reheve  the  tightness  of  the  bandages 
in  a  few  hours  by  nicking  them.  Very  few  sutures  should  be  used  in 
these  cases  of  shock,  or  in  those  where  the  soft  parts  are  sinus-riddled. 

II.  Transfixion  Flaps.  Advantage.  Great  rapidity.  Disadvantages. 
Those  given  at  p.  138,  on  a  large  scale.  This  method  may  be  used  where 
much  speed  is  needed,  as  in  a  double  amputation  after  a  railway  accideiit, 
or  where  many  wounded  require  attention,  as  after  a  great  battle.  It 
is  also  adapted  to  the  wasted  muscles  of  a  patient  who  has  long  suffered 
from  some  chronic  disease  of  knee  or  leg,  but  even  here  it  is  inferior  to 
the  mixed  method. 

Operation.  The  surgeon,  standing  to  the  right  side  of  either  Umb,  with 
his  left  index  and  thumb  marking  the  site  of  his  intended  bone-section, 
raises  with  his  hand  the  soft  parts  on  the  front  and  sides  of  the  thigh,  and 
sends  his  knife  across  the  hmb  in  front  of  the  femur.  The  knife  should 
be  entered  well  below,  so  as  to  get  as  large  an  anterior  flap  as  possible,  and 
at  its  entry  should  be  pushed  a  Uttle  upwards  so  as  to  go  easily  over 
the  bone.  An  anterior  flap  is  then  cut  four  to  four  and  a  half  inches 
long,  with  a  broadly  curving,  almost  square  extremity,  and  not  too  thin 
at  its  edge.  This  being  raised  by  the  surgeon  or  an  assistant,  the  knife 
is  now  passed  behind  the  bone,  and  a  posterior  flap  cut  of  the  same 
length  as  the  anterior,  the  making  of  this  flap  being  somewhat  facilitated 
by  drawing  the  soft  parts  on  the  back  of  the  limb  away  from  the  bone. 

If  the  hmb  be  very  bulky,  the  knife  should  be  kept  well  away  from 
the  bone,  especially  behind  it ;  thus  the  more  superficial  muscles  only 
will  be  included  in  the  posterior  flap. 

Both  flaps  having  been  retracted,  the  remaining  soft  parts  are  severed 
with  circular  sweeps,  and  the  rest  of  the  operation  completed,  as  at 
p.  847,  but  with  this  difference,  that  here  there  will  be  more  need  of 
trimming  some  of  the  soft  parts  clean  and  square.^ 

III.  The  Circular  Method.  I  may  here  state  briefly  why  this  method 
is,  nowadays,  considered  inferior,  both  in  the  thigh  and  elsewhere,  to 

^  While  dres.ser  to  the  late  Mr.  Poland,  I  once  saw  the  femoral  vessels  split  for  about 
three  and  a  half  inches  by  his  rapid  hands.  This  amputation  of  the  thigh  by  transfixion 
was  his  last  operation  at  Guy's  Hosi^ital.  He  was  even  then  facing  with  quiet  brave- 
ness  the  bronchitis  which,  a  very  few  days  later,  ended  his  hfe. 


AMPUTATION  THROUGH  THE  THIGH  849 

that  by  flaps.  In  saying  this,  it  is  not  denied  that  in  many  cases  stumps 
by  the  circular  method  are  fully  equal  to  those  by  flaps  ;  indeed,  in  many 
it  is  impossible  to  tell,  in  later  years,  which  method  has  been  employed. 
On  the  whole,  however,  the  flap-method  has  the  following  advantages  : 
(1)  It  is  most  generally  applicable,  e.g.  in  most  parts  not  circular  and 
at  the  joints.  (2)  By  it  the  surgeon  can  better  adapt  his  skin  covering 
to  his  needs,  e.g.  when  the  skin  is  less  available  on  one  aspect  of  the 
limb  than  on  another.  (3)  There  is  less  risk  of  a  conical  stump  ;  and 
(4)  of  a  cicatrix  adherent  to  the  bone.  The  great  advantage  of  the  circular 
method,  viz.  that  the  vessels  and  nerves  are  cut  square,  and  that, 
thus,  the  former  retracting  more  easily,  fewer  need  securing,  while 
there  is  less  risk  of  bulbous  ends  forming  on  the  latter. 

One  more  advantage  of  the  flap-method  is  the  greater  rapidity, 
especially  when  transflxion  is  employed,  though  this,  in  these  days  of 
anaesthetics,  is  only  of  importance  in  a  few  cases. 


Fig.  340.     Circular  amputation  through  the  thigh.     The  skin  and  fascia  lata 

may  be   difficult   to  retract  without  a  vertical  slit  on  the   outer  side.      The 

muscles  are  sewn  over  the  bone  with  catgut  sutures. 

The  circular  method  is  only  to  be  adopted  here  in  the  case  of  the 
lower  third  of  wasted  thighs,  or  in  those  of  young  subjects.  Even  here 
the  greater  tendency  of  the  posterior  muscles  to  retract  must  be  met  by 
cutting  them  about  three-quarters  of  an  inch  longer  than  those  in  front. 

While  this  operation  is  for  the  above  reasons  not  recommended  in 
practice,  it  may  be  made  use  of  in  the  lower  third  of  the  thigh  in  the 
cases  mentioned  above.  On  the  dead  subject,  the  student  who  has  not 
had  a  chance  of  performing  it  upon  the  arm,  may  make  use  of  it  here. 

Operation.  As  this  method  has  been  described  in  detail  under  ampu- 
tation of  the  arm,  it  will  be  only  briefly  given  here.  The  preHminaries  are 
those  already  given.  The  surgeon  standing  to  the  right  of  the  hmb,  the 
assistant,  who  stands  on  the  opposite  side  to  him,  but  nearer  the  trunk, 
draws  up  the  skin  with  both  hands.  The  surgeon,  stooping  a  httle, 
passes  his  knife  first  under  the  Hmb  then  above,  across,  and  so  around 
it  till  by  dropping  the  knife  vertically  the  back  of  the  instrument  looks 
towards  him,  while  its  heel  rests  on  that  side  nearest  to  him.  He  then 
makes  a  circular  sweep  around  the  thigh,  this  being  aided  by  the  assistant 
who  has  charge  of  the  hmb  rotating  it  so  as  to  make  the  soft  parts  meet 

SURGERY  I  54 


850       OPERATIONS  ON  THE  LOWER  EXTREMITY 

the  knife.  The  surgeon  then  taking  hold  of  the  edge  of  the  incision, 
dissects  up  a  cufE-hke  flap  of  skin  and  deep  fascia  about  two  inches  in 
length,  cutting  it  of  even  thickness  all  round  the  limb.  The  flap  is 
then  folded  back,  and  the  remaining  soft  parts  divided  with  circular 
sweeps  of  the  knife.  In  doing  this  the .  greater  contraction  of  the 
hamstring  muscles  must  be  remembered,  and  these  muscles  cut  rather 
longer  than  those  in  front.  All  the  muscles  are  cut  obliquely  from  below 
upwards  towards  the  bone  at  the  point  selected  for  section,  which  is 
generally  about  four  and  a  half  inches  above  the  skin  incision.  Care 
must  be  taken,  if  it  is  thought  needful,  after  making  the  circular  sweeps, 
to  free  the  bone  higher  up,  and  so  to  secure  its  being  well  buried  in  the  soft 
parts,  but  not  to  prick  the  already  divided  femoral  vessels  which  lie  in 
close  proximity  to  the  femur  in  the  lower  third.  The  muscles  are  care- 
fully sewn  together. 

IV.  Rectangular  Flaps  of  Mr.  Teale.  This  method  is  fully  described  later. 
It  is  not  recommended  here,  as  it  is  expensive,  involving  division  of  the  bone 
nearer  to  the  trunk  than  other  methods.  (1)  Owing  to  the  bulkiness  of  the  long 
anterior  flap,  it  is,  here,  especially  difficult  to  fold  and  adjust  it  at  the  conclusion  of 
the  operation,  and  still  more  so  to  keep  it  adjusted  if  primary  union  fails.  (2)  Its 
chief  advantages — keej^ing  the  end  of  the  bone  well  buried,  and  cutting  the  vessels 
and  nerves  clean  and  square — are  also  sufficiently  attained  by  the  other  flap  methods 
already  given,  especially  the  mixed  method  (p.  816). 

V.  Lateral  Flaps.  This  method  has  certain  grave  objections  here.  (1)  The  sawn 
femur,  tilted  upwards  by  the  ilio-psoas,  is  very  liable  to  press  against  the  upper  angle 
of  the  flaps,  and  to  come  through  at  this  spot,  and  necrose.  (2)  If  this  does  not 
take  place,  the  bone  often  adheres  to  the  cicatrix  here,  while  the  flaps  hang  down 
and  away  from  it. 

It  should  only  be  made  use  of  when  no  other  method  is  available,  as  in  a  case 
where,  owing  to  the  condition  of  the  soft  parts,  flaps  can  only  be  got  by  making 
one  long  external  and  a  short  internal,  or  vice  versa. 

Operation.     This  method  will  be  found  fully  described  at  p.  905. 

This  will  be  a  convenient  place  for  making  a  few  remarks  which  may 
be  useful  to  my  juniors  on  certain  grave  conditions  in  which  amputa- 
tion through  the  thigh  may  be  called  for.  I  refer  to — A.  Amputation 
during  shock  ;  B.  Multiple  amputations  ;  and  C.  Amputation  for  gan- 
grene. 

I  take  first  A,  the  question  of  the  advisability  of  primary  amputa- 
tion in  severe  injuries,  while  shock  is  present.  Each  case  must  be  studied 
by  itself  according  to  the  conditions  present,  both  as  regards  the  injury 
and  the  patient.  If  a  general  rule  can  be  formulated  it  would  be  to  run 
the  risk,  inevitably  great,  and  operate  as  soon  as  possible.  Delay,  say 
for  six  or  twelve  hours,  will  not  remove  the  factor  of  shock  altogether, 
while  it  exposes  the  patient  to  other  dangers.  H.  Cushing  ^  strongly 
advocates  early  amputation.  "  Here  a  state  of  shock  may  already  be 
present,  and  the  attendant  ordinarily  is  ad\ased  to  wait  for  some  hours, 
during  which  time  a  readjustment  of  conditions  is  expected  to  take  place, 
and  the  severity  of  shock  to  diminish.  As  a  matter  of  fact,  the  very 
conditions  are  present  which  tend  to  perpetuate  or  to  increase  the  already 
existent  degree  of  shock.  Such  an  increase  is  brought  about  by  a  con- 
tinuation of  afferent  sensory  impulses.  The  tourniquet  itself,  which  has 
been  apphed  at  the  time  of  the  accident,  although  controlling  the  loss  of 
blood,  constantly  adds,  from  pain,  to  the  shock  of  the  original  injury. 
The  dragging  of  the  mangled  hmb  on  the  great  sensory  nerve  trunks, 
which  are  rarely  severed,  gives  impulses  of  pain  with  every  movement  of 

^  Ann  of  Surg.,  September  1902. 


AMPUTATION  THROUGH  THK  THKHl      8.51 

the  ol'teii  restless  patient,  iiiipulses  which  in  such  a  state  cause  leflexly  a 
further  lowering  of  blood  pressure.  Strychnia,  intravenous  infusion, 
and  delay  are  the  usual  measures  advocated  for  such  states.  1  believe 
they  are,  if  not  actually  harmful,  certainly  not  helpful.  The  real  indica- 
tion is  to  rid  the  patient  of  the  centripetal  impulses,  originating  in  the 
crushed  member,  by  cocuinisation  and  division  of  the  large  nerves,  so 
often  exposed  in  a  mangled  limb,  by  ligation  of  vessels,  and  the  earliest 
possible  removal  of  the  painful  tourniquet.  Under  proper  management, 
with  i)ossible  strapping  of  the  abdomen  to  hold  up  the  blood  pressui(i, 
witli  morphia  in  small  amounts  to  control  restlessness,  and  with  a  proper 
avoidance  of  those  conditions  which  during  the  operation  would  increase 
shock,  I  believe  that  it  is  no  heresy  to  advocate  ether  ana)thesia  (never 
chloroform)  and  early  operation  for  most  cases  of  severe  traumatism  of  the 
extremities."  Spinal  ana?sthesia  is  a  great  boon  in  these  cases,  and 
axillary  or  intravenous  infusion  before,  during,  and  after  the  operation 
are  of  great  value.  The  earlier  the  amputation  the  less  the  fear  of 
sepsis. 

B.  Multiple  amputations.  The  main  points  here  are  :  (1)  To  per- 
form the  operations  together.  Thus  when  the  services  of  three  operators 
can  be  secured  a  triple  amputation  can  be  completed  in  thirty-five 
minutes.  (2)  In  such  a  case  a  large  saline  infusion  should  be  made  into 
one  of  the  main  veins  severed  during  the  amputations.  (3)  As  advised 
by  Crile,  eucaine  should  be  injected  into  the  main  nerve  trunks 
(p.  28).  (4)  No  time  should  be  lost  in  tying  a  number  of  smaller 
vessels.  The  main  trunks  should  be  secured,  and  Spencer- Wells  forceps 
applied  to  other  bleeding-poi]its,  or  the  wound  packed  with  gauze  and 
firmly  bandaged.  Such  bandages  will  need  nicking  in  an  hour  or  two. 
(5)  There  should  be  no  close  or  tight  suturing  ;  any  attempt  to  secure 
primary  neatness  will  only  defeat  its  own  end.  (6)  As  sterilisation  will 
probably  be  incomplete,  wet  gauze  dressings  should  be  appUed,  to  be 
replaced  for  the  first  few  days,  when  the  danger  of  haemorrhage  has 
passed,  by  boracic  acid  fomentations.  (7)  For  the  first  two  days  the 
patient  should  have  a  room  to  himself. 

C.  Amputation  in  eases  of  gangrene.  These  may  be  divided  into 
acute  and  chronic.  In  the  former  a  high  amputation  is  the  patient's 
only  chance.  In  the  lower  extremity  the  resort,  though  the  only 
one,  is  much  more  desperate.  Knott  ^  recommends  amputation  in 
two  stages  in  acute  traumatic  cases.  A  circular  amputation  is  first  per- 
formed just  above  the  line  of  apparent  demarcation.  Later,  when  the 
patient's  condition  is  improved,  a  second  operation,  which  consists  in  a 
higher  division  of  the  bone  and  approximation  of  the  soft  parts,  is  done. 
The  reasons  for  advising  this  are  that  the  first  operation  may  remove  the 
source  of  infection,  and  that  the  cutting  of  flaps  and  introduction  of 
sutures  tend  to  produce  gangrene  in  structures  the  circulation  of 
which  is  already  bad.  Knott  has  practised  the  above  method  four 
times — once  in  the  upper  third  of  the  thigh,  once  in  the  middle  third  of 
the  forearm,  and  twice  in  the  upper  third  of  the  leg — with  uniformly 
good  results.  2 

1  Jonrn.  Amer.  Med.  Asfoc.  April  11,  1903. 

2  The  following  case  is  of  some  interest,  as  it  shows  that  sometimes  the  worst  forms  of 
spreading  gangrene  may  be  prevented  by  an  amputation,  though  the  surgeon  may  not  be 
aware  of  this  at  the  time.  Three  years  ago,  a  young  man  who  had  been  run  over  on  the 
South  Eastern  Railway  was  admitted  with  the  lower  part  of  one  leg  so  smashed  as  to  call 
for  amputation  through  the  upper  third.     This  was  done  by  my  house  surgeon,  Dr. 


852       OPERATIONS  ON  THE  LOWER  EXTREMITY 

Amputation  in  Chronic  Gangrene.  I  refer  here  to  cases  originating 
in  cardiac  disease,  frost-bite,  typhoid  fever,  pneumonia,  and  the  more 
common  ones,  viz.  those  simulating  the  senile  form  in  which,  in  an 
elderly  patient  after  an  injury,  e.g.  to  the  leg,  thrombosis  begins  in  a 
large  muscular  branch,  and  creeps  up  into  the  tibial  arteries,  and  lastly, 
and  more  especially,  to  senile  gangrene.  And  I  use  the  term  "  chronic  " 
rather  than  "  dry  "  because  senile  gangrene,  of  which  I  speak  more 
particularly,  is  only  dry  while  it  remains  limited  to  the  toes,  owing  to  the 
small  supply  of  fluid  and  the  readiness  of  evaporation.  While  in  many 
of  the  other  cases  of  chronic  gangrene  the  surgeon  will  do  well  to  wait 
because  the  progress  is  so  slow,  and  because,  owing  to  the  completeness  of 
the  dryness,  infection  and  toxaemia  are  absent,  this  delay  will  thus 
allow  of  a  much  less  severe  amputation  and  a  more  useful  artificial 
Hmb  ;  this  is  not  the  case  where  there  is  evidence  of  the  gangrene  being 
"  mixed."  Here  evidence  of  infection  may  show  itself  at  any  moment, 
and  owing  to  the  vitaUty  of  the  patient,  may  be  rapidly  fatal.  Sooner 
or  later,  senile  gangrene  reaches  the  sole,  and  now  becomes  moist  as  well 
as  dry,  and  the  result  of  infection  will  speedily  follow.  For  this  reason, 
and  because  estabhshed  gangrene  of  the  toes  means  a  bed-ridden  patient 
and  a  death  in  life,  because  the  pain  and  loss  of  sleep  admit  of  no  real 
alleviation,  and,  together  with  the  progressive  impairment  of  damaged 
viscera,  will  but  further  lower  the  depressed  vitality  to  a  point  unable 
safely  to  meet  the  operation  when  this,  often  too  late,  is  consented  to — 
for  these  reasons  I  advocate  strongly  amputation  through  the  lower  third 
of  the  thigh  in  senile  gangrene  as  soon  as  this  is  estabhshed  in  the  toes.  I 
take  it  for  granted  that  the  other  factors  in  the  question  relating  to  the 
patient's  general  condition  are  sufficiently  favourable.  My  experience 
would  lead  me  to  look  upon  diabetes  and  albuminuria,  especially  in 
stout  patients  with  an  unstable  mental  condition,  as  prohibitive.  If  a 
surgeon,  early  in  his  experience,  be  asked  about  the  value  of  local  inter- 
ference, e.g.  detachment  of  gangrenous  parts,  incisions,  or  a  low  amputa- 
tion, the  results  are,  as  a  rule,  so  extremely  bad  that  such  questions  should 
not  be  entertained.  Amputation  high  up  in  the  leg  gives  results  but 
httle  better,  owing  to  the  condition  of  the  vessels.  Thus  of  thirteen 
cases  recorded  by  Heidenhain  in  only  two  did  the  flaps  heal,  two  died  of 
reappearing  gangrene,  nine  were  reamputated.  In  amputation  through 
the  lower  third  of  the  thigh,  the  results  improve  owing  to  the  better 
nutrition  of  the  parts.  Thus  of  sixteen  cases  amputated  through  and 
above  the  knee-joint  eight  recovered  and  eight  died  (Heidenhain). 
G.  Belhngham  Smith  and  H.  E.  Durham  found  that  of  eighteen  cases  of 
amputation  through  the  thigh  ten  recovered  (in  four  there  was  some 
gangrene  and  infection  of  the  flaps)  ;  eight  died.  While  the  step  will 
always  remain  one  of  great  gravity,  one  in  which  both  sides  of  the  question 
must  be  fairly  placed  before  the  patients  and  the  decision  left  to  them, 
and  while  it  too  often  proves  only  palliative  owing  to  reappearance, 

Norman  Ticehurst,  now  of  St.  Leonards.  When  I  scrutinised  the  condition  of  the 
ligatured  vessels,  I  happened,  by  the  merest  chance,  to  detect  some  bubbles  of  gas  in  the 
connective  tissue  between  some  of  the  intermuscular  septa.  Pointing  this  out  as  an 
instance  of  the  far-reaching  effects  of  a  very  severe  injury,  I  suggested  that  the  tissue 
affected  should  be  cut  out  and  forwarded  in  a  sterile  tube  to  the  Bacteriological  Depart- 
ment, and  further  directed  that  a  drainage-tube  should  be  inserted  and  very  few  sutures 
employed.  The  flaps  sloughed  almost  in  their  entirety,  and,  in  a  few  days,  the  report 
reached  us  that  the  bacillus  of  malignant  oedema  had  been  present.  The  patient  recovered, 
and  the  stump  was,  ultimately,  most  serviceable.  The  soil  at  the  site  of  the  accident  was 
that  of  the  permanent  way  between  London  Bridge  and  Cannon  Street  Stations. 


AMPUTATIONS  IMMEDIATELY  ABOVE  KNEE-JOINT   853 

ultimately,  of  gangrene  in  the  opposite  limb,  I  consider  it  abundantly 
justified  in  suitable  cases  for  the  reasons  already  given,  and  I  would 
lay  stress  on  the  amputation  being  through  the  lower  third  of  the  tliigh, 
and  here  only.  The  greater  distance  from  the  gangrene,  the  better 
nutrition  of  the  parts,  the  vascular  muscular  tissues,  the  single  large 
artery  easy  to  secure,  all  emphasise  this  point.  The  chief  details  to 
bear  in  mind  are  to  see  that  the  Esmarch  bandage  or  its  equivalent  is  put 
on  witii  great  care,  to  cut  the  flaps  sufhciently  long  and  thick  and  uniform 
—and  here  every  cutting  instrument  should  be  of  the  sharpest — ^not  to 
insert  too  many  or  too  tight  sutures,  and  to  make  use  of  drainage.  It  is 
very  difficult  to  make  out  the  condition  of  the  main  artery  beforehand. 
If  it  be  thrombosed,  an  unusual  number  of  small  vessels  will  probably 
need  securing.  Where  it  is  rigid  and  calcareous,  the  ligature  must  not  be 
too  small,  and  some  of  the  sheath,  and,  if  needful,  some  fascial  or  muscular 
tissue  as  well,  must  be  included  in  it.  In  two  of  my  cases  in  which  this 
condition  of  the  femoral  artery  was  present,  uninterrupted  healing  and 
recovery  followed.     In  diabetic  patients  spinal  anaesthesia  is  indicated. 

AMPUTATIONS  IMMEDIATELY    ABOVE   THE  KNEE-JOINT 

While  conditions  admitting  of  the  performance  of  these  amputations 
are  not  common,  the  surgeon  should  be  familiar  with  them,  especially 
with  that  of  harden,  owing  to  the  importance  of  preserving  as  much  as 
possible  of  the  femur  and  adductors. 

Methods  :  (i)  Garden's  (Figs.  341  and  342).  (ii)  Gritti's  Trans- 
condyloid  (Figs.  343  and  345).  (iii)  Stokes's  Supracondyloid,  an  important 
modification  of  the  above  (Figs.  344,  34(5,  347,  and  348). 

All  the  above,  but  especially  the  two  latter,  possess  the  following 
advantages  (which  they  share  with  amputation  through  the  knee-joint 
over  amputation  through  the  thigh),  viz.  : 

(1)  The  patient  can  bear  his  weight  in  walking  on  the  face  of  his 
stump  ;  thus,  he  is  not  compelled  to  take  his  bearing  from  the  tuberosity 
of  the  ischium,  or  to  walk  as  if  he  had  an  ankylosed  hip-joint  (Stokes), 
as  is  the  case  after  amputation  of  the  thigh.  (2)  Very  good  power  of 
adduction  over  the  artificial  limb  remains.  Every  surgeon  must  have 
noticed  how  badly  of?  a  patient  is  in  this  respect  after  an  ordinary  amputa- 
tion through  the  thigh.  By  these  methods  the  adductors  are  left  almost 
intact,  even  to  part  of  the  strong  vertical  tendon  of  the  adductor  magnus, 
the  result  being  that  the  balance  between  the  adductors  and  the  ab- 
ductors of  the  thigh  remains  practically  undisturbed,  and  the  patient 
when  walking  has  none  of  that  difficulty  (which  is  seen  after  thigh 
amputations)  of  bringing  the  limb  which  he  has  swamg  forwards  in  again 
under  the  centre  of  gravity.^  (3)  The  medullary  canal  is  not  opened  : 
on  this  account  there  is  less  risk  of  necrosis  and  osteo-myelitis  if  the 
stump  becomes  infected.  (4)  There  is  less  shock,  because  (a)  the  limb 
is  removed  farther  from  the  trunk,  (6)  the  muscles  are  divided  not  through 
their  vascular  bellies,  but  through  their  tendons. 

(i)  Garden's  Amputation 

Advantages.  This  valuable  amputation  has  some  points  in  common 
with  Syme's  amputation  at  the  ankle-joint.  In  both  the  bone-section 
is  made  not  through  a  medullary  canal,  but  through  vascular,  quickly 

^  The  importance  of  the  preservation  of  the  quadriceps  extensor,  given  by  the  Stokes- 
Gritti  method,  need  only  be  alluded  to. 


854       OPERATIONS  ON  THE  LOWER  EXTREMITY 

healing  cancellous  tissue,  in  both  the  skin  reserved  for  the  face  of  the' 
stump  has  been  used  to  pressure,  though  not  equally  so,  for  the  skin 
preserved  in  the  ankle- amputation  is  thick  and  callous,  in  the  other 
thiiuier  and  more  sensitive. 

Lord  Lister  ^  thus  recommends  this  amputation  :  "  This  operation, 
when  contrasted  with  amputation  in  the  lower  third  of  the  thigh,  presents 
a  remarkable  combination  of  advantages.  It  is  less  serious  in  its  im- 
mediate effects  upon  the  system,  because  a  considerably  smaller  quantity 


Fig.  341.     (Caixlcn.) 

of  the  body  is  removed,  and  also  because,  the  limb  being  divided  where 
it  consists  of  little  else  than  skin,  bone,  and  tendons,  fewer  blood-vessels 
are  cut  than  when  the  knife  is  carried  through  the  highly  vascular  muscles 
of  the  thigh ;  the  popliteal  and  one  or  two  articular  branches  being,  as  a 
general  rule,  all  that  require  attention,  so  that  loss  of  blood  is  much 
diminished.  In  the  further  progress  of  the  case  the  tendency  to  pro- 
trusion of  the  bone,  which  often  causes  inconvenience  in  an  amputation 
through  the  thigh,  is  rendered  comparatively  slight  by  the  ample  extent 
of  the  covering  provided,  and  also  by  the  circumstance  that  the  divided 
hamstrings  slip  up  in  their  sheaths,  so  that  the  posterior  muscles  have 


Fig.  342.     (Garden.) 

comparatively  little  power  to  produce  retraction.  The  superiority  of  the 
operation  is  equally  conspicuous  as  regards  the  ultimate  usefulness  of  the 
stump,  which,  from  its  great  length,  has  full  command  of  the  artificial 
limb,  while  its  extremity  is  well  calculated  for  sustaining  pressure,  both 
on  account  of  the  breadth  of  the  cut  surface  of  the  bone  divided  through 
the  condyles,  and  from  the  character  of  the  skin  habituated  to  similar 
treatment  in  kneeling.  Considering  therefore  that  this  procedure  can 
be  substituted  for  amputation  of  the  thigh  in  the  great  majority  of  cases 
both  of  injury  and  disease  formerly  supposed  to  demand  it,  '  Garden's 
operation  '  must  be  regarded  as  a  great  advance  in  surgery."  ^ 

1  Sijilem  of  Surge^y,  vol.  iii,  p.  705. 

"  Other  advantages  given  by  Mr.  Garden  are,  the  favourable  position  of  the  stump  for 
dressing  and  drainage ;  its  painlessness,  the  chief  nerves  being  cut  high  up  and  slipping 
upwards  out  of  the  waj^ ;  and  the  cicatrix  being  drawn  clear  of  the  point  of  the  bone, 
and  out  of  reach  of  pressure. 


AMPUTATIONS  BIMEDTATELY  ABOVE  KNEE-JOINT   855 

Disadvantayes.  The  cliicl"  of  those  is  the  sloughing  of  the  long 
anterior  flap  which  nuiy  occur,  "  in  spite  of  faultless  operating,"  espe- 
cially if  the  skin,  of  which  it  chiefly  consists,  has  been  damaged  by 
injury  or  disease,  or  if  the  patient  be  old  or  weakly,  thus  leading  to  an 
adherent,  tender  scar,  and  a  useless  stump.  Another  very  important 
objection  is  that  the  stump  is  too  long  to  fit  on  an  artificial  limb,  having 
its  knee-joint  on  a  level  with  the  opposite  knee,  so  that  the  asymmetry 
is  easily  noticed,  especially  when  the  patient  sits. 


Fig.    343.      Gritti's  transcondyloid  section 

of  the  femur,  leaving  a  stump  too  long  and 

a   surface   too    large  for  the  sawn  patella 

to  fit. 


Fig.  344.    Stokes'   supracondyloid   am- 
putation, leaving  a  shorter  stumji  and 
a   surface    much  moro    easily  fitted  by 
the  sawn  patella. 


Operation.  According  to  its  introducer  this  amputation  consists  in  raising  a 
rounded  tiap  from  the  front  of  the  joint  (Figs.  341  and  342),  dividing  everything  else 
straight  down  to  the  bone,  and  sawing  this  slightly  above  the  plane  of  the  muscles. 

The  operator,  standing  on  the  right  side  of  the  limb,  takes  it,  between  his  left 
forefinger  and  thumb,  at  the  spot  selected  for  the  base  of  the  flap,  ^  and  enters  the 
point  of  his  knife  close  to  his  finger,  bringing  it  round  through  the  skin  and  fat  below 
the  patella  to  the  spot  pressed  by  his  thumb,  then  turning  the  edge  do\\mwards  at 
a  right  angle  with  the  line  of  the  limb,  he  passes  it  through  to  the  spot  where  it  first 
entered,  cutting  outwards  through  everything  behind  the  bone.  The  flap  is  then 
reflected,  and  the  remainder  of  the  soft  parts  divided  straight  dowii  to  the  bone  ; 
the  muscles  are  then  slightly  cleared  uijw^ards,  and  the  saw  apj)lied  "  through  the 
base  of  the  condyles."     The  projecting  j)art  of  the  fe*nur  may  be  rounded  off.     Where 


Fig.  345.     (Farabeuf.) 


Fig.  346.     (Farabeuf.) 


there  is  any  doubt  about  the  vitality  of  the  large  anterior  flap,  a  short  posterior 
one  should  be  made,  the  anterior  one  thus  not  needing  to  be  so  long. 

Owing  to  the  risk  of  sloughing  of  the  long  anterior  flap,  Lord  Lister's  modifica- 
tion, by  which  two  shorter  flaps  are  employed,  is  always  to  be  preferred.  "  The 
surgeon  first  cuts  transversely  across  the  front  of  the  limb  from  side  to  side  at  the 
level  of  the  anterior  tuberosity  of  the  tibia,  and  joins  the  horns  of  tliis  incision 
posteriorly  by  carrying  the  knife  backwards  obliquely  at  an  angle  of  45  degrees  to 
the  axis  of  the  leg  "through  the  skin  and  fat.  The  limb  being  elevated,  he  dissects 
up  the  posterior  skin  flap,  and  then  proceeds  to  raise  the  ring  of  integument  as  in 
a  circular  operation,  taking  due  care  to  avoid  scoring  the  subcutaneous  tissue ; 

1  This  corresponds  with  the  upper  border  of  the  patella,  the  limb  being  extended. 
The  lower  margin  comes  down  to  the  tubercle  of  the  tibia,  as  in  Fig.  34L  [See.  also 
Brit.  Mid.  Jonrn.,  18G4,  vol.  i,  p.  41G.) 


856       OPERATIONS  ON  THE  LOWER  EXTREMITY 

and  dividing  the  hamstrings  as  soon  as  they  are  exposed,  and  bending  the  knee,  he 
finds  no  difficulty  in  exposing  the  upper  border  of  the  patella.  He  then  sinks  his 
knife  through  the  insertion  of  the  quadriceps,  and  having  cleared  the  bone  immedi- 
ately alx)ve  the  articular  cartilage,  and  holding  the  limb  horizontal,  he  applies  the 
saw  vertically,  and  at  the  same  time  transversely  to  the  axis  of  the  limb  (not  of  the 
bone),  so  as  to  ensure  a  horizontal  surface  for  the  patient  to  rest  on."' 

(ii)  Gritti's  Transcondyloid  (Figs.  343  and  345).     (iii)  Stokes's  Supra- 
condyloid  Amputation  (Figs.  344,  346,  347  and  348). 


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Fig.  347.     Stokes-Gritti  amputation. 

For  fuller  information  on  the  above  amputations  I  would  refer  my 
readers  to  a  paper  I  contributed  to  the  Giuj  s  Hasp.  Reports,  vol.  xxiii, 
p.  211,  1878. 

But  while  this  osteo-plastic  method  shares  with  that  of  Garden  the 
advantages  given  above  (p.  854),  the  difficulty  of  securing  a  satisfactory 
section  of  a  small  mobile  bone  like  the  patella,  and,  later,  of  retaining 
it  accurately  in  situ,  is  usually  very  considerable.  From  an  extended 
experience  of  this  operation  I  much  prefer  that  of  Stephen  Smith  when 
the  conditions  admit  of  it. 

The  two  methods  are  often  confused.  Between  them  there  is  this  all-important 
difference  :  in  Gritti's  the  section  of  the  femur  is  made  through  the  condyles  ;  in 
Stokes's,  at  least  half  an  inch  above  them.  In  other  words,  the  one  operation  is 
trans-,  the  other  supra-condyloid. 


AMPUTATIONS  IMMEDIATELY  ABOVE  KNEE-JOINT   857 

On  this  point  great  stress  has  been  laid,  and  very  rightly,  by  Sir  W.  Stokes,  and 
a  comparison  of  the  two  operations  will  convince  every  one  that  he  Wiis  correct. 
If  tlie  section  of  the  femur  be  made  through  the  condyles  (Fig.  343),  the  sawn 
patella  will  not  fit  down  into  place.  It  will  either  be  drawn  up  altogether  on 
to  the  front  of  the  femur,  or  else  will  project  forwards,  .somewhat  like  the  half- 
open  lid  of  a  box  (Fig.  345),  at  an  angle  to  the  broad  sawn  surface,  which  is  al.so  too 
large  for  it  to  cover,  and  across,  and  off  which  it  is  liable  to  be  shifted  by  the 
contraction  of  the  quadriceps,  if  it  has  been  found  j)ossible  to  get  it  into  place. 
To  effect  this,  an  amount  of  force  will  be  required  which  is  almost  certain  to 
result  in  bruising  of  the  cut  jx-riosteum  on  the  edge  of  the  femur,  and  con.se- 
quent  necro.sis.  If,  on  the  other  hand,  the  saw  is  made  to  pass  a  full  inch  above 
the  condyles  (Fig.  344),  the  patella  will  fall  readily  into  place  (Fig.  346),  it  will  cover 
more  completely  the  now  smaller  surface  of  the  femur,  and  will  remain  easily  in 
situ  here,  the  Haps  when  brought  together  presenting  the  apjxjarance  shown  in 
Fig.  348. 

Operation.  An  Esmarch's  bandage  having  been  applied,  the  limb  brought  over 
the  edge  of  the  table  and  supjxjrted,  and  the  opposite  one  secured  out  of  the  way, 
the  surgeon,  stancbng  to  the  right  of  the  limb,  with  his  left  index  finger  and  thumb 
marking  the  base  of  the  Hap,  makes  an  incision  commencing  (on  the  left  side)  an  inch 
above  and  rather  behind  the  external  condyle,  carried  vertically  downwards  to  a 
point  oppo.site  to  the  tibial  tubercle,  then  broadly  curved  across  the  leg  and  carried 
upwards  to  a  jX)int  opposite  to  that  from  which  it  started.     This  Hap  having  been 


Fig.  348.     Stokes-Gritti  amputation.     Stump. 

dissected  upwards,  together  with  the  patella  (after  section  of  the  ligamentum 
patellse),  a  posterior  flap  is  cut  nearly  as  long  as  the  anterior.  This  may  be  effected 
in  one  of  two  ways,  either  by  the  surgeon  looking  over  and  then  stooping  a  little 
(the  limb  being  now  raised),  next  drawing  the  knife  from  without  inwards  across 
the  popliteal  .space,  thus  marking  out  and  then  dissecting  up  a  skin  Hap,  or  by  trans- 
fixing and  cutting  the  flap  from  within  outwards.  Of  the  two  I  prefer  the  first  : 
the  latter  is  the  speedier,  but  less  suited  to  bulky  limbs.  The  flaps  being  retracted, 
the  soft  parts  are  cut  through  with  a  circular  sweep  a  full  inch  above  the  articular 
surface  of  the  femur  ;  the  bone  is  then  sawn  through  here,  and  the  limb  removed. 
The  posterior  surface  of  the  patella  is  next  removed  with  a  metacarpal  or  small 
Butcher  saw.  This  last  step  is  one  of  con-siderable  difficulty,  owing  to  the  mobility 
of  the  bone  ;  it  will  be  facilitated  bj^  an  assistant  with  both  his  hands  everting 
and  projecting  the  under-surface  of  the  anterior  flap,  so  as  to  make  the  patella 
stand  out  from  it. 

The  vessels — popliteal,  one  or  two  articular,  and  the  anastomotic- — having  been 
secured,  drainage  is  provided,  and  the  flaps  are  brought  together  with  numerous 
points  of  suture,  save  at  the  angles. 

Even  where  the  flaps  are  cut  of  proper  length  and  the  femur  is  sawn  at  the  proper 
height,  the  patella  may  still  not  remain  acciu-ately  in  situ.  If  there  seem  any 
doubt  on  this  point,  or  if  the  patient  is  very  muscular,  additional  security  may  be 
given  by  passing  sutiires  of  sterilised  silk  between  the  tissues  on  the  under-surface 
of  the  anterior  flap,  at  the  edges  of  the  patella,  and  the  soft  parts  in  the  posterior 
flap  (avoiding  the  vicinity  of  the  large  vessels).  Wiring  or  pegging  the  bones  or 
division  of  the  rectus  muscle  on  the  under-surface  of  the  anterior  flap  are  unsatis- 
factory complications. 


858       OPERATIONS  ON  THE  LOWER  EXTREMITY 

REMOVAL  OF  AN  EXOSTOSIS  FROM  NEAR  THE 
ADDUCTOR  TUBERCLE  ^ 

As  these  growths  are  by  no  means  unconnnon  in  adolescents,  this 
operation  will  be  briefly  described  here.  Aseptic  excision  has  now 
replaced  any  other  operation,  such  as  subcutaneous  fracture. 

Operation.  The  parts  having  been  thoroughly  sterilised,  the  knee 
is  flexed  so  as  to  bring  down  the  synovial  membrane,  and  the  limb 
placed  on  its  outer  side.  A  free  incision,  about  three  and  a  half  inches 
long,  is  made  over  the  growth,  down  to  the  vastus  internus,  and  any 
superficial  vessels  attended  to.  The  muscular  fibres  are  then  cleanly 
cut  through,  and  the  bluish-grey  cartilage  which  caps  the  swelling  now 
comes  into  view.^  Any  muscular  branches  being  now  carefully  secured, 
and  the  wound  dried,  the  cut  vastus  is  pulled  aside  with  retractors,  and 
the  base  of  the  growth  being  thoroughly  exposed,  it  is  shaved  off  with 
an  osteotome  or  chisel,  leaving  exposed  cancellous  tissue.  The  muscular 
fibres  are  then  united  with  catgut,  and  the  wound  closed  with  fishing-gut. 
The  dressings  are  firmly  bandaged  to  prevent  oozing  from  the  bone. 

FRACTURES  OF  THE  FEMUR 

The  following  remarks  apply,  chiefly,  to  interference  for  ununited 
factures  :  more  inmiediate  interference  is  chiefly  called  for  in  injuries 
to  the  lower  end  of  the  bone. 

I.  Ununited  Fractures  about  the  Neck.  Lord  Lister  recorded  as  long 
ago  as  1871  ^  the  case  of  an  ununited  extracapsular  fracture  of  the  femur 
in  a  man,  aged  45,  where,  eighteen  months  after  the  injury,  he  cut  down 
on  the  fragments,  with  antiseptic  precautions,  and  gouged  them,  the 
fracture  being  then  firmly  put  up.  Recovery  was  complete,  the  man 
walking  well. 

Indications  for  this  rarely  called-for  operation  would  be  a  patient 
before,  or  perhaps  at,  middle  age,  with  good  vitality  and  much  pain  or 
loss  of  function  ;  there  should  be  no  evidence  of  osteoarthritis.  Dr. 
L.  Freeman,  of  Denver,  has  recorded  one  case  of  his  own  and  collected 
thirteen  others.*  Dr.  G.  E.  Davis  ^  recorded  a  case  of  intracapsular 
fracture  successfully  treated  by  a  screw.  Some  years  ago  one  of  us 
(R.  P.  R.)  successfully  treated  a  recent  intracapsular  fracture  in  an  old 
lady  by  exposing  the  head  and  neck  of  the  femur  and  passing  a  long 
screw  through  the  great  trochanter,  and  the  neck  into  the  head  of  the 
femur. 

Operation.  The  incision  usually  employed  will  be  the  anterior  one.® 
All  fibrous  tissue  between  the  fragments  must  be  removed  with  scissors, 
gouge,  &c.  As  little  bone  as  possible  is  to  be  taken  away.  Drilling 
and  fixation  of  the  fragments  is  most  difficult,  partly  from  their  position, 
partly  from  their  softened  condition.  Screws,  pegs,  long  nails,  a  gimlet 
left  in  eight  weeks  (Sayre),  have  been  employed.  They  can  only  be  intro- 
duced through  a  separate  incision  made  over  the  outer  aspect  of  the 

^  This  account  will  serve  for  the  removal  of  other  exostoses,  e.g.  those  met  with  at 
the  deltoid  insertion,  the  spine  of  the  scapula,  or  the  pelvis. 

-  Any  synovia-like  fluid  now  escajiing  comes  probably  from  a  bursa  over  the  growth, 
not  from  the  joint. 

'  Brit.  Med.  Journ.,  August  26. 

"  Ann.ofSnrg.,  1904.  vol.  ii,  p.  561.  ^  Ibid.,  August  1905.  p.  282. 

*  The  presence  of  a  skiagram  may  help  the  surgeon  during  the  operation. 


FRACTURES  OF  THE  FEMUR  859 

great  trochanter.  This  bone  must  be  well  raised  first  and  kept  up  by 
a  peg,  &c.,  owing  to  its  tendency  to  drop  backwards.  The  drill  and 
peg  must  pass  through  the  trochanter  and  lu^ck  well  into  the  head.  'J'his 
requires  much  care.  Whatever  means  of  fixation  is  used  should  be  left 
in  until  there  is  evidence  of  sufficient  consolidation.  As  is  the  case  else- 
where, a  sinus  often  forms  at  the  time  that  the  screw,  &c.,  becomes  loose. 
The  patient  should  be  kept  in  bed  for  six  weeks,  and  a  Hessing  or 
Thomas's  splint  then  applied,  so  that  the  patient  can  get  about  without 
transmitting  any  weight  through  the  affected  femur.  The  results  arc 
encouraging,  a  satisfactory  degree  of  mobility  and  good  use  of  the  limb 
being  recorded  in  most  cases. 

Some  shortening  remains.  In  a  few  cases  the  fragments  have  again 
become  loose.  In  another  small  series  of  cases  the  head  of  the  femur  has 
been  removed  ;  in  spite  of  the  shortening,  the  result  is  stated  to  have  been 
good. 

II.  Ununited  Fractures  of  the  Shaft.  The  risk  of  failure  after  opera- 
tions for  this  condition  is  well  known.  The  difficulties  which  may  be 
present  during  and  after  these  operations  are  very  considerable  ;  amongst 
them  sufficient  exposure  of  the  fragments,  keeping  the  wound  aseptic, 
and  the  parts  in  correct  apposition  afterwards  {vide  infra),  are  most 
prominent. 

Operation.  Resection  and  fixation  of  the  fragments  is  indicated 
here.  This  is  especially  so  in  long-standing  cases,  where  other  methods 
have  failed,  where  there  is  very  little  attempt  at  repair,  where  an  artificial 
joint  exists,  or  where,  after  a  severe  injury,  necrosis,  atrophy  of  the  frag- 
ments, and  fibrous  union  have  followed. 

The  operation  of  resection  should  always  be  performed  with  strict 
aseptic  precautions,  otherwise  the  risks  of  suppuration,  osteo-myelitis, 
and  pyemia  owing  to  the  very  free  incision  required,  the  exposure  of 
cancellous  tissue,  and,  perhaps,  of  the  medullary  canal,  are  considerable. 
The  following  most  important  preliminary  points  are  given  by  Sir  F. 
Treves  :  ^  "  (1)  It  will  be  well  in  some  cases  to  apply  extension  for  a 
week  or  two  before  the  operation  ;  this  partly  overcomes  the  shortening 
produced  by  contracted  muscles,  and  enables  the  surgeon  to  make  trial 
of  the  sphnt  he  proposes  to  employ  afterwards.  (2)  Before  undertaking 
this  operation  the  surgeon  should  understand  that  its  success  depends 
more  upon  the  completeness  of  the  arrangements  that  are  made  for 
keeping  the  bones  in  position  after  the  operation  than  upon  the  operation 
itself,  provided  the  latter  be  carried  out  with  due  care.  .  .  .  Care  in  the 
adjusting  of  the  fragments,  and  infinite  and  continued  care  in  the  after- 
treatment,  are  the  main  elements  of  success  in  the  present  class  of  case. 
The  success  of  the  operation  depends  far  more  upon  (1)  absolute  asepsis, 
and  (2)  accurate  apposition  with  careful  provision  for  the  maintenance 
of  the  same  by  means  of  the  plates  until  firm  union  can  take  place.  The 
maintenance  of  apposition  should  not  depend  on  external  splints,  but  on 
effective  bone  carpentry.  For  asepsis  Lane's  technique  and  instruments 
are  invaluable  and  incomparable.  The  limb  having  been  rendered  blood- 
less, if  practicable,  with  Esmarch  bandages,^  the  fracture  is  exposed  by  a 

^  Oper.  Surg.,  vol.  i,  p.  588. 

^  This  step  is  condemned  by  some,  notably  by  8ir  F.  Treves  {loc.  supra  cit.,  p.  588).  I 
admit  that  it  leads  to  much  oozing  from  the  cut  surfaces,  but,  having  tried  both  ways,  I 
am  of  opinion  that  this  can  be  safely  met  by  applying  ample  well-adjusted  dressings 
before  the  bandage  is  removed,  and  that  the  advantage  of  a  bloodless  wound  during  a  most 
difficult  and  prolonged  operation  is  almost  incalculable. 


860       OPERATIONS  ON  THE  LOWER  EXTREMITY 

free  incision,  five  to  eight  inches  long,  on  the  outer  side  of,  and  going  down 
to,  the  bone.  The  incision  should  be  made  along  the  line  of  the  inter- 
muscular septum  between  the  vastus  externus  and  biceps.  If  it  be  need- 
ful to  expose  the  inner  aspect  of  the  fragments,  a  second  incision  must 
be  made  through  the  vastus  internus  so  as  to  be  external  to  the  large 
vessels.  The  ends  are  freed  and  raised,  and  a  thin  layer  of  bone,  about  a 
quarter  of  an  inch  in  thickness,  removed  from  each.  The  soft  parts 
must  be  protected  with  retractors.  Only  if  it  be  absolutely  needful 
should  the  fragments  be  thrust  or  dragged  out  of  the  wound  ;  any 
disturbance  of  the  periosteum  should  be  as  restricted  as  possible. 
When  the  ends  of  the  bone  are  cut  square  a  saw  is  preferable.  If 
they  can  be  made  to  interlock,  by  shaping  these  in  part  into  the 
form  of  a  >>  ,  or  by  stepping  them,  a  chisel  will  be  useful :  the 
ends  of  the  bones  are  first  steadied  with  forceps.  The  fragments  are 
now  brought  into  exact  apposition,  and  to  facilitate  this  it  may  be 
necessary  to  divide  adhesions  or  tendons,  or  to  remove  any  intervening 
fibrous  or  fibro-cartilaginous  material,  or  a  sequestrum.  Lane's  plates 
and  screws  are  the  best  means  of  maintaining  apposition  of  the 
fragments. 

A  full  account  of  the  clamp  devised  by  Dr.  C.  Parkill  and  its  various 
uses  is  given  in  the  Ann.  of  Surg.,  May  1898.  Here  will  be  found  also  the 
reports  of  fourteen  cases  in  which  the  clamp  had  been  used.  The  fact 
that  success  was  obtained  in  each  of  these  cases  constitutes  a  strong  claim 
for  a  more  extended  trial.  Owing  to  its  numerous  parts,  it  is  complicated, 
and  the  projection  of  a  portion  of  the  instrument  calls  for  constant  atten- 
tion to  keeping  the  skin  sterile.  In  the  only  case  in  which  I  have  seen 
this  clamp  used  it  was  not  successful.  The  remarks  made  below  on 
fractures  of  the  leg  should  also  be  referred  to. 

III.  Injuries  about  the  lower  end  of  the  Femur.  E.g.  supra-  and 
inter-condyloid  fractures  and  injuries  to  the  epiphysis.  Where,  after  an 
attempt  under  anaesthesia,  a  skiagram,  taken  on  the  second  or  third  day, 
shows  that  the  position  of  the  fragments  is  unsatisfactory,  it  is  quite 
justifiable,  especially  in  a  young  and  healthy  patient,  to  resort  to  opera- 
tion if  the  surroundings  and  skill  of  the  surgeon  are  suitable.  In  the  case 
of  the  shaft  the  dangers  of  the  relations  increase  from  below  upwards  ; 
here,  in  addition  to  the  importance  of  the  relations,  the  presence  of  the 
knee-joint,  the  possibility  of  injury  to  the  pophteal  vessels,^  the  bulk 
and  fixity  of  the  lower  fragment,  have  all  to  be  remembered.  Adhesions 
here  form  so  quickly  that  interference  should  be  resorted  to  in  the  first 
week.  The  following  are  the  chief  points  which  need  attention.  (1)  The 
chief  incision  should  be  on  the  outer  side  along  the  outer  border  of 
the  biceps  tendon,  prolonged  upwards  along  the  fine  of  the  external 
intermascular  septum  already  mentioned  ;  in  any  extension  of  the  in- 
cision below  care  must  be  taken  of  the  external  pophteal  nerve.  (2)  If 
the  joint  be  uninjured,  the  synovial  membrane  should  be  avoided  by 
keeping  the  incision  low  down.-  (3)  Division  of  the  tendo  Achillis,  while 
variable  in  the  aid  which  it  affords,  should  always  be  resorted  to.     (4)  The 

1  (Edema  of  the  foot,  persisting  after  alteration  in  the  position  of  the  limb,  will  be  an 
indication  for  operation. 

2  The  persistent  stiffness  of  the  joint  which  is  so  liable  to  follow  a  successful  reduction 
of  the  fragments  would  make  one  very  chary  of  dividing  the  extensor,  or  opening  the 
knee  joint  so  as  to  insert  a  finger  to  aid  in  the  replacement  as  advised  by  some.  If  the 
joint  be  infected,  it  is  another  matter. 


FRACTURES  OF  THE  FEMUR  861 

position  of  the  fragments/  the  aspect  of  their  surfaces,  the  amount  of 
tilting,  rotation,  &c.,  being  determined  by  inspection  after  adequate 
exposure,  reduction  nnist  be  effected  by  manipulations  aided  by  leverage. 
The  wound  and  its  adjacent  area  being  protected  with  sterile  gauze,  ex- 
tension is  made  on  the  leg  in  the  extended  and  flexed  positions,  while  the 
surgeon  and  an  assistant  hold  the  fragments  with  long  forceps,  and  lever 
the  ends  into  apposition,  no  fingers  being  placed  in  the  wound  throughout 
the  operation.  The  difliculties  now  present  are  the  locking  of  the  lower 
fragment  between  the  closely  adjacent  femur  and  tibia ;  in  the  case  of  a 
separated  epiphysis  this  may  have  carried  with  it  a  portion  of  the  diaphysis 
which  may  need  careful  enucleation,  and,  this  failing,  detachment  with 
a  chisel,  or  the  upper  end  of  the  diaphysis  may  be  held  in  a  buttonhole- 
like slit  by  a  detached  sheath  of  periosteum,  this  requiring  careful  slitting 
up.  If  the  leverage  of  a  periosteal  elevator  is  required,  care  must  be  taken 
not  to  inflict  needless  damage  on  the  deUcate  and  softened  epiphysial 
structures.  (5)  When  replacement  has  been  effected  there  is  not,  in  my 
experience,  the  same  difficulty  in  retaining  these  fragments  in  position 
that  is  met  with  in  injuries  about  the  elbow-joint.  Plates  and  screws 
or  long  screws  are  used  to  maintain  apposition.  (6)  It  is  needless  to 
insist  on  the  need  of  the  most  rigid  asepsis  throughout.  (7)  The  after- 
position,  whether  flexed  or  extended,  will  mainly  depend  upon  the 
position  in  which  it  has  been  found  easiest  to  replace  and  fix  the  frag- 
ments. As  I  have  stated,  the  amount  of  mobility  of  the  joint,  even 
where  rapid  healing  has  been  secured,  is  often  disappointing,  and,  in 
separation  of  the  epiphysis  especially,  in  addition  to  some  stiffness  of 
the  joint  and  shortening,  some  degree  of  genu  valgum  or  varum  is  very 
likely  to  follow  if  the  hmb  be  used  prematurely. 

^  The  difference  in  the  displacement  in  a  case  of  separated  epiphysis  and  supra- 
condyloid  fracture  will  be  remembered.  In  the  former  case  the  epiphysis  is  displaced 
upwards,  and  the  lower  end  of  the  diaphysis  will  be  felt  in  the  popliteal  space.  In  the 
case  of  the  fracture  the  lower  fragment  is  drawn  backwards,  and  arrested  behind  the 
upper,  with  its  fractured  surface  looking  into  the  space  behind. 


CHAPTER  XLIl 
OPERATIONS  INVOLVING  THE  KNEE-JOINT 

AMPUTATION    THROUGH    THE   KNEE-JOINT.     ERASION    OF    THE 
KNEE-JOINT.     EXCISION  OF  THE  KNEE-JOINT.     ARTHRODESIS. 

AMPUTATION  THROUGH  THE  KNEE-JOINT  (Fig.  349) 

Chief  Methods  :  I.  By  Lateral  Flaps.  II.  By  Long  Anterior  and  Short 
Posterior  Flaps.  Of  these  the  first  is  far  the  superior.  The  great  objection 
to  the  second  is,  that  in  order  to  get  sufficient  covering  to  fall  readily- 
over  the  large  condyles,  a  long  anterior  flap  must  be  cut ;  as  this 
must  reach  two  inches  below  the  tibial  tubercle,  a  good  deal  of  its 
blood-supply  which  comes  from  below,  e.g.  from  the  recurrent  tibial, 
must  be  cut  off,  and  the  flap  is  thus  hable  to  slough.  This  risk  is  much 
diminished,  and  the  blood-supply  better  equalised,  by  the  method  of 
lateral  flaps. 

I.  Amputation  by  Lateral  Flaps.  This,  the  method  of  Dr.  Stephen 
Smith,!  was  brought  before  English  surgeons  by  Mr.  Bryant.^  The 
femoral  artery  having  been  controlled,  the  limb  supported  over  the 
edge  of  the  table,  and  shghtly  flexed,  the  surgeon,  standing  on  the 
right  side  of  either  limb,  marks  out  two  broad  lateral  flaps  as  follows  : 
His  left  thumb  and  index  finger  being  placed,  the  former  over  the 
centre  of  the  head  of  the  tibia,  the  latter  at  the  corresponding  point 
behind,  opposite  the  centre  of  the  joint,  he  marks  out  (in  the  case  of 
the  right  limb)  an  inner  flap  by  an  incision  which,  commencing  close 
to  the  index  finger,  is  carried  down  along  the  back  of  the  limb  for 
about  three  inches  and  a  half,  and  then  curves  upwards  and  forwards 
across  the  inner  aspect  of  the  leg,  till  it  ends  in  front  just  below  the 
thumb. ^  The  knife  not  being  taken  off,  a  similar  flap  is  then  shaped 
from  the  outer  side,  but  in  the  reverse  direction.  Dr.  Stephen  Smith 
calls  attention  to  the  following  points  :  In  making  these  flaps,  they 
should  be  cut  broad  enough  to  secure  ample  covering  for  the  condyles, 
and  the  inner  one  should  be  made  additionally  full  as  the  internal  condyle 
is  longer  than  the  external.  The  flaps  should  be  at  least  three  inches 
and  a  half  long,  if  of  equal  length.  They  consist  of  skin  and  fasciae. 
When  they  have  been  raised  as  far  as  the  line  of  the  articulation  the 
ligamentum  patellae  are  severed,  allowing  the  patella  to  go  upwards. 
The  soft  parts  around  the  joint  are  then  cut  through  with  a  circular 

^  New  ror^Jo?/r?!.o/il/f(^.,  September  1852  ;  ^wier.Jowni.  i/crf.  iSci.,  January  1870. 

2  Med.-Chir.  Trans.,  vol.  Ixix,  p.  163. 

^  Dr.  S.  Smith  begins  his  incision  about  an  inch  below  the  tubercle  of  the  tibia,  and 
carries  it  up  rather  higher  behind,  viz.  to  the  centre  of  the  articulation.  It  will  be  found 
easier  to  open  the  joint  and  to  detach  the  semilunar  cartilages  from  the  tibia  by  making 
the  incision  as  recommended  above. 

862 


AMPUTATION  TIIROlCill  THE  KNEE-JOINT        80;3 

sweep,  and  the  leg  removed.  In  doing  this,  the  limb  being  flexed  to 
relax  the  parts  and  facilitate  opening  the  joint,  the  semilunar  cartilages 
will  very  likely  be  found  closely  encircling  the  condyles  of  the  fenmr. 
Mr.  Bryant,  in  the  paper  already  quoted,  and  Dr.  Brinton,^  as  long  ago 
as  1872,  have  strongly  advised  that  the  semilunar  cartilages  should 
be  left  in  situ  by  severing  the  coronary  ligaments  which  tie  them  to  the 
tibia.  They  thus,  in  Dr.  .Brinton's  words,  form  "  a  cap,  fitted  on  the 
end  of  the  femur,  which  preserves  all  the  fascial  relations,  effectually 
prevents  retraction,  and  guards  against  the  projection  of  the  condyles." 


Fig.    349.     Amputation  thi'ough  tho  knee-joint  by  lateral  flai:)S;  the 
internal  flap  is  the  longer  to    cover   the    more  prominent   internal 
condyle.      The  semilunar  cartilages  are  left  in  the  stump. 

This  precaution  will  obviate  a  serious  objection  to  amputation  through 
the  knee-joint.  For  a  time  the  patient  bears  his  weight  well  on  the  end 
of  the  stump.  But  after  some  months  the  ends  of  the  condyles  (if  impro- 
tected  by  the  menisci)  begin  to  fret  the  thin  overlying  skin,  and  within  a 
year  of  the  amputation  the  patient,  usually,  has  to  have  his  artificial  limb 
altered. 

II.  By  a  Long  Anterior  and  a  Short  Posterior  Flap.  The  position  of  the  patient 
and  the  smgeon  being  as  at  p.  862,  the  latter  with  his  left  index  finger  and  thumb 
on  either  side  of  the  interval  between  the  femur  and  tibia,  enters  his  knife  (in  the 
case  of  the  right  limb)  just  below  the  finger  and  internal  condyle,  carries  it  straight 
down  along  the  inner  side  of  the  leg  till  it  reaches  a  spot  two  inches  below  the  tibial 
tubercle  ;  then  squarely  across  the  leg  till  it  reaches  a  corresponding  point  well  back 
upon  the  outer  side,  and  thence  up  to  a  point  just  below  his  thumb,  or  to  the  ex- 
ternal condyle.  This  flap  is  then  dissected  up,  containing  the  patella,  as  thickly 
as  possible,  and  almost  rectangular  in  shape,  anything  like  pointing  of  its  lower 
end  being  most  carefully  avoided  as  certain  to  lead  to  sloughing. 

This  flap  being  raised,  a  posterior  flap  is  made  about  two-thirds  the  length  of 
the  first,  as  at  p.  847,  either  by  dissection  from  without  inwards,  or  by  transfixion 
after  disarticulation. 

1  Philad.  Med.  Times,  December  28,  1872, 


864       OPERATIONS  ON  THE  LOWER  EXTREMITY 


ERASION  1  OF  THE  KNEE-JOINT 

Definition.  By  this  operation,  which  we  owe  to  G.  A.  Wright,^  of 
Manchester,  is  meant  a  systematic  removal  of  the  tuberculous  synovial 
membrane  ;  the  ligaments,  as  far  as  these  are  diseased,  are  also  removed, 
the  bones  and  cartilage  being  dealt  with  by  paring  with  a  knife,  or  by 
a  gouge  or  sharp  spoon.  The  more  advanced  the  disease  the  less  typical 
will  be  the  erasion.  "When  sinuses  are  present,  and  the  joint  is  the  seat 
of  mixed  infection,  the  risks  of  failure  of  any  attempt  to  save  the  limb 
are  hugely  increased.  Where  an  abscess  is  present,  G.  A.  Wright  ^  deals 
with  this  by  stages.  The  abscess  shovild  be  thoroughly  cleared  out 
first,  the  wound  closed,  and  erasion  performed  after  heahng  has  taken 
place.  This  plan  is  not  apphcable  to  cases  where  the  whole  joint  is 
suppurating.  Where  sinuses  exist  he  has  still  found  it  possible  in  some 
cases  to  render  the  parts  aseptic  by  excision  of  the  walls  of  the  tuber- 
culous tracts,  and  the  use  of  powerful  disinfectants,  of  which  he  con- 
siders turpentine  to  be  one  of  the  best.  Thus  while  erasion  is 
directed  chiefly  to  the  soft  structures  which  are  usually  the  primary 
seat  of  the  disease,  it  entails  a  need  of  much  wider  attention  to  other 
structures,  especially  in  hospital  cases  which  have  passed  beyond  the 
desired  early  stage. 

The  old  excision  of  former  days,  with  the  attention  of  the  operator 
directed  to  the  bones  rather  than  to  the  synovial  membrane,  is  an  opera- 
tion of  the  past.  Erasion  is,  when  possible,  always  to  be  preferred 
to  excision.  With  increasing  experience  the  more  will  a  surgeon's 
operation  here  partake  of  an  erasion,  especially  if  he  has  much  to  do  with 
children.  But  in  my  experience,  with  the  advanced  cases  which  are 
still  so  frequent,  the  operation  is  rarely  an  erasion  alone  ;  in  the  great 
majority  of  cases  the  ends  of  the  bones  are  affected.  While  the  gouge 
is  invariably,  at  any  age,  to  be  preferred  to  the  saw,  as  some  surgeons 
still  prefer  excision,  and  as  excision  may  be  required  after  the  failure 
of  erasion  in  tuberculous  cases,  and  in  a  few  w^hich  are  not  tuberculous, 
e.g.,  osteo-arthritis,  I  have  described  both  operations.  With  proper 
conservative  treatment  neither  is  often  required. 

Value  of  Erasion  as  compared  with  Excision  ;  Suitable  and  Unsuitable 
Gases.  Where  a  knee-joint,  the  site  of  tuberculous  trouble,  resists,  in 
hospital  patients,  careful  conservative  treatment  continued  for  a  year, 
where  there  is  but  little  evidence  of  caseation  in  the  joint  (very  difficult 
to  tell,  but  indicated  by  chronic  obstinacy  of  the  disease,  by  spots  where 
the  feel  is  distinctly  doughy,  or  becoming  bluish  in  tint) — in  other  words, 
where  the  disease  is  early,  but,  owing  to  the  patient's  surroundings, 
will  go  on  from  bad  to  worse,  erasion  is  indicated  and  far  preferable  to 
excision.  Its  advantages  are,  (1)  There  is  no  removal  of  bone-shces, 
and  still  less  any  interference  with  the  epiphyses.  Thus  the  only  shorten- 
ing which  follows  is  that  due  to  premature  synostosis  of  the  epiphysial 
line  (W.  Cheyne),  and  disuse  of  the  hmb,  too  often  allowed  to  become 

1  Arthrectomy  was  a  term  introduced  by  Volkmann  (Ce7it.  f.  Chir.,  1888) ;  it  is  less 
accurate,  and,  etymologically,  comes  too  near  to  excision. 

2  Lancet,  1881,  vol.  ii,  p.  992  ;  Med.  Chron.,  July  1885  ;  and  one  together  with 
Mr.  Haslam,  Brit.  Med.  Journ.,  vol.  ii,  1903,  p.  888.  See  also  a  paper  by  Mr.  Shield 
{Ann.  of  Surg.,  February  1888),  and  one  by  Mr.  E.  Owen  (Mcd-Chir.  Trans.,  vol.  Ixxii, 
p.  56). 

'  Loc.  supra  cit. 


ERASIOX  OF  THE  KXEE-JOIXT  865 

flexed.  This  advantage  will  be  at  once  recognised  when  it  is  remem- 
bered that  the  increase  in  length  of  the  femur  takes  place  chiefly  at 
the  junction  of  its  shaft  with  tlie  lower  epiphysis,  and  in  the  case  of  the 
tibia  at  its  upper  epiphysis.  In  one  of  my  cases,  a  girl  of  11,  there  was 
not  only  no  shortening,  but  repeated  careful  measurements  showed 
hall  an  inch  increase  of  length,  perhaps  due  to  the  increase  of  vascularity, 
about  the  above-mentioned  epiphyses.  (2)  With  regard  to  the  retention 
of  mobility,  and  the  advantage  at  first  claimed  for  it,  this,  in  my  opinion, 
has  been  much  exaggerated.  I  have  no  doubt  whatever  that  a  larger 
number  of  carefully  published  cases  will  show  that  where  movement  is 
sought  for,  the  risk  is  run  of  a  certain  degree  of  permanent  flexion,  of 
attacks  of  pain  and  swelling,  and  of  the  formation  of  troublesome  sinuses. 
I  should  strongly  dissuade,  from  any  attempt  to  secure  mobility  in  the 
case  of  the  knee  and  ankle.  (3)  The  ligaments  are  less  interfered  with, 
and  thus,  the  ties  of  the  joint  being  preserved,  firm  union  is  more  speedy. 
This  advantage  is  only  true  of  the  desirable  early  cases,  and  is  not  to  be 
expected  where  the  whole  of  the  interior  of  the  joint  has  been  interfered 
with  to  allow  of  eradication  of  every  diseased  structure.  (4)  If  per- 
formed early,  erasion,  as  excision  does,  but  in  a  less  expensive  way, 
cuts  short  the  disease,  and  thus  gives  a  considerable  saving  of  time. 
(5)  It  is  better  suited  to  young  children.  Thus,  as  it  does  not  arrest 
development,  it  may  be  used  very  early.  Wright  has  operated  "  with 
perfect  success  in  a  child  under  two  years  of  age." 

The  disadvantage  of  erasion — I  am  speaking  only  from  an  experience 
of  twenty-six  cases,  of  which  two  required  excision  later,  and  two  others 
amputation — is,  I  think,  chiefly  this,  that  if  the  operation  fail,  excision 
is  rendered  much  more  difficult.  I  cannot  here  at  all  agree  with  the  state- 
ment of  my  old  friend,  the  chief  authority  on  this  subject,  that  erasion, 
if  it  fail,  leaves  the  limb  little,  if  at  all,  in  worse  condition  for  excision 
afterwards.  This  is  true  of  the  limb,  but  not  of  the  joint.  In  one  of  my 
erasions  which  required  excision,  I  found  that  the  previous  operation 
had  entirely  obliterated  the  usual  landmarks,  and  that  great  difiiculty  was 
experienced  and  much  care  needed  in  dealing  viith  such  parts  as  the  re- 
mains of  the  posterior  hgament.  The  ultimate  result  here  {vide  infra) 
was  good.  Another  minor  disadvantage,  and  one  shared  by  excision, 
is  the  after- flexion.  In  my  opinion  the  habihty  to  this  is  greater  after 
erasion.  After  both  operations,  prolonged  fixation,  for  at  least  two 
years  after  erasion,  is  to  be  insisted  upon. 

To  recapitulate,  the  cases  most  suitable  for  erasion  are  those  where  the 
disease  is  Kmited,  or  almost  hmited,  to  the  synovial  membrane,  with 
little,  if  any,  caseation ;  where  the  cartilage  and  bones  are  almost  in- 
tact as  shown  by  the  X  rays,  where  there  are  no  abscesses  or  sinuses, 
where  there  is  no  e\ndence  of  other  tuberculous  disease,  and  where  the 
power  of  repair  is  satisfactory. 

Operation.  The  prehniinaries  are  the  same  as  for  excision  (p.  868). 
A  transpatellar  incision  should  be  employed.  Many  other  incisions. 
e.g.  a  flap  usually  going  through  the  hgament,  a  median  vertical  one 
spHtting  the  quadriceps,  patella  and  hgament,  and  two  lateral 
incisions,  have  all  been  employed.  I  have  used  the  first,  but 
prefer  that  through  the  patella  as  best  combining  adequate  exposure 
of  the  parts  and  retention  of  the  patella  in  order  to  meet  the  inevitable 
tendency  to  flexion.  But  to  ensure  thorough  exposure  of  tha  supra- 
patellar region,  a  very  dangerous  area  on  account  of  its  numerous  nooks 

SURGERY  I  ;; 


866       OPERATIONS  ON  THE  LOWER  EXTREMITY 

and  crannies,  which  give  lurking-places  to  tuberculous  mischief,  I  always 
sHt  this  pouch  right  up  to  its  very  top  with  a  sharp-pointed  bistoury, 
thus  dividing  the  upper  flap  into  two.  G.  A.  Wright  in  his  last  paper 
writes :  "I  now  do  the  transverse  transpatellar  operation  with  a 
vertical  upward  incision  occasionally  added  to  facihtate  removal  of 
disease  tracking  up  the  subcrural  sac.  I  usually  divide  the  aponeurosis 
on  each  side  of  each  half  of  the  patella  for  an  inch  or  more  to  facihtate 
exposure."  The  flaps  being  then,  one  by  one,  thoroughly  everted  with 
a  sharp  hook,  taking  the  upper  half  of  the  joint  first,  I  seize  the  tip  of 
one  of  the  flaps  with  mouse-tooth  forceps,  and  then,  with  blunt-pointed 
scissors  curved  on  the  flat,  dissect  the  diseased  synovial  membrane  off 
the  under-surface  of  the  split  quadriceps  expansion  in  a  continuous 
strip  till  the  uppermost  hmit  of  the  suprapatellar  pouch  is  reached. 
The  reflection  of  the  synovial  membrane  over  the  front  of  the  femur 
is  then  dealt  with  in  the  same  way,  leaving  the  periosteum  on  this  quite 
clean.  The  joint  being  then  well  bent,  and  the  tibia  being  brought 
forward  as  directed  (p.  871),  the  crucial  hgaments,  the  semilunar 
cartilages,  the  intercondyloid  notch,  and  the  synovial  reflections  behind 
the  crucial  hgaments  are  carefully  inspected.  To  do  this  thoroughly, 
it  is  absolutely  needful  to  divide  the  lateral  ligaments  sufficiently.  With 
regard  to  the  other  structures,  some  retain  the  semilunar  cartilages, 
if  healthy ;  others  remove  them  in  any  case.  For  my  part,  as  it  is  so 
essential  to  remove  all  the  synovial  membrane,  and  this  is  impossible 
unless  the  semilunar  cartilages  go,  I  always  remove  them.  With  regard 
to  the  crucial  ligaments,  the  anterior  nearly  always  requires  removal ; 
as  regards  the  posterior,  the  whole  ligament,  or  as  much  of  it  as  possible, 
should  be  left,  since  its  removal  is  extremely  hable  to  be  followed  by 
backward  displacement  of  the  tibia.  The  intercondyloid  notch,  and  the 
reflection  behind  the  crucial  ligaments,  is  then  taken  in  hand,  very 
wide  flexion  of  the  joint,  and  a  finger  of  an  assistant  in  the  popliteal 
space,  here  facihtating  this,  the  most  difficult  and  important  part  of  the 
operation.  When  much  disease  is  present  here  in  the  synovial  mem- 
brane, both  crucial  ligaments  must  be  unhesitatingly  removed,  and,  if 
needful,  the  overhanging  posterior  part  of  the  condyles  must  be  cut 
away.  In  dealing  with  the  synovial  membrane  in  the  intercondyloid 
notch,  the  surgeon  must  remember  that  he  will  never  have  a  similar 
chance  of  dealing  with  the  disease  here,  and  that,  if  any  is  left  behind, 
excision,  and  perhaps  amputation,  will  be  called  for.  The  synovial  mem- 
brane around  the  lower  half  of  the  patella  is  then  removed,  and  finally  the 
ends  of  the  bones  are  examined.  Any  pits  and  foci  are  gouged  out 
and  more  extensive  ulceration  shaved  off  with  a  strong  sharp  knife. 
Drainage  is  rarely  required,  save  of  course  in  infected  cases,  or  where 
the  condition  of  the  parts  will  certainly  give  rise  to  much  oozing 
later.  The  two  ends  of  the  wound  should  never  be  closely  sutured. 
The  dressings  are  apphed,  and  not  until  all  is  completed  is  the 
Esmarch  bandage  removed. 

The  after-treatment  is  the  same  as  after  excision.  As  there  is 
the  same  long-continued  tendency  for  the  limb  to  become  flexed, 
there  is  the  same  urgent  need  for  a  rigid  apparatus  for  at  least  two 
years. 

Causes  of  Failure  after  Erasion.  These  are  much  the  same  as  those 
given  under  excision.  The  chief  of  them,  persistence  of  the  disease  from 
failure  to  eradicate  it  at  the  first  operation,  is  there  dealt  with. 


EXCISION  OF  THE  KNEE-JOINT  867 


EXCISION  OF  THE  KNEE-JOINT 

Indications.     A.  For  Disease,     B.  Injury, 
A.  For  Disease, 

(i)  Tuberculous  disease. 

On  this  subject  the  remarks  ah'eady  made  (p.  864)  on  erasion  should 
be  referred  to.  With  careful  conservative  treatment,  the  need  of  this 
operation  has  been  greatly  reduced.  The  writer  never  perforn)S  it  for 
tubercle  except  when  the  bone  end  is  seriously  diseased  and  invaded  as 
shown  by  the  X-rays.  The  following  points  require  mention  as  well : 
One  is  age.  The  chief  growth  of  the  femur  takes  place  at  its  lower  end. 
By  fifteen,  and  still  more  by  seventeen,  the  growth  of  the  bone  is  largely 
completed.  Thus,  in  young  subjects,  especially  before  ten,  as  httle 
of  the  bones  as  possible  should  be  removed,  and  gouging  should  largely 
replace  the  saw.  While  the  old-fashioned  excision,  in  which  attention 
was  chiefly  directed  to  the  ends  of  the  bones,  is,  as  already  stated,,  very 
largely  an  operation  of  the  past  in  tuberculous  cases,  it  may  still  be  called 
for  in  the  following  :  where  the  disease  is  of  long  standing  ;  where  there 
is  backward  displacement  of  the  tibia ;  where  the  disease  has  started 
as  an  epiphysial  osteitis. 

While  the  subject  of  tuberculous  disease  of  the  knee-joint  is  being 
considered,  the  question  of  amputation  will  arise  in  certain  cases.  Sir 
H.  Howse,^  gives  the  following  conditions  which  call  for  this  step.  They 
are:  A.  Constitutional,  (a)  Lardaceous  disease,  (p)  Tuberculous  disease 
of  the  lungs  or  other  viscus.  (y)  Great  emaciation  without  any  very 
evident  visceral  disease.  {S)  Multiple  joint  disease  (seep.  865).  B.  Local. 
(a)  Osteitis  or  periostitis  extending  along  the  shafts  of  either  femur 
or  tibia,  as  shown  by  great  thickness  or  tenderness  of  the  bone.^  ((3)  Very 
great  infiltration  of  tuberculous  material  into  the  soft  parts,  extending 
far  beyond  the  Umits  of  the  joint. 

(ii)  Some  cases  of  failed  erasion  in  which  the  mischief  is  too  exten- 
sive for  curetting,  but  does  not  call  for  amputation. 

(iii)  Disorganisation  of  the  knee  with  flexion  after  pyaemia,  and 
other  forms  of  infective  arthritis. 

(iv)  Osteo-arthritis.  Where  one  joint  only  is  affected,  and  the 
patient  is  not  past  middle  hfe,  excision  gives  good  results.  The  surgeon 
must  be  prepared  for  sawing  very  dense  bones. 

(v)  Ankylosis.  Excision  can  usually  be  abandoned  here  for  better 
operations  (p.  877),  e.g.  dividing,  with  aseptic  precautions,  the  union, 
with  an  osteotome  introduced  first  on  one  side  and  then  on  the  other 
and  worked  forwards  under  the  patella  and  skin,  and  backwards  as  far 
as  the  popliteal  artery  allows.  If  this  fail,  a  double  osteotomy  of  the 
femur  and  tibia  should  be  performed  rather  than  excision,  an  operation 
which,  in  the  case  of  true  bony  ankylosis,  is  hable  to  be  severe,  pro- 
longed, and  to  leave  a  large  wound,  and,  in  the  case  of  young  subjects, 
to  lead  to  further  shortening  of  a  hmb  already  atrophied  and  weakened 
from  disease.  I  would  strongly  urge  caution  in  rapidly  and  com- 
pletely straightening  a  knee-joint  which  has  long  been  the  seat  of  a 

^  Ouy^s  Hospital  Reports,  1894. 

2  Sir  H.  Howse  points  out  that,  occasionally,  tenderness  and  thickening  may  be  due  to 
a-sequestrum,  which  may  be  successfully  removed,  and  later  on  a  usefullimb  obtained  by 
excision. 


868       OPERATIONS  ON  THE  LOWER  EXTREMITY 

bony  ankylosis  in  a  bad  position  and  call  attention  to  the  case  related 
at  p.  877. 

(vi)  Old  Neglected  Infantile  Paralysis.  The  question  of  excision  here 
is  referred  to  (p.  878),  under  the  heading  of  Arthrodesis. 

B.  Injury.  Here  such  injuries  as  those  from  gunshot  and  those 
from  a  lacerated  wound  or  a  compound  fracture  must  be  considered 
separately. 

(1)  Gunshot.  "  The  results  of  the  excisions  of  the  knee-joint  performed  during 
the  American  civil  war,  whether  the  operations  were  primary,  intermediary,  or 
secondary,  were  not  very  encouraging,  forty-four  of  the  fifty-four  cases  in  which 
the  issues  were  ascertained  having  terminated  fatally,  a  mortality  of  81-4  per  cent., 
exceeding  the  mortality  of  the  amputations  of  the  thigh  (53-8)  by  27-6  per  cent."  ^ 
Sir  T.  Longmore^  lays  down  these  definite  rules :  "From  all  the  experience  which 
has  been  gained  regarding  gunshot  wounds  in  which  the  knee-joint  has  been  opened, 
especially  if  the  surfaces  of  the  bone  have  escaped  damage,  as  may  occasionally 
happen  with  modern  narrow  rifle  bullets,  and  even  in  other  cases  where  one  of  the 
bones  has  been  fissured,  or  jiartial  fracture  has  occurred,  provided  early  immobilisa- 
tion of  the  injured  parts  can  be  secured,  antiseirtic  treatment  carried  out,  and  the 
general  surroundings  are  sufficiently  hygienic,  it  may  now  be  laid  down  as  a  rule 
that  conservative  treatment  ought  to  be  adopted.  When,  however,  the  circum- 
stances under  which  the  wounds  have  been  inflicted  are  such  that  the  precautionary 
methods  and  modes  of  treatment  mentioned  cannot  be  put  into  practice,  when 
the  patients  are  liable  to  be  moved  frequently  or  to  long  distances  hurriedly,  and 
without  adequate  protection,  or  when  the  joint  is  not  only  penetrated,  but  the 
surrounding  coverings  are  much  lacerated,  or  the  bones  are  comminuted  and  the 
fragments  completely  detached,  the  sacrifice  of  the  limb  by  amputation  above  the 
joint  is  the  only  measure  calculated  to  afford  a  fair  promise  of  safety  of  life  to  the 
patient." 

Mr.  Makins,  C.B.,  in  his  standard  work,^  from  which  I  have  already  quoted, 
writes  (p.  238),  that  while  the  knee-joint  was  the  one  most  commonly  injured, 
"  injuries  to  the  joint  gave  less  anxiety  than  is  the  case  in  civil  practice.  The  old 
difficulty  of  deciding  on  partial  as  against  full  excision  or  amputation  was  never 
met  with  by  us.  We  had  merely  to  do  our  first  dressings  with  care,  fix  the  joint  for 
a  short  period,  and  be  careful  to  commence  passive  movements  as  soon  as  the 
wounds  were  properly  healed  to  obtain  in  the  great  majority  of  cases  perfect  results. 
If  suppuration  occurred,  the  choice  between  incision  and  amjjutation  had  to  be 
considered.  Amputation  was  sometimes  indicated  in  cases  of  severe  bone-splinter- 
ing, but  was  as  a  rule  only  performed  after  an  ineffectual  trial  to  cut  short  general 
infection  of  the  septicoemic  type  by  incision."  Association  of  popliteal  aneurysm 
with  wounds  of  the  knee-joint  was  comparatively  common. 

(2)  Injuries  other  than  gunshot.  Excision  is  rarely  indicated  here.  Occasionally 
in  hospital  practice  excision  is  the  best  treatment  of  flail  knee  following  violent 
injuries  tearing  the  crucial  and  lateral  ligaments. 

Operation.  Before  and  throughout  an  excision  of  the  knee,  or  rather 
a  combination  of  partial  excision  with  erasion,  the  operator  should 
bear  in  mind  the  following  points  :  (1)  to  remove  every  atom  of  the 
disease  ;  (2)  to  secure  good  drainage  ;  (3)  to  leave  the  bones  in  good 
position  ;  (4)  to  ensure  absolute  immobility  afterwards  ;  (5)  to  watch 
for  and  at  once  attack  any  relapse.  The  more  I  performed  this  opera- 
tion, the  more  did  I  feel  the  truth  of  the  words  of  Prof.  Bruns,  of  Tubingen, 
that,  while  formerly  its  chief  object  was  to  remove  all  affected  bone,  it 
should  now  be  considered  of  chief  importance  to  remove  all  the  tuber- 
culous material  that  can  possibly  be  got  away,  and  that  the  surgeon 
should  not  content  himself  with  snipping  away  all  he  can,  leaving  the 
rest  to  caseate  or  become  scar-tissue  if  it  will,  but  pursue  it  with  the 
same  earnest  aim  of  extermination  as  he  would  in  the  case  of  malignant 

1  Otis,  loc.  supra  cit.,  p.  419.  2  Syst.  of  Stirg.,  vol.  i,  p.  565. 

*  Surgical  Experiences  in  South  Africa,  1899-1900. 


EXCISION  OF  THE  KNEE-JOINT  8G9 

disease.  I  would  not  ))y  the  al)()ve  seem  to  speak  slightingly  of  the  value 
of  securing  lieaithy  and  correctly  sawn  surfaces  of  bone,  as  on  these 
largely  depend  linn  ankylosis  and  a  sound  and  useful  limb,  but  I  would 
insist  on  the  fact  that  such  surfaces  are  secured  in  vain  if  tuberculous 
material  is  allowed  to  remain,  and  that  other  instruments,  e.q.  sharp 
spoons  and  scissors  curved  on  the  flat,  are  to  the  full  as  useful  as  the 
saw. 

Before  the  time  of  the  excision,  any  flexion  of  the  knee  should  be 
corrected  as  far  as  possible  by  careful  weight-extension.  A  knee  should 
rarely  be  excised  while  flexed.  Such  a  step  will  only  be  liable  to  lead 
to  removing  bone  needlessly  in  order  to  straighten  the  limb.  The  risk 
of  gangrene  is  alluded  to  at  p.  877. 

The  parts  having  been  duly  sterilised,  the  foot  elevated  and  a  tourni- 
quet ^  applied  at  the  top  of  the  thigh,  the  linil)  is  brought  over  the  edge 
of  the  table,  flexed,  and  held  by  an  assistant. 

From  the  moment  of  commencing  the  operation  to  its  very  close  the 
surgeon  must  bear  in  mind  the  inveteracy  of  tuberculous  material 
(malignancy  would  probably  not  be  too  strong  a  word),  and  in  his  en- 
deavours to  extirpate  the  disease  completely  his  operation  will  combine 
the  operations  of  erasion  and  excision  rather  than  follow  the  typical  lines 
of  either. 

The  following  modes  of  exposing  the  joint  will  be  given  here  : 

A.  Transverse,  removing  the  Patella.  B.  Transverse,  through  the 
Patella.  C.  The  Semilunar  Flap  (lately  recommended  by  Mr.  Barker, 
and  attributed  by  him  to  Moreau). 

A.  Transverse,  removing  the  Patella.  This,  the  older  method,  is 
still  resorted  to  by  those  surgeons  who,  like  Sir  H.  Howse,  beUeve  that 
if  the  patella  is  retained,  a  most  serious  risk  is  run  of  leaving  behind 
tuberculous  material  which  will  require  removal  later  on  under  less 
favourable  circumstances,  and  this  failing,  may  lead  to  amputation. 

The  surgeon,  standing  on  the  left  ^  side  of  the  diseased  knee  (the  oppo- 
site limb  being  tied  to  the  table),  makes  an  incision  right  across  the  joint 
from  the  back  of  one  condyle  to  that  of  the  otlier.^  This  incision  passes 
over  the  lower  part  of  the  patella  and  exposes  the  lateral  hgaments  at 
once.  The  soft  parts  being  then  dissected  up  for  two  inches  above 
the  patella,  so  as  to  expose  the  suprapatellar  pouch,  deep  incisions  are 
made  above  and  below  the  patella,  which  is  then  removed  and  the  joint 
opened. 

If  the  patella  is  ankylosed  to  the  condyles,  it  must  be  removed  by  a 
blunt  elevator,  aided  by  a  narrow  saw,  or,  better,  by  an  osteotome  and 
mallet.  No  violence  should  be  used  in  opening  a  joint  partially  anky- 
losed, or  the  epiphyses  may  easily  be  separated  from  the  shaft,  especially 
in  a  child. 

I  invariably,  when  raising  the  flap  of  soft  parts  in  an  excision  of  the 

^  Some  object  to  the  tourniquet  as  needless  and  as  likely  to  lead  to  troublesome  oozing 
after  the  operation.  This  may  be  met  by  firm  pressure  and  even  bandaging  on  of  the 
dressings,  before  the  tourniquet  is  removed.  If  a  tourniquet  bandage  is  not  applied,  the 
bleeding  during  the  operation  interferes  with  the  removal  of  diseased  tissues,  requires 
constant  pressure  to  arrest  it,  and  taxes  the  patient's  resources  considerably.  Its  use 
meets  another  risk,  which  is  possibly  hypothetical,  and  that  is  it  renders  impossible  the 
general  diffusion  of  tuberculous  material  by  the  cut  veins  and  lymphatics. 

2  This  position  renders  it  much  easier  for  him  to  saw  the  femur  and  tibia. 

3  Beyond  this  spot  the  incision  should  not  go,  for  fear  of  wounding  the  internal 
saphena  vein.  This  would  lead  to  troublesome  osdema  of  the  foot  and  leg,  and,  if  the 
wound  should  become  infected,  might  bring  about  phlebitis  and  pyaemia. 


870       OPERATIONS  ON  THE  LOWER  EXTREMITY 

knee,  however  performed,  slit  them  up  by  a  vertical  incision,  going  to 
the  upper  limit  of  the  suprapatellar  pouch,  so  as  to  expose  fully  all  its 
folds  and  recesses.  Unless  this  is  done,  tuberculous  material  is  very 
easily  left  behind,  and,  later  on  breaking  down,  leads  to  oedema,  per- 
sistent sinuses,  perforation  of  the  pouch  and  spread  of  disease  amongst 
the  adductors  and  into  the  vicinity  of  the  femoral,  and  perforating  vessels, 
where  it  is  impossible  to  eradicate  it,  amputation  being  eventually  called 
for, 

B.  Transverse,  through  the  Patella.  This  method,  by  preserving  the 
patella  and  the  insertion  of  the  quadriceps,  partly  counterbalances  the 
flexing  action  of  the  ham-strings  at  the  same  time.  Used  by  Volkmann 
many  years  ago,  it  was  again  brought  under  the  notice  of  English 
surgeons  by  Mr.  Golding  Bird  in  a  case  which  he  brought  before  the 
CUnical  Society.  ^ 

For  arguments  against  preserving  the  patella  I  must  refer  my  readers 
to  Sir  H.  Howse's  article.^  I  am  of  opinion,  myself,  that  in  young  sub- 
jects where  the  union  is  certain  to  yield  for  some  time,  it  is  well  worth 
while,  in  cases  where  the  disease  is  not  too  advanced,  to  preserve  the 
patella,  though  to  ensure  the  full  benefit  of  this  step,  fresh  osseous  surfaces 
should  be  prepared  on  this  bone  and  on  the  femur  and  tibia,  so  as  to 
promote  bony  union.  Another  and  minor  argument  in  favour  of  pre- 
serving this  bone  is  that  the  anastomoses  about  the  joint  are  less  in- 
terfered with.  This  method  is  not  adapted  to  cases  where  caseation 
is  advanced,  and  its  adoption  only  lessens,  but  does  not  remove,  the 
liability  to  subsequent  flexion. 

The  transverse  incision  is  made  here  much  as  in  the  first  method, 
only  across  the  middle  of  the  patella  ;  this  is  sawm  through  or  divided 
with  a  stout  knife,  the  fragments  turned  up  and  down,  and  the  joint 
fieely  opened. 

C  Semilunar  Flap  (Moreau,  Barker).  Here  a  large  U-shaped  flap 
is  raised  by  a  semilunar  incision,  starting  above  one  condyle,  descend- 
ing to  the  level  of  the  tibial  tubercle,  crossing  the  leg  here  and  running 
up  to  a  corresponding  point  on  the  other  side.  In  raising  this  flap, 
which  includes  all  the  soft  parts  down  to  the  bone,  either  the  ligamentum 
patellae  should  be  severed  (suturing  of  this  being  resorted  to  later),  or 
the  tuberosity,  attached  to  the  ligament,  is  removed  with  a  chisel,  and 
subsequently  wired  down  (Barker). 

The  joint  having  been  opened  by  one  of  the  above  incisions,  it  is 
well  to  slit  with  a  sharp  bistoury  the  suprapatellar  pouch  ^  up  to  its 
upper  limits  (readily  reached  by  a  finger),  so  as  to  lay  bare  every  crevice 
and  to  remove  every  atom  of  diseased  tissue.  The  cut  margins  being 
held  on  the  stretch  by  two  forceps^  the  surgeon  with  mouse-toothed 
forceps  seizes  the  cut  edge  of  the  synovial  lining  of  the  capsule,  and 
with  curved  scissors  removes  it  in  one  piece,  first  from  under  the  vasti 
muscles  and  then  along  its  reflexion  on  to  the  femur  down  to  where  it 
ceases  at  the  margins  of  the  articular  cartilage. 

Next  the  lateral  and  crucial  ligaments  are  examined,  and  every  par- 
ticle of  diseased  tissue  removed,  only  bright,  glistening,  clearly  healthy 
ligamentous  tissue  being  left.^     But  as  naked-eye  examination  in  parts 

^  Trans.,  vol.  xvi,  p.  82.  ^  Loc  supra  cit. 

*  I  look  on  this  as  one  of  the  most  cardinal  points  of  the  operation. 

*  Prof.  Oilier  (loc.  infra  cit.  and  Rev.  de  Chir.,  1882)  drew  attention  to  preserving 
the  lateral  ligaments,  if   possible,  together  with   all   healthy  periosteum  and  capsule. 


EXCISION  OF  THE  KNEE-JOINT 


871 


perhaps  not  absolutely  bloodless  may  easily  be  fallacious,  it  is  much 
better  in  doubtful  cases  to  remove  these  completely  than  to  run  any 
risk  whatever.  The  assistant  who  is  in  charge  of  the  limb  now  brings 
the  head  of  the  tibia  well  into  view  by  pulling  the  calf  of  the  leg  well 
forward  with  one  hand  while  he  further  dislocates  the  bone  by  pushing 
up  the  leg  (Fig.  351). 

The  condition  of  the  semilunar  cartilages  is  next  examined,  and  if 


( 


y  ./ 


t!^ 


-(t,^i_:...j 


Fig.  350.     Excision  of  the  knee.     The  patella  has  been  reflected  in  a 
semilunar  flap. 

they  are  invaded  by  tuberculous  tissue,  if  it  is  intended  to  perform  a 
complete  excision,  they  must  be  cut  away  entirely. 

The  back  of  the  joint  is  next  taken  in  hand.  This  region  can  be  far 
more  effectively  dealt  with  after  removal  of  the  bones.  If,  owing  to 
the  case  being  an  early  one,  with  Uttle  or  no  caries,  the  surgeon  desires 
to  remain  content  with  an  erasion,  he  must  still  deal  thoroughly  with 
the  posterior  Hgament  ^  and  deeper  parts  of  the  sides  of  the  joint  with 
all  recesses  and  folds  of  the  s}Tiovial  membrane.  To  expose  these  parts 
thoroughly  is  a  matter  of  some  difficulty.  The  assistant  should  mani- 
pulate the  limb  as  above  directed  at  one  time,  at  another  flex  the  leg 

I.e.  those  tissues  which  wiU  keep  the  bones  in  place  and  which  will  tend  to  produce  ossify- 
ing material.  This  will  not  interfere,  if  carefully  carried  out.  with  extirpating  diseased 
parts,  while  it  will  go  far  to  prevent  progressive  flexion  of  the  joint. 

1  This  and  the  posterior  parts  of  the  semilunar  fibro- cartilages  are  liable  to  be  in- 
efficiently treated. 


872 


OPERATIONS  ON  THE  LOWER  EXTREMITY 


back  towards  the  table,  while  occasionally  a  sterilised  finger  in  the 
popliteal  space  will  keep  within  reach  any  altered  tissue  that  it  is  desired 
to  deal  with.  Every  pains  must  be  taken  to  use  the  scissors  systemati- 
cally and  thoroughly  here  as  elsewhere  until  healthy  tissues  are  reached, 
and  not  to  dread  the  popliteal  artery  too  much.  This  should  be  enforced 
for  two  reasons.  If  any  diseased  tissue  is  left  here,  it  will  be  shut  in 
after  the  limb  is  extended  and  be  impossible  to  deal  with,  save  by  a  fresh 
and  probably  unsuccessful  operation.  Again,  there  is  always  a  risk, 
especially  in  a  surgeon's  earlier  operations,  of  his  not  dealing  with  disease 


Fig.  351. 


Excision  of  the  knee.     The  upper  surface  of  the  tibia  is  sawn  from 
behind  forwards. 


here  with  sufficient  thoroughness  from  dread  of  injuring  the  popliteal 
artery.  This  vessel  may  be  avoided  by  (1)  not  dipping  the  points  of  the 
scissors  deeply,  but  using  the  blades  as  far  as  possible  parallel  with  the 
course  of  the  vessel  ;  (2)  remembering  that  even  after  the  posterior 
crucial  ligament  has  been  removed  (a  detail  often  imperfectly  carried 
out)  there  is  still  a  considerable  thickness  of  tissue  in  front  of  the 
artery. 

After  all  diseased  tissues  at  the  back  have  been  thoroughly  eradicated, 
the  deeper  aspects  of  the  sides  of  the  joint  must  be  examined.  Where 
caseating  foci  have  spread  down  on  the  inner  side  of  the  joint,  the  tendons 
of  the  sartorius,  semi-membranosus,  and  semi-tendinosus  may  need 
exposing. 

It  remains  to  describe  the  removal  of  the  bones  in  case  erasion  is 
not  sufficient.  Where  excision  is  evidently  needed,  the  bones  should 
be  sawn  after  the  suprapatellar  pouch   is  cleared  out,  and  before  the 


EXCISION  OF  THE  KNEE  JOINT  873 

posterior  aspect  of  the  joint  is  taken  in  hand,  as  this  step  will  be  much 
facilitated  thereby. 

The  femur,  held  as  steady  as  possible,  is  taken  first.  A  groove  for 
the  saw  is  first  so  marked  out  with  the  scalpel  as  to  remove  about  one- 
third  of  the  condyles.  In  severer  cases,  or  where  the  above  section  will 
clearly  be  insufficient,  half,  or  even  two-thirds,  of  the  articular  surface 
may  be  removed,  but  no  section  should  be  made  farther  back  than  this, 
or  the  epipyhsis  will  be  trenched  upon  with  serious  after-results.^  Care 
should  be  taken,  in  making  the  section  of  *he  femur,  to  ensure  that  the 
plane  of  the  sawn  surface  shall  be  at  right  angles  to  the  axis  of  the  shaft. 
Sir  H.  Howse  prefers  to  saw  the  femur  while  this  is  held  vertically. 

The  tibia  is  taken  next,  and  a  groove  marked  out  with  the  knife 
about  half  an  inch  below  the  articular  cartilage.  A  Butcher  saw,  set 
horizontally,  is  used  from  behind  forwards,  and  on  a  perfectly  level 
plane.  Neither  here  nor  in  sawing  the  femur  must  the  slightest  wobbling 
of  the  saw  be  permitted. 

About  half  an  inch  only  of  the  tibia  should  be  removed,  just  enough 
in  fact  to  expose  healthy  cancellovis  tissue,  and  no  more.  Of  the  femur 
no  more  than  an  inch  and  a  half  should  be  removed  if  possible.-  Any  soft, 
yellow  cheesy,  fatty  patches,  any  cancellous  tissue  into  which  pulpy 
tissue  has  dipped  after  perforating  the  cartilage,  should  be  carefully 
removed  with  a  gouge.  Where,  however,  there  is  much  caries,  or  the 
above  patches  are  numerous,  breaking  down  readily  under  the  finger- 
nail, more  than  one  sHce  of  bone  had  better  be  removed. 

The  whole  wound  is  now  finally  most  carefully  scrutinised,  every 
outlying  angle  and  recess  being  examined  for  tuberculous  tissue  left 
behind. 

The  tourniquet  is  now  by  some  removed,  and  while  sterile  pads 
wrung  out  of  hot  1  in  2000  hydr.  perch,  are  held  firmly  over  the  sawn 
tibia,  any  bleeding-points  in  the  upper  half  of  the  wound  are  attended 
to.  The  safest  way  of  arresting  the  bleeding  is  by  underrunning  with 
chromic  gut  and  fine  needles  all  the  vessels  which  spirt,^  as  practised 
by  Sir  H.  Howse,  or  as  I  greatly  prefer,  by  Mr.  Barker's  plan  {vide  infra). 
Bleeding  from  the  cancellous  tissue  w^ill  be  arrested  by  placing  the  bones 
in  contact.  If  there  is  any  tendency  of  the  edges  of  the  skin  to  fold 
in,  these  must  be  shortened. 

The  best  means  of  meeting  the  haemorrhage,  and  one  which  I  have 

^  Dr.  Hoffa,  of  Wurzburg  {Arch.  f.  Iclin.  Chir.,  Band  xxii,  Heft  4,  1885;  Annals  of 
Surgery,  March  1886),  brings  forward  cases  to  show  that  removal  of  both  epiphyses  led, 
at  the  end  of  ten  years,  to  shortening,  amounting  to  25i  cm.  (1  cm.  ,*y  inch),  while  in 
another  case  it  amounted  in  two  years  to  10  cm.  Loss  of  the  femoral  epiphysis  alone 
showed  17  cm.  of  shortening  in  six  years,  and  7  cm.  in  a  year  and  a  half.  Two 
cases  of  the  like  duration  affecting  the  tibial  line  showed  respectively  15^  and  6  cm. 
It  is,  however,  well  known  that  considerable  shortening  may  occur  in  cases  treated 
expectantly. 

^  If  the  surgeon  is  obliged  to  trench  upon  the  ejiiphyses  it  should  be  with  the  gouge, 
and  not  with  the  saw,  if  possible.  In  one  case  of  a  boy,  aged  7,  the  bones  being  carious, 
soft,  and  fatty,  a  large  patch  of  cheesy,  fatty  bone  presented  itself  in  the  head  of  the 
tibia  after  the  first  slice  had  been  removed.  On  removing  this,  the  gouge  entered  the 
medullarj'  canal,  which  was  exposed,  gaping  on  the  sawn  surface.  I  was  doubtful  how 
far  union  would  take  place  here,  but  three  j-ears  later  the  boy  had  a  most  useful  limb, 
probably  from  a  ring  of  epiphysial  tissue  being  left. 

3  The  following  vessels  will  be  found  to  give  the  chief  trouble  after  a  combined  erasion 
and  excision  :  one  or  two  running  down  in  the  periosteum  over  the  femur,  one  or  two 
in  the  cut  periosteum  surrounding  the  sawn  margin  of  the  tibia,  and  one  from  the  azygos 
articular  in  the  posterior  ligament. 


874       OPERATIONS  ON  THE  LOWER  EXTREMITY 

followed  in  all  my  later  cases  of  excision  and  erasion,  is  that  advised  by- 
Mr.  Barker.  1  The  tourniquet  is  here  not  removed  until  the  dressings 
in  sufficiently  thick  successive  layers,  e.g.  sterilised  gauze  and  wool, 
are  firmly  bandaged  in  position.  To  admit  of  sufficient  pressure  being 
appfied  to  check  the  oozing  and  to  distribute  it  miiformly  throughout 
the  dressings,  a  sterile  white  bandage  should  first  be  applied  from  the  foot 
to  the  upper  third  of  the  leg.  If  one  of  Sir  H.  Howse's  sphnts  is  employed 
the  tourniquet  must  be  apphed  sufficiently  high  up  the  thigh  not  to 
interfere  with  the  limb  being  placed  in  the  sphnt,  as  this  has  to  be 
done  before  the  dressings  are  applied.  I  have  found  this  plan  most 
satisfactory. 

The  patella,  if  sa'vvn,  is  now  drilled  and  wired,  or  united  with  stout 
catgut.     I  prefer  the  first,  the  wire  being  cut  short  and  buried  in  the 


A.  B. 

Fig.  352.     A  and  B  show  the  line  of  the  epiphyses  which  enter  into  the  knee- 
joint,  seen  from  the  front.     That  of  the  fibula  is  also  seen.     They  are  taken 
from  a  well-grown  subject  of  about  18.     (Farabeuf.) 

tendon  above  the  patella  in  the  way  described  at  p.  882.  As  an  additional 
precaution  against  the  inevitable  tendency  to  flexion,  Mr.  A.  H.  Tubby 
advises  ^  that  the  anterior  aspects  of  the  ends  of  the  femur  and 
tibia  and  the  posterior  aspects  of  the  patella  be  removed.  The  four 
portions  of  bone  are  then  united  with  a  silver  wire,  which  is  embedded. 
The  question  now  arises  whether  the  tibia  and  femur  should  be  united 
by  wiring  or  pegging.^  I  am  of  opinion  that  if  the  bones  have  been  so 
sawn  as  to  bring  their  faces  squarely  together,  with  sufficiently  exact 
closeness  to  prevent  more  than  a  finger-nail  being  inserted  between  them, 
and  if  they  are  put  up  with  the  security  which  is  given  by  Sir  H.  Howse's 
method,  the  above  aids  are  not  needed.^  Failure  of  excision  is  due 
not  to  deficiency  of  repair  in  the  bones,  but,  as  a  rule,  to  persistence 
of  tuberculous  material. 

1  Hunt.  Lect.,  supra  cit.  2  j^^n.  Med.  Journ.,  1903,  vol.  ii,  p.  893. 

3  The  bones  have  been  united  with  different  forms  of  pegs  or  nails,  or  by  wire,  stout 
carbolised  silk,  or  chromic  gut. 

*  I  may  be  speaking  with  insufficient  knowledge,  but  I  am  under  a  strong  impression 
that  the  advocates  of  these  aids  have  not  made  trial  of  the  absolute  fixity  ensured  by  a 
well-applied  Howse's  splint  ( yic^e  infra).  Mr.  Morrant  Baker's  and  Mr.  Howard  Marsh's 
methods  of  fixing  the  bones  by  steel  or  bone  pins  will  be  found  in  the  Brit.  Med.  Joxirn., 
1887,  vol.  xi,  pp.  321,  389. 


EXCISION  OF  THE  KNEE-JOINT  875 

The  need  of  drainage  must  vary  with  the  experience  of  the  operator. 
If  the  bone  surfaces  are  well  together,  if  the  angles  of  the  wound  are 
left  open,  and  if  aseptic  precautions  have  been  taken  throughout,  drainage 
is  rarely  required.  Sir  H.  Howse's  splint  is  now  applied.  To  those 
who  are  not  familiar  with  it  the  following  brief  account  ^  may  be  useful. 
The  arrangement  will  be  found  most  simple,  and  equally  efficient  in 
admitting  of  antiseptic  dressing  and  maintaining  the  parts  in  absolute 
rest.  The  splint  consists  of  two  interrupted  tinned-iron  troughs  for 
the  thigh  and  leg  joined  by  a  posterior  bar.  This  is  from  four  to  six 
inches  long,  according  to  the  age  of  the  patient ;  it  is  convex  from  side 
to  side  to  avoid  cutting  into  the  popliteal  space,  and  can  be  lengthened 
or  shortened  if  any  alterations  in  the  interruption  are  required.  At 
the  end  of  the  sphnt  is  an  adjustable  foot-piece. 

The  limb  being  laid  in  the  sphnt,  attention  must  be  paid  to  the 
posterior  bar  being  in  the  centre  of  the  popliteal  space  ;  the  foot  must 
be  well  down  on  the  foot-piece  ;  if  the  splint  grips  the  thigh  or  leg  too 
tightly  or  rides  too  loosely,  it  must  be  bent  out  or  in  with  iron  "  crows." 
The  dressings  are  now  applied  as  at  p.  873.  Great  care  must  be  taken 
to  bandage  from  below  upwards  and  from  within  outwards,  the  bandage 
being  laid  on  evenly  and  firmly  so  as  to  distribute  the  discharges  evenly 
right  through  the  dressings,  and  to  prevent  their  coming  through  at  one 
or  two  spots.  The  sphnt  is  next  secured  to  the  hmb  with  "  waxed  band- 
ages," prepared  by  passing  them  through  a  mixture  of  ordinary  yellow 
wax  and  olive  oil,  in  proportions  sufficient  to  make  the  wax  soft  and 
workable.  After  they  are  applied  to  the  leg  and  thigh  they  are  painted 
over  with  a  little  hot  wax-mixture,  so  as  to  make  them  weld  into  one 
mass. 2  The  limb,  thus  secured,  is  slung  with  cord  and  pulley  to  Sir  H. 
Howse's  modification  of  Salter's  cradle.  This  occupies  the  lower  part 
of  the  bed  ;  the  patient  lies  on  a  half  water-bed.  Thomas's  knee-sphnt 
may  also  be  used.  G.  A.  Wright  employs  a  back  and  two  side  splints 
for  about  three  weeks,  and  then  a  Thomas's  splint,  which  is  kept  on  for 
at  least  two  years. 

The  chief  points  now  are  (1)  to  ensure  as  absolute  immobility  as 
possible  ;  (2)  to  employ  as  infrequent  ^  dressing  as  practicable  ;  (3)  to 
watch  for  every  sign  of  reappearance  of  the  disease,  and  to  attack  it  at 
once. 

After-treatment.  Morphia  or  laudanum  should  be  used  freely  at 
first,  if  needful.  If  there  be  no  reason  to  the  contrary  the  dressings 
should  be  left  undisturbed  for  about  a  week.  If  tuberculous  foci  persist, 
these  must  be  slit  up  with  a  sharp-pointed  curved  bistoury,  and  scraped 
out  with  sharp  spoons.  While  this  may  be  repeated  every  two  weeks 
on  five  or  six  occasions  successfully,  the  more  dehberately  the  surgeon 
endeavours  to  extirpate  the  disease  both  in  the  soft  parts  and  in  the 

1  Guys  Hospital  Reports,  1877,  vol.  xxii,  p.  503,  and  the  accompanying  plate. 

2  The  splint  is  usually  lined  with  lint  wrung  out  of  the  above  mixture,  or  boracic  acid 
lint.  But  the  popliteal  bar  and  any  of  the  splint  close  to  the  wound  must  be  metal  only, 
uncovered,  to  prevent  infection.  If  any  spaces  exist  between  the  limb  and  the  splint 
they  may  be  filled  in  with  cotton- wool,  soaked  in  some  of  the  hot  wax-mixture. 

3  Infrequency  of  dressing  has  been  strongly  insisted  on  by  Prof.  Oilier  {Rev.  de  Chir., 
August  1887;  ^?iwa/.so/^Mrgrer?/,  November  1887,  p.  424).  This  most  important  economy 
• — of  pain  to  the  patient,  and  time  to  the  surgeon — is  only  to  be  secured  by — (1)  Removing 
every  atom  of  the  disease  that  can  be  got  at.  (2)  Providing  drainage.  The  more 
thoroughly  the  disease  is  extirpated,  the  less  need  is  there  to  drain  ;  but  however  com- 
pletely the  disease  is  removed,  many  sutures  should  not  be  employed,  especially  at  the 
ends  of  the  wound      (3)  Securing  as  dry  a  wound  as  possible. 


876       OPERATIONS  ON  THE  LOWER  EXTREMITY 

bones,  the  more  he  treats  it  as  if  malignant,  at  first,  the  less  often  will 
he  have  to  interfere  later  on. 

In  about  three  months,  Sir  H.  Howse's  sphnt  may  be  left  off  and 
a  Thomas's  knee-splint  is  applied.  This  conducts  the  weight  from  the 
pelvis  along  the  splint  to  the  heel  of  the  foot.  Some  such  fixed  apparatus 
should  be  worn,  in  children,  for  two  to  three  years.  If  the  case  be  lost 
sight  of,  the  splint  vdW  be  removed,  with  the  inevitable  result  of  flexion. 

In  early  life  callus-like  material  is  thrown  out  quickly,  and  often 
somewhat  irregularly,  between  the  bones,  but  it  is  extremely  slow  in 
really  ossifpng.  As  the  quadriceps  extensor  wastes  much  more  quickly 
than  the  hamstrings,  even  when  the  patella  is  retained,  the  latter  muscles 
keep  up  their  action  on  the  tibia  for  months,  and  even  for  years,  until 
the  union  is  firm.  Tenotomy  has  been  advised,  and  even  resection  of  all 
the  hamstring  tendons.^  I  think,  however,  that  retaining  the  bones 
immobile  and  in  good  position,  securing  early  healing  of  the  wound, 
wearing  a  stiff  apparatus  and,  whenever  practicable,  using  the  trans- 
patellar  method,  will  best  ensure  a  limb  soundly  ankylosed  in  good 
position. 

Causes  of  Cases  not  doing  well,  Failure  and  Death  after  Erasion  and 
Excision  of  the  Knee.  (1)  Inveterate  persistence  of  the  disease  leading 
to  (a)  giving  way  of  the  suprapatellar  pouch,  and  the  results  mentioned 
at  p.  866  ;  ((3)  to  formation  of  caseating  foci,  especially  at  the  back  of 
the  joint  (p.  87),  and  only  to  be  removed  by  re-excision  or  amputation. 
(2)  An  unhealthy  condition  of  the  bone  ends,  vdth  caries  and  chronic 
osteo-myelitis.  (3)  Slowly  progressive  thickening  creeping  up  along  the 
lower  end  of  the  femur  and  do\\Ti  the  upper  end  of  the  tibia,  indicating 
a  persistent  tuberculous  periostitis.  While  the  latter  mischief  can  be 
often  dealt  with  by  vigorous  curetting,  all  these  conditions  are  grave, 
and  where  the  vitality  of  the  patient  is  poor,  or  when  other  unfavourable 
conditions  are  present,  indicate  the  need  of  considering  the  advisability 
of  amputation.  While  an  unpromising  limb  can  often  be  saved  by 
vigorous  curettings  repeated  two  or  three  times  at  intervals  of  a  week, 
the  treatment  to  be  aimed  at  is  preventive  by  thoroughly  going  over  the 
ground  at  the  first  operation.  When  the  surgeon  is  in  doubt  as  to  ampu- 
tation he  should  examine  the  bones  with  the  X-rays.  (4)  Deficient 
reparative  power,  leading  to  bed-sores,  emaciation,  and  hectic.  (5)  Co- 
existence of  subsec{uent  development  of  such  \asceral  diseases  as  phthisis, 
&c.  (6)  Infective  conditions.  For  these  the  surgeon  \^dll,  nowadays, 
be,  as  a  rule,  entirely  to  blame.  (7)  Secondary  haemorrhage.  Another 
very  rare  condition.  (8)  Fat  embohsm.  This  is  a  still  rarer  condition, 
but  one  which,  on  account  of  the  interest  it  excited  some  years  ago,  and 
because  it  has  once,  at  least,  proved  fatal,  deserves  mention  here. 

The  case  was  that  of  a  child,  aged  12,  submitted  to  excision  for  pulpy  disease 
by  Vogt.  of  Griefswald.2  The  bones  were  so  fatty  as  to  cut  with  a  knife.  Though 
but  little  chloroform  had  been  given,  and  the  loss  of  blood  had  been  slight,  the  patient 
died  twenty-four  hours  later  with  shallow  respirations,  feeble  pulse,  and  low  tem- 
perature. Fat  embolism  of  the  huigs,  extensively  diffused,  was  found  post  mortem. 
Vogt  considered  that  this  case  predisposed  to  fat  embolism.  Thus  cut  vessels  were 
exposed  on  the  sa'mi  sm-faces  with  plenty  of  free  oily  matter  close  by,  and  unable  to 
escape,  owing  to  the  bone-ends  being  in  close  contact  (two  wire  sutm-es  were  used). 
A  similar  case,  after  hip  resection,  by  Prof.  Liike,  is  mentioned.    Prof.  Vogt  thought 

1  Dr.  Phelps,  Neiv  York  Med.  Record.  July  21,  1886;  Annals  of  Surgery,  October 
1886,  p.  364. 

2  Cent.  f.  Chir.,  1883,  S.  24. 


ARTHRODESIS  877 

tliat  ho  would  iiin])ii(ate  in  another  oaHc  if,  after  excision  of  the  knee,  the  limb  could 
not  be  atraightened  without  close  apposition  of  the  sawn  fatty  bone-ends. 

(9)  Shock.  This,  thougli  rare,  must  be  remembered.  (10)  Flexion  and 
ankylosis.  The  frequency  of  these  and  their  prevention  have  already 
been  referred  to.  In  cases  occurring  after  erasion  the  union  is  always 
fibrous,  and  the  limb  can  usually  be  straightened  with  the  aid  of  an 
anaesthetic  and  division  of  tlic  hamstrings  (q.v.).  Great  care  must  be 
taken  not  to  strain  the  epiphysial  lines.  In  those  cases  where  back- 
ward displacement  of  the  tibia  is  present  as  well,  the  old  incision  should 
be  opened  up,  and  the  uniting  material  divided  with  an  osteotome. 
If  this  fail  a  partial  excision  must  be  performed,  no  formal  wedge  being 
taken  away,  but  the  ends  of  the  bone  successively  chiselled  away  until 
the  limb  can  be  straightened.  But  where  a  much-flexed  limb  is  com- 
pletely straightened  at  once,  the  warning  given  below  must  be  remembered. 
After  excision  the  union  is  usually  bony.  In  the  slighter  degrees  of 
deformity  division  of  the  bony  material  with  a  chisel  or  osteotome  usually 
suffices,  the  limb  being  gradually  straightened.  Where  the  deformity 
is  more  marked,  osteotomy  of  the  femur  above  the  joint,  and,  if  needful, 
the  tibia  also,  is  preferable  to  performing  a  second  excision,  or  removing 
a  wedge  of  bone. 

As  I  shall  not  have  space  again  to  refer  to  this  matter  of  ankylosis 
of  the  knee,  I  would  strongly  urge  caution  in  rapidly  and  completely 
straightening  a  knee-joint  which  has  long  been  the  seat  of  bony  anky- 
losis in  a  bad  position.  My  attention  was  drawn  to  this  matter  in  a 
painful  way  many  years  ago. 

A  girl  of  19  had  been  admitted  under  my  care  with  bony  ankylosis  of  the  knee  at  a 
right  angle,  dating  to  disease  seventeen  years  before.  Finding  that  I  was  unable  to 
materially  im^jrove  the  position  by  subcutaneously  sawing  through  the  bony  union  I 
excised  the  joint  and  straightened  it  completely.  The  foot  and  leg  remaining  cold,  an 
anaesthetic  was  given  next  day,  and  the  limb  put  up  flexed.  The  mischief  was,  how- 
ever, done.  The  coldness  remained,  all  pulsation  in  the  tibials  stopped,  and  gangrene 
evidently  threatening,  the  thigh  was  amputated,  the  patient  sinking  afterwards.  ^ 

At  the  necropsy,  osteophytes  were  found  on  the  posterior  border  of  the  tibia 
projecting  backwards,  and  it  was  evident  that  over  these,  when  the  limb  was 
straightened,  the  popliteal  vein,  a  very  small  one,  had  been  stretched  and  closed. 

ARTHRODESIS 

By  the  above  term  is  meant  the  denuding  of  a  joint  of  its  cartilage 
so  as  to  produce  either  partial  or  complete  ankylosis,  the  object  being 
to  save  a  hospital  patient  with  a  flail- joint  the  need  of  expensive  ap- 
paratus. The  operation  was  first  practised  by  Albert,  of  Vienna,  in 
1878,  and  was  introduced  into  this  country  by  Mr.  R.  Jones,  of  Liver- 
pool, who  reported  twenty-six  cases  operated  on  without  mishap  in  the 
Provincial  Medical  Journal  of  December  1894. 

As  the  knee  and  the  ankle-joints  frequently  require  combined  atten- 
tion, arthrodesis  of  these  two  joints  is  consideied  together. 

The  operator  aims  at  partial  or  complete  ankylosis.  It  is  not  easy 
to  predict  accurately  which  will  occur.  Partial  ankylosis — ten  or 
fifteen  degrees  of  movement  being  advantageous  for  walking  purposes 

1  Just  after  this  another  London  surgeon  published  a  very  similar  case.  Sufficient 
attention  has  not  been  drawn  to  this  matter.  It  would  have  been  much  wiser  on  my 
part,  with  such  dense  and  old-standing  ankylosis,  to  have  put  the  limb  up  flexed  at  first, 
or  to  have  rectified  the  position  in  two  stages  with  an  osteotome.  I  have  adopted  the 
step  successfully  since,  in  much  older  patients,  with  almost  as  much  contraction. 


878       OPERATIONS  ON  THE  LOWER  EXTREMITY 

— is  desired  usually  at  the  ankle.  Without  the  removal  of  much  bone 
it  is  not  easy  to  bring  about  a  complete  ankylosis  here.  If  a  partial 
ankylosis  is  desired  merely,  a  thin  layer  of  cartilage  is  gouged  away,  care 
being  taken  that  the  whole  area  of  cartilage  is  lemoved.  If  the  ankle 
be  wholly  paralysed,  ankylosis  should  "be  as  complete  as  possible.  If 
arthrodesis  is  employed  as  an  aid  to  tendon  transplantation,  the  ankylosis 
is  best  if  partial. 

Fixation  of  the  knee  is  very  rarely  desirable,  for  it  is  a  serious  dis- 
advantage to  the  power  of  bending  one  or  especially  both  knees.  Even 
when  all  muscular  control  of  the  knee  is  lost,  the  patient  can  walk  fairly 
well  with  the  aid  of  lateral  steel  supports  ^\ith  a  ring  catch  at  the  knee 
enabUng  the  patient  to  stand  firmly,  and  yet  bend  the  knee  while  sitting. 
If  any  power  of  flexing  the  hip  remains,  the  knee  swings  like  an  artificial 
limb.  Occasionally  the  deformity  is  too  great  to  allow  the  knee  to  be 
straightened  without  removal  of  bone  at  the  knee..  In  the  rare  cases 
in  which  arthrodesis  is  indicated  at  the  knee,  complete  bony  ankylosis 
with  a  straight  hmb  is  desirable,  as  partial  fixation,  with  no  controlhng 
muscles,  inevitably  means  stretching  of  the  fibrous  union.  It  is  necessary, 
except  in  very  young  children,  to  peel  the  joint  of  its  cartilage  completely, 
even  attacking  the  patella. 

The  indications  for  arthrodesis  are  given  by  Messrs.  Tubby  and  R. 
Jones  ^  as  follows  :  (a)  complete  paralysis  of  all  the  muscles,  resulting 
in  a  flail  limb  ;  (6)  complete  paralysis  of  muscles  about  a  joint,  resulting 
in  a  flail  joint ;  (c)  partially  paralysed  joints,  where  the  deformity  is  fixed, 
or  where  the  joint  becomes  deformed  the  moment  pressure  is  put  upon 
it ;  {d)  as  an  aid  to  muscle-transplautation,  where  it  is  necessary  to 
guard  against  over-stretching  of  newly  transplanted  tendons,  or  where 
these  tendons  are  not  strong  enough  to  control  the  joint. 

The  disadvantages  of  the  operation  are :  (a)  some  probable  shorten- 
ing of  the  limb  ;  (6)  the  limitation  of  extension  or  flexion  ;  (c)  the  need 
of  a  support  in  certain  cases. 

The  authors  do  not  consider  the  amount  of  shortening  to  be  a  factor 
sufficiently  serious  to  lay  stress  upon.  "  In  reference  to  the  loss  of  ex- 
tension and  flexion,  we  must  admit  that  there  are  circumstances  where 
such  a  loss  may  be  keenly  felt.  This  is  scarcely  appHcable  to  the  ankle, 
but  markedly  so  in  the  knee-joint.  Many  people  Avith  complete  para- 
plegia or  monoplegia,  who  have  ample  means  to  renew  their  supports, 
will  feel  acutely  the  disadvantage  of  not  being  able  to  bend  the  knee 
when  sitting.  In  public  places  the  stiff',  straight  limb  has  obvious  draw- 
backs. To  a  working  lad,  however,  it  is  a  great  boon  to  be  independent 
of  supports,  with  their  expense  and  worries,  and  this  independence 
is  not  at  all  compensated  by  the  power  of  flexion.  Such  cases  must  be 
treated  in  accordance  with  their  desires,  bearing  in  mind  that  a  patient 
may  quite  well  know  what  will  suit  him  best.  The  argument,  however, 
never  obtrudes  in  the  case  of  the  ankle,  where,  in  the  rare  cases  of  com- 
plete fixation,  a  tolerable  degree  of  movement  is  carried  on  at  the  mid- 
tarsal  joint." 

A  painful  condition  after  arthrodesis,  when  weight  is  borne  on  the 
joint,  is  comparatively  common  in  adults,  but  it  usually  disappears  in  a 
few  weeks  or  months. 

The  writers  mentioned  above  do  not  recommend  arthrodesis  in  the 
case  of  the  hip- joint.     "  It  would  be  difficult  to  carry  it  to  a  successful 

^  Surgery  of  Paralysis,  p.  173. 


ARTHRODESIS  879 

issue,  and,  generally  speaking,  preternatural  mobility  at  the  hip  is  not 
so  serious  a  disadvantage.  The  results  at  the  ankle-joint  are  better 
than  those  at  tiic  knee." 

As  an  aid  to  tendon-transplantation  at  the  ankle  arthrodesis  has  been 
found  by  Messrs.  Tubby  and  R.  Jones  very  successful.  In  equino- 
valgus  this  is  especially  the  case.  Given  an  ankle  with  very  slackened 
structures,  paralysis  of  the  tibiales.  and  preternatural  raobiUty,  arthro- 
desis will  limit  movement  of  the  ankle  to  a  few  degrees,  combined  with 
the  introduction  of  appropriate  tendons  into  the  tibiales  or  into  the 
periosteum  in  order  to  restore  the  movement  of  inversion.  An  opera- 
tion on  similar  lines  may  be  needed  in  equino- varus.  In  tahpes  calcaneus 
arthrodesis  of  the  ankle,  combined  with  shortening  of  the  tendo  Achillis, 
is  far  superior  to  shortening  of  the  tendon  alone,  which  is  liable  to  be 
disappointing  from  yielding  of  the  shortened  tendon. 

It  is  necessary  in  all  cases  to  prolong  the  use  of  apparatus,  as  it 
takes  a  considerable  time  for  the  joints  to  become  fixed. 

Arthrodesis  oJ  the  Knee-joint.  As  already  said  this  should  be  rarely 
performed  for  even  passive  flexion  and  extension  are  very  desirable  at 
the  knee.  The  skin  having  been  sterilised  and  a  tourniquet  apphed, 
an  incision  is  made  across  the  front  of  the  joint,  traversing  half  its  cir- 
cumference, and  curved  so  as  to  pass  below  the  lower  end  of  the  patella. 
The  flap  is  turned  up,  the  joint  flexed  strongly,  the  semilunar  cartilages 
removed,  and  with  a  sharp,  short-bladed  knife  or  gouge  the  cartilage 
should  be  peeled  ofi  the  bones,  so  as  to  leave  a  raw  surface  over  their 
whole  extent.  The  crucial  ligaments  may  or  may  not  be  left.  All 
haemorrhage  having  been  arrested,  the  joint  is  closed  without  drainage. 

Arthrodesis  of  the  Ankle-joint.  This  may  be  performed  in  one  of 
four  ways,  according  to  the  circumstances  of  the  case  :  (1)  by  a  trans- 
verse incision  across  the  front  of  the  joint ;  (2)  by  a  perpendicular 
incision  along  the  mid-hne  in  front  of  the  joint ;  (3)  by  an  antero-external 
incision  just  external  to  the  tendons  of  the  extensor  communis  digitorum  ; 
(4)  by  a  posterior  incision  over  the  tendo  Achillis. 

In  old-standing  cases,  where  the  foot  assumes  the  equino-varus 
position,  and  where  all  the  muscles  are  paralysed,  the  transverse  incision 
across  the  front  of  the  joint  is  preferable.  The  division  of  the  tendons 
is  then  of  no  consequence,  and  an  excellent  view  is  obtained  of  the  joint. 
If  there  be  any  compunction  in  dividing  the  tendons  they  can  quite 
easily  be  drawn  aside,  with  the  exception,  perhaps,  of  the  peroneus 
tertius.  If  firm  union  be  desired  not  only  all  the  cartilage,  but  even  some 
of  the  bone  as  well,  must  be  removed.  Where  some  power  still  remains 
in  the  extensors  of  the  toes,  a  hnear  vertical  incision  may  be  preferred, 
and  so,  too,  where  tahpes  equinus  is  present  and  the  astragalus  is  dis- 
placed forwards.  The  posterior  incision  is  useful  in  tahpes  calcaneus, 
where  the  joint  can  easily  be  reached  from  behind.  The  incision  is  made 
close  to  the  centre  of  the  tendo  Achillis,  which  is  drawn  to  one  side  or 
divided,  while  the  incision  is  carried  do\vn  to  the  bone.  The  capsule 
is  opened,  and  the  gouging  completed.  If  there  be  any  power  in  the 
gastrocnemius,  the  tendo  Achilhs  must  be  shortened  through  the  same 
incision. 

Before  having  recourse  to  arthrodesis  and  tendon-transplantation, 
care  should  be  taken  to  overcome  completely  by  mechanical  means  any 
deformity  of  the  foot  or  leg.  If  this  be  not  done,  considerable  traction 
may  be  needed  immediately  after  operation — -a  process  to  be  avoided 


880       OPERATIONS  ON  THE  LOWER  EXTREMITY 

when  possible.     In  spite  of  the  trophic  nature  of  the  lesions,  wounds 
heal  rapidly  and  soundly. 

In  the  after-treatment  a  Thomas's  knee-splint  is  recommended  while 
the  patient  is  in  bed,  and  this  should  be  changed  to  a  "  caliper  "  when 
walking  commences.  For  the  ankle  nothing  is  better  than  a  posterior 
sphnt. 

My  own  experience  of  arthrodesis  is  somewhat  limited,  being  derived 
from  six  cases  of  the  operation  in  the  knee-joint  and  three  in  the  ankle, 
in  two  of  which  the  ankle  and  knee-joints  were  operated  upon  simul- 
taneously.^ I  have  never  succeeded  in  obtaining  more  than  close 
fibrous  union  even  when  the  ends  of  the  bone  had  been  actually 
trenched  upon.  The  knee  was  exposed  by  the  transpatellar  incision 
and  care  was  taken  not  to  damage  the  lateral  hgaments  more  than  could 
be  helped  ;  the  menisci  and  the  anterior  crucial  hgament  were  removed. 
In  the  removal  of  the  articular  cartilage  by  gouge,  chisel,  oj.-  a  curved, 
blunt-pointed  knife,  a  good  deal  has  to  be  done  by  touch,  if  the  ligaments 
of  the  already  unstable  joint  are  not  to  be  needlessly  weakened.  In 
the  case  of  the  ankle-joint  I  made  use  of  a  transverse  incision,  suturing 
most  of  the  severed  tendons  afterwards,  and  in  this  joint  I  consider  the 
insertion  of  a  wire  between  the  tibia  and  astragalus  most  advisable,  as 
a  means  of  increasing  the  stability.  In  two  of  the  cases  thus  treated, 
when  seen  respectively  three  and  five  years  later,  the  wire  had  caused 
no  trouble. 

As  in  the  case  of  tendon-transplantation,  too  much  must  not  be 
expected  from  arthrodesis.  In  only  two  of  my  cases  am  I  able  to 
say  ■w^th  certainty  that  the  result  admitted  of  the  patient  entirely 
dispensing  with  supporting  apparatus.  The  simplicity  and  uncom- 
plicated nature  of  arthrodesis  justify  resort  to  it  in  the  hope  that 
it  will  improve  the  abiUty  of  the  patient  to  make  use  of  any  remaining 
power  which  he  may  possess.  Even  when  the  ends  of  the  bone  have 
been  thoroughly  exposed — and  this  is  essential — it  is  difficult  to  ensure 
stable  bony  ankylosis.  The  conditions  necessary  for  such  ankylosis 
are  wanting.  In  early  life,  even  if  small  sections  of  bone  are  removed 
with  the  saw — and  no  more  is  permissible  for  fear  of  further  serious 
interference  with  the  growth  of  the  already  dwarfed  and  dwindled  limb 
— ^the  surfaces  of  bone  are  scant  and  puny.  The  rims  of  cartilage  ex- 
posed are,  relatively,  very  large.  Further,  the  loss  of  power  over  the 
muscles  of  the  thigh  and  leg  is,  usually,  advanced  and  confirmed. 

WIRING  FRACTURES  OF  PATELLA 

In  the  words  of  Lord  Lister,  who  introduced  the  operation  in  1883, 
"  no  man  is  justified  in  performing  such  an  operation  miless  he  can  say 
with  a  clear  conscience  that  he  considers  himself  morally  certain  of 
avoiding  the  entrance  of  any  septic  mischief  into  the  wound." 

The  chief  points  to  consider  here  are  (1)  the  age  of  the  patient,  i.e. 
up  to  about  forty-five,  the  state  of  his  tissues  and  viscera,  and  his  amena- 
bility to  directions  ;  (2)  the  amount  of  separation,  i.e.  a  distance  of 
over  half  an  inch  ;  (3)  marked  tilting  of  the  fragments  backwards  or 
forwards  ;    (4)  great  distension,  as  this  is  an  indication,  as  far  as  it 

1  It  is  right  that  I  should  add  that  my  cases  of  arthrodesis  were  performed  at  a  time 
before  tendon-transplantation  was  in  vogue.  I  thus  failed  to  obtain  any  of  those  ad- 
vantages which  may  accrue  from  the  combination  of  the  two  operations. 


WIRING  FRACTURES  OF  PATELLA  881 

goes,  of  laceration  of  the  lateral  parts  of  the  capsule  ;  (5)  the  occupa- 
tion of  the  patient :  the  more  active  this  is,  the  more  it  involves  work 
on  dilTorent  levels,  the  more  is  operative  treatment  indicated. 

In  any  case  the  two  sides  of  the  question  and  the  risks  should  be 
put  before  the  patient.  He  should  understand  that  while  good  results 
are  certainly  obtainable  by  ordinary  means,  lifelong  care  will  be  needed 
to  avoid  such  strains  as  are  involved  in  stumbling,  especially  on  going  up 
and  down  stairs,  and  he  should  realise  that  much  of  the  success  of  the 
after-treatment  rests  with  him.  As  I  have  stated  in  the  account  of 
fracture  of  the  olecranon,  it  is  well  that  the  patient  should  have  an  oppor- 
tunity of  discussing  the  matter  with  another  who  has  been  operated  upon. 

The  above  remarks  apply  to  cases  of  simple  fracture  ;  in  compound 
cases,  the  need  of  cleansing  the  joint  by  irrigation,  &c.,  is  an  additional 
reason  for  operating  although  the  prospect  of  success  is  not  so  good. 

Operation.  (1)  I  shall  first  take  cases  of  recent  fracture.  The 
rarer  ones  of  older  standing  are  considered  at  p.  884.  The  question  as  to 
the  best  time  for  interference  now  arises.  While  several  who  are  authori- 
ties recommend  operation  during  the  first  few  hours  when  this  is  practi- 
cable, as  a  rule  I  should  advise  waiting  until  the  fourth  day,  when  synovitis 
and  oedema  are  subsiding.  Another  reason  is  that  this  gives  more  time 
for  thoroughly  sterilising  the  parts.  Owing  to  its  density  and  rugse, 
the  skin  here  is  one  of  the  most  difficult  to  deal  with  satisfactorily.  If 
operation  is  resorted  to  at  once  the  vigorous  measures  required,  e.g.  in 
a  patient  habitually  working  in  dust,  may  lead  to  a  condition  of  der- 
matitis. Boracic  acid  fomentations,  applied  at  once  and  continually 
to  remove  the  horny  epithelium  here,  pave  the  way  for  thorough  sterilisa- 
tion with  iodine.  Further,  in  my  opinion,  waiting  till  the  third  day 
gives  opportunities  for  a  more  thorough  examination  of  the  patient 
externally,  e.g.  for  other  injuries,  the  presence  of  any  focus  of  suppura- 
tion, &c.,  while  it  finds  him  in  a  better  state  for  the  anaesthetic.  I 
admit  that  this  delay  may  lead  to  more  coagulation  in  the  joint,  but 
this  disadvantage  I  consider  a  minor  one. 

Every  detail  for  the  securing  of  complete  asepsis  having  been  secured, 
and  a  tourniquet  applied  round  the  upper  third  of  the  thigh,  the  parts 
are  best  exposed  by  a  flap-incision.  The  writer  generally  employs  one 
with  its  convexity  downwards,  believing  that  this  best  secures  the  vitality 
of  the  flap.  The  incision  commences  on  a  level  with  the  upper  margin 
of  the  patella,  about  one  inch  to  one  side,  passes  downwards  to  a  point 
a  httle  below  the  level  of  the  line  of  fracture,  where  it  is  carried  across 
the  Umb  and  then  upwards  to  a  point  corresponding  to  that  from  which 
it  started.  He  has  not  found  that  this  incision  in  any  way  interferes  with 
kneeling  afterwards,  an  objection  which  has  led  others  to  prefer  a  flap 
with  its  extremity  upwards  or  outwards.  A  flap-incision  has  the  un- 
doubted advantages  of  better  exposure  of  the  parts,  facilitating  the 
deahng  with  the  fragments,  the  removal  of  clots,  and  uniting  the  lateral 
parts  of  the  capsule,  if  injured  ;  lastly,  where  drainage  is  necessary, 
it  is  easily  secured. 

Lord  Lister  used  the  vertical  incision  ;  Prof.  Kocher  employs  a  slightly 
curved  one.  In  any  case  the  transverse  part  of  the  incision  should  never 
be  opposite  the  fine  of  fracture,  and  in  marking  out  and  raising  a  flap 
care  should  be  taken  to  secure  uniform  nutrition  and  vitality  and  to 
interfere  with  the  parts  as  httle  as  possible.  For  the  exposure  of  the 
fragments,  removal  of  any  intervening  tissue,  clearing  away  of  clots, 

SURGERY  I  56 


882        OPERATIONS  OX  THE  LOWER  EXTREMITY 

drilling  the  bones,  and  passage  of  and  dealing  with  the  wire,  the  details 
given  for  like  treatment  of  the  olecranon  should  be  carefully  followed. 

Either  silver  wire  of  medium  size  or  a  Y-shaped  plate  may  be  used ; 
the  former  is  more  difficult  to  insert  well,  but  secures  better'apposition 
than  one  or  more  plates,  which  are  apt  to  allow  some  tilting  of  the  frag- 
ments with  gaping  of  their  cartilaginous  lips.  A  circular  wire  passing 
above,  below  and  twice  through  the  patella  secures  the  most  perfect 


V- 


Fig.  35.3.     Wiring  patella  after  reflecting  a  flap  inwards.     This  method  of  wiring 
secures  excellent  apposition. 

apposition  {see  Fig.  353).  This  does  not  enter  the  joint  to  cause  later 
trouble  from  friction,  as  in  the  Barker  method.  Above  and  below  the 
wire  passes  through  the  rectus  and  patella  tendons,  and  the  twisted 
ends  of  the  wire  are  buried  in  the  rectus  tendon  just  above  the  patella, 
where  it  is  safe  from  pressure. 

By  some  American  surgeons  wire  has  been  replaced  by  absorbable 
material,  e.g.  catgut,  silk,  kangaroo-tendon,  thus  doing  away  with 
any  risk  of  after-trouble  with  the  wire,  a  risk  which  is  nowadays  extremely 
small.  Some  have  gone  farther  and  advised  suture  only  of  the  torn 
periosteum  and  fibrous  tissues.^  In  a  number  of  cases  this  has  been 
found  sufficient,  as  there  is  no  risk  of  the  fragments  here  shifting 
longitudinally  or  laterally  if  the  quadriceps  extensor  be  kept  relaxed 

1  Gibbon,  Rodman,  Aim.  of  Surg.,  June  1904,  pp.  1023,  1026. 


WIRING  FRACTURES  OF  PATELLA 


883 


for  two  or  three  weeks.  The  arguments  for  and  against  this  step  appear 
to  me  to  be  as  follows  :  Drilling  the  fiagment  is  the  most  difficult  part 
of  the  operation,  and  necessarily  adds  to  the  amount  of  distuibance  of 
the  parts,  and  the  risk  of  infection.  On  the  other  hand,  if  the  fiagments 
themselves  are  not  wiied,  the  after-rest  must  be  prolonged  in  (nder  to 
secure  bony  union.  Instead  of  the  splint  being  rcmovtd  in  ten  days  and 
the  patient  being  up  in  a  fortnight,  a  period  of  at  least  six  weeks  will  be 


Fig.  354.     Plating  patella. 


After  reflecting  a  flap  inwards, 
is  also  sewn. 


The  aponeurosis 


required.     During  this  time   massage   will,   of  course,   be  assiduously 
employed. 

I  have  no  experience  of  Mr.  Barker's  method  of  passing  wire  around  the 
fragments.!  Dr.  J.  B.  Roberts  2  has  employed  a  simpler  method  {see  Fig. 
354)  by  passing  a  silk  or  catgut  purse-string  suture  round  the  fragments. 
These  are  encircled  with  a  suture  passed,  by  means  of  four  punctures, 
through  tendon  and  aponeurosis.  This  method  does  not  open  the  joint, 
and  while  not  securing  such  perfect  adaptation  of  the  fragments  as  is 
secured  by  wiring,  has  been  followed  by  satisfactory  function.  One 
of  Dr.  Roberts's  patients  was  able  to  carry  kegs  of  beer  up  and  down 
stairs  as  well  as  was  the  case  before  the  fracture.  In  answer  to  the 
objection  to  such  methods  that  they  do  not  admit  of  removal  of  blood 
clots  or  fibrous  tissue  between  the  fragments.  Dr.  Roberts  argues  that 

1  Brit.  Med.  Journ.,  April  18,  1896.  ^  Ann.  oj  Surg.,  June  1904,  p.  1027. 

56' 


SURGERY  I 


884        OPERATIONS  ON  THE  LOWER  EXTREMITY 

Nature  will  remove  the  former  "  by  absorption  as  she  has  been  doing 
for  years  before  the  open  operation  was  advocated."  As  to  any  perios- 
teum between  the  fragments,  this  can  be  removed  without  opening 
the  joint  by  elevating  the  hmb  so  as  to  relax  the  quadriceps,  and  rubbing 
firmly  together  the  approximated  fragments.  The  "  dull  crepitus  at  the 
beginning  of  the  manipulation  will  be  followed  by  a  sharp  bony  crepitus 
as  the  fragments  of  periosteum  are  crowded  away." 

(2)  Certain  Cases  of  Old  Fracture  of  the  Patella.  This  important 
matter  must  be  taken  somewhat  in  detail.  Lord  Lister  goes  so  far  as 
to  consider  ^  that  "  the  ununited  case  is  in  every  respect  worse  as  a 
subject  of  operation  than  the  recent."  This  is  chiefly  owing  to  the 
wasting  of  the  fragments  and  their  greater  separation.  Again,  in  recent 
cases,  there  is  no  need  to  pare  the  fragments,  for  after  sponging  away 
of  clots  the  surfaces  are  ready  for  coaptation.  The  chief  points  here 
justifying  resort  to  wiring  are  :  {a)  Failure  of  previous  treatment,  es- 
pecially in  hospital  patients.  (6)  A  useless  hmb,  especially  in  a  man 
whose  occupation  entails  much  walking  or  standing,  where  the  gait  is 
helpless  and  requires  much  attention,  or  where  many  falls  have  followed 
involving  serious  risk  of  fracture  on  the  opposite  side,  (c)  Where  both 
patellae  are  fractured,  {d)  Where  the  patient  is  young  and  has  many 
years  of  active  life  before  him.  (e)  Where,  if  not  young,  the  patient  is 
sufficiently  healthy.  (/)  Where  enough  is  known  of  the  patient's  habits 
to  ensure  his  being  amenable. 

Operation.  The  fragments  when  exposed  ^  are  generally  found  em- 
bedded in  fibrous  tissue,  thickened  synovial  membrane,  and  old  decolorised 
coagulum.  This  must  be  snipped  or  cut  away,  and  any  spirting  vessels 
in  the  thickened  synovial  membrane  must  be  secured.  A  very  thin 
section  from  each  fragment  is  then  removed  with  a  narrow-bladed  saw, 
this  needing  much  caution  in  the  case  of  the  lower  one,  which  is  the 
smaller  of  the  two.  If  the  fragments  can  now  be  pressed  into  close 
apposition,  nothing  usually  remains  save  to  wire  them,  but  the  case  is 
by  no  means  so  simple  where  the  bones  are  widely  apart. 

Thus,  in  one  of  my  cases,  many  years  ago,  after  paring  the  fragments— these  were 
quite  two  and  a  half  inches  from  each  other — and  aftermost  forcible  traction  the 
upper  could  only  be  made  to  descend  three-quarters  of  an  inch.  Malgaigne's  hooks 
were  applied  and  tightly  screwed  up,  but  with  no  result  on  the  desired  ajjproxi- 
mation.  The  lateral  exj)ansions  of  the  quadriceps  were  next  still  more  fully  divided 
(cut  muscular  fibres  being  seen  on  the  inner  side),  but  the  fragments  were  almost  as  far 
apart  as  ever.  As  the  only  alternative  to  excising  the  joint  (in  order  to  substitute 
a  firm  support  for  the  flail-like  limb),  I  now  divided  partially  the  rectus  tendon, 
but  it  was  not  till  the  upper  fragment  was  only  held  by  a  narrow  stout  band  at  its 
upper  and  inner  parts  that  it  could  be  brought  into  apposition  with  the  lower  one. 
The  result  was  excellent.  At  the  present  day,  elongation  of  the  quadriceiis,  if 
needful,  would  be  employed.  In  a  young  man  with  a  straight  stiff  knee  a  year  after 
the  fracture,  the  writer  divided  the  quadriceps  in  a  zigzag  manner  and  lengthened 
it  enough  to  allow  the  knee  to  be  bent  90°  after  the  patella  had  been  wired.  Later 
the  range  of  movement  increased  and  power  returned  to  the  normal. 

Owing  to  the  tension,  wire  must  be  used  in  these  cases,  according 
to  the  directions  given  already.  Owing  to  the  bones  being  probably 
degenerated  from  disuse,  the  circular  method  already  described  is  par- 
ticularly valuable. 

1  Lancet,  November  3,  188.3. 

*  In  one  case,  the  skin  being  dimpled,  puckered  down,  and  adherent  between  the 
fragments.  I  had  to  cut  away  a  piece  about  three-quarters  of  an  inch  wide. 


WIRING  FRACTURES  OF  PATELLA  885 

Where  the  lower  fragment  is  too  small  to  hold  a  wire,  this  may  be 
passed  throuirh  the  ligamentum  patellar,  as  has  been  done  by  Lord 
Lister  '  and  Air.  Teale.'-  One  wire  would  appear  to  be  sufficient.  Though 
this  unites  the  centre  of  the  fragments  exactly,  a  very  slight  interval 
remains  at  the  edges  but  does  not  interfere  with  an  excellent  result. 
Drainage  is  not  re(piired. 

A  massive  sterile  dressing  is  firmly  applied  to  prevent  oozing  into  the 
joint  and  tissues  around  it.  The  limb  is  elevated,  but  no  splint  is  applied, 
the  dressings  limit  flexion  sufficiently.  As  soon  as  the  wound  is  healed, 
every  pains  nuist  be  taken,  by  massage,  &c.,  to  improve  the  atrophy 
of  the  quadriceps.     Healing  should  be  complete  in  two  weeks. 

The  question  of  passive  movement  now  arises.  From  the  third 
day  passive  movement  is  gently  and  increasingly  carried  out.  Also 
voluntary  movements  are  encouraged.  The  greater  part  of  the  dressing 
is  removed  after  four  days,  thus  allowing  freer  movement.  Usually,  in 
two  to  three  weeks  after  the  operation  the  patient  may  get  up  and  begin 
to  use  the  limb  (with  the  aid  of  two  sticks  at  first),  flexion  and  extension 
being  diligently  practised.  Unless  the  joint  is  very  stiff,  massage,  friction, 
and  gentle  persevering  movement,  aided  by  time  and  patience,  will 
be  sufficient.  If  an  anaesthetic  is  given,  movements  must  be  made 
cautiously,  as  the  patella  has  been  refractured  on  this  occasion  more 
than  once.^  In  every  case  a  knee  support  consisting  of  side  steels  with 
a  stop  joint  is  used  for  at  least  three  months  after  the  wiring.  This  allows 
movement  and  prevents  refracture  from  time  to  time,  mere  range  of 
movement  is  allowed  by  altering  the  position  of  the  screw  stop.  The 
instrument  is  not  used  at  night,  and  is  also  taken  oft"  for  the  exercises  and 
passive  movements. 

Difficulties  in  Wiring  the  Patella.  (1)  Atrophied  surface  of  the 
fragments,  making  it  difficult  to  refresh  them  satisfactorily.  (2)  A 
very  small  lower  fragment.  (3)  Fragments  embedded  in  very  firm 
fibrous  tissue,  fascial,  periosteal,  and  synovial,  or  old  coagulum.  This 
condition  will  prevent  satisfactory  apposition  unless  the  intervening 
tissue  be  all  removed.  In  a  very  interesting  case  recorded  by  Mr.  0. 
Ward  ^  it  was  found,  on  exploring  the  fragments,  that  the  capsular 
tissues  torn  off  the  lower  fragment  remained  attached  above,  and  hung 
like  a  flap  between  the  fractured  surfaces,  eft'ectually  preventing  their 
apposition.  It  is  suggested  that  some  such  comphcation  may,  in  many 
cases  which  have  been  treated  in  the  usual  way,  cause  the  fragments 
to  fall  apart  as  time  goes  on.  This  is  the  view  held  by  Sir  W.  Macewen,^ 
who  collected  thirteen  cases  of  transverse  fracture  of  the  patella,  in  which 
portions  of  soft  tissue  intervened  between  the  fragment  in  such  a  manner 
as  to  render  osseous  union  an  impossibility.  (4)  A  contracted,  rigid 
quadriceps  (p.  884).  (5)  Indipping  skin  (p.  884).  (6)  Multiple  frag- 
ments. This  may  cause  much  difficulty,  especially  if  it  is  the  lower 
and  usually  smaller  fragment  which  is  comminuted.     If  the  lower  frag- 

1  Loc.  supra  cit.  2  Brit.  Med.  Journ.,  June  9,  1883. 

3  In  one  of  Lord  Lister's  cases  {loc.  supra  cit.),  passive  movement  being  employed 
with  "  considerable  force  "  four  weeks  after  the  wiring,  the  rigid  quadriceps  not  yielding, 
the  wire  gave  way,  and  the  cicatrix  (a  long  longitudinal  one),  which  had  healed  save 
where  the  wire  projected,  opened.  The  joint  was  at  once  washed  out  antiseptically, 
and,  six  days  later,  some  coagula  were  removed,  and  the  old  wire  retwisted.  An  ex- 
cellent limb  was  the  result. 

*  Lancet.  November  1.  1884. 

5  Ibid.,  November  17,  1883  ;   Ann.  of  Surg.,  March,  1887,  p.  178. 

SURGERY  I  ,  56' 


886        OPERATIONS  ON  THE  LOWER  EXTREMITY 

ment  is  not  large  enough  to  bear  wiring,  the  wire  may  be  passed  through 
the  ligamentum  patellae.  Where  the  fracture  is  multiple,  the  smaller 
fragments  mav  first  be  united  by  fine  wire,  and  then  bv  stouter,  to  the 
larger  one.  But  where  they  are  found  to  be  much  loosened  in  their 
periosteal  covering,  it  will  be  wiser  to  be  content  with  carefully  uniting 
the  torn  periosteum,  and  enforcing  longer  rest  afterwards. 

Causes  of  Failure  or  Trouble  afterwards.  These  are  mainly  :  (1)  In- 
fective conditions.  (2)  Trouble  with  the  wire.  This  rarely  occurs 
where  the  wire  has  been  well  hammered  down,  some  adjacent  fibrous 
tissue  dra\vn  over  it,  and  the  flap-incision  made  use  of,  or  a  trans- 
verse one  Ipng  below  the  site  of  the  wire.  In  one  of  my  cases  of  old 
fracture  the  patient  returned,  nearly  a  year  later,  with  great  tender- 
ness over  the  wire.  She  was  extremely  thin,  and  had  knelt  early  and 
much.  On  removing  the  wire  I  found  that  I  had  made  three  or  four 
half-twists  instead  of  two.  In  another  case,  operated  on  by  the  late 
Mr.  Davies  Colley,  a  small  bursa,  the  size  of  a  thrush's  egg,  containing 
fluid,  formed  around  the  twist.  This,  made  with  the  greatest  symmetry, 
consisted  of  four  half-twists.  Where  it  is  nessary  to  remove  the  wire, 
this  may  be  done,  with  the  aid  of  eucaine,  by  a  small  incision  over  it. 
The  wire  is  first  untwisted  and  straightened  ;  one  end  is  next  cut  off 
short,  and  the  other  grasped  in  dressing  forceps  and  wound  romid  these. 
It  is  then  extracted  without  jerking.  If  this  step  be  required  before  a 
period  of  six  or  eight  weeks  after  the  operation,  care  not  to  break  down 
the  union  will  be  needful.^  (3)  InabiHty  to  bring  the  fragment  together 
in  long-standing  cases.  Mr.  Turner  -  mentions  a  case  in  which  the 
operation  was  abandoned,  as  it  was  found  impossible  to  get  the  frag- 
ments together  after  wiring  them.  The  patient  was  "  no  better  and  no 
worse  "  eventually.  (4)  Refracture  from  a  fall  within  a  few  weeks  or 
months  of  the  operation.  This  is  common,  when  a  splint  or  stop- jointed 
steel  support  is  not  used  in  the  after  treatment.  (5)  Necrosis  of  a  frag- 
ment. This  is  a  comphcation  rather  than  a  cause  of  failure.  It  is 
especially  likely  to  occur  after  severe  compound  fractures  in  which  the 
periosteum  was  much  injured  at  the  time  of  the  accident.  This  happened 
with  an  upper  fragment  in  a  case  of  Dr.  G.  R.  Fowler's.^  About  three 
months  after  the  wiring,  this  fragment,  about  the  size  of  a  walnut,  was  re- 
moved. It  was  now  found  that  "  the  joint  was  perfectly  closed  by  a  thick 
fibrous  capsule  underlying  the  necrosed  portion,  connected  to  the  upper 
margins  of  the  nowfirmly  miited  two  lower  fragments,  and  forming  a  strong 
bond  of  union  between  the  quadriceps  above  and  what  remained  of  the 
patella  below."  The  resulting  limb  was  useful,  with  considerable  move- 
ment at  the  knee-joint.  (6)  With  the  increasing  frequency  with  which 
this  operation  is  resorted  to,  there  is  another  cause  of  failure,  partial 
at  least,  for  which  surgeons  must  be  prepared  in  patients  no  longer  young, 

^  The  following  show  that  the  wire  may  occasionally  excite  irritation  and  lead  to 
serious  results.  Sir  W.  Macewen  {loc.  infra  cit.)  mentions  a  case  which  came  under 
observation  three  months  after  suture  of  the  patella,  with  acute  suppurative  arthritis  of 
the  joint  and  ulceration  of  the  cartilage.  A  probe  passed  through  a  sinus  detected  the 
wire  surrounded  by  carious  bone.  The  twist  was  still  intact,  but  the  loop  was  loose,  the 
bone  having  become  inflamed,  softened,  and  ulcerated.  Excision  of  the  joint  was  required. 
This  shows  that  occasionalh^  the  wire  may  excite  irritation,  and  thus  lead  to  serious 
results.  Mr.  Turner  (Lancet,  1887.  vol.  i,  p.  572)  records  a  case  in  which  Mr.  M.  Robson, 
of  Leeds,  had  wired  an  ununited  fracture  of  the  patella,  three  gold  wires  being  employed. 
The  patient,  an  epileptic,  probably  injured  the  knee  repeatedly,  the  wires  worked  out, 
and  the  knee-joint  became  acutely  inflamed,  requiring  free  incisions  and  drainage. 

2  Clin  Soc.  Trans.,  vol.  xviii.  p".  41.  3  ^nn.  of  Surg.,  1885,  p.  248. 


REMOVAL  OF  LOOSE  BODIES  FROM  KNEE-JOINT    887 

and  that  is  a  condition  allied  to  osteo-arthritis,  set  up  by  the  injury, 
and,  in  part,  by  the  wiring.  A  patient  of  mine,  aged  42,  in  whom  the 
healing  and  movements  regained  had  been  most  satisfactory,  returned 
six  weeks  later  on  account  of  pain  and  increasing  stiffness  in  the  joint. 
The  wire  was  giving  no  trouble  whatever,  but  both  to  the  feel  and  the 
ear  the  joint  gav^e  marked  evidence  of  osteo-arthritis  ;  there  had  not 
been  time  for  the  occurrence  of  lipping. 


REMOVAL  OF  LOOSE  BODIES  ^  FROM  THE  KNEE-JOINT 

Operation.  The  parts  should  be  kept  at  rest  for  some  days  and  most 
scrupulously  sterilised.  I  will  draw  attention  to  the  danger  in  opening 
a  large  and  complicated  joint  like  the  knee,  even  greater  care  being 
needed  here  than  in  the  case  of  the  peritoneal  sac  owing  to  the  smaller 
power  of  resistance  possessed  by  the  synovial  membrane.  Owing  to  the 
great  mobility  of  some  of  these  bodies,  it  is  well  to  harpoon  them  with  a 
sterilised  needle,  if  possible,  at  the  beginning  of  the  operation.  In 
all  cases  a  skiagram  is  taken  before  operation,  for  in  many  cases 
several  loose  bodies  are  present.  The  sesamoid  bones  sometimes  seen 
in  the  gastrocnemius  tendons  must  not  be  mistaken  for  loose  bodies. 
A  tourniquet  is  always  used,  for  this  makes  the  operation  much  easier, 
speedier  and  safer.  The  joint  is  then  deliberately  and  sufficiently  opened. 
If  there  is  no  localising  evidence,  the  best  incision  is  half  an  inch  internal 
to  the  patella  and  its  tendon,  for  loose  bodies  are  generally  lodged  between 
the  condyles  and  are  easily  seen  and  scooped  out  through  the  incision. 
The  scoop  or  finger  can  be  passed  up  into  the  pouch  of  synovial  membrane 
under  the  crureus.  This  incision  has  the  further  advantage  of  allo^\^ng 
the  internal  cartilage  to  be  seen  from  above,  so  that  any  detachment 
or  laceration  of  it  can  be  recognised.  As  a  rule  an  incision  2i  inches  long 
suffices.  A  similar  incision  on  the  outer  side  is  sometimes  necessary.  In 
difficult  cases  a  loose  body  may  be  brought  into  view  by  putting  the 
joint  through  its  different  movements,  or  by  flushing  it  out  with  sterile 
saline  solution.  These  steps  should  always  be  taken  before  making 
other  incisions  which  are  likely  to  interfere  with  the  joint's  functions. 

In  the  case  due  to  injury  (footnote,  p.  886),  on  cutting  freely  into  the  joint,  I 
came  down  upon  a  tiny  pedunculated  body  attached  close  to  a  healed  depressed 
gap  in  the  rim  of  the  internal  condyle.  As  it  was  certain  that  this  body  could  not  be 
the  offending  one,  the  portion  of  detached  articular  rim  was  only  found  after  a 
prolonged  search  in  the  extreme  upper  end  of  the  suprapatellar  pouch.  The 
patient  made  an  excellent  recovery,  and  resumed  his  work  as  a  South  Eastern  Rail- 
way porter.  This  case  proves  conclusively  that  the  late  Sir  G.  M.  Humphry  was 
wrong  in  his  statement  that  the  articular  cartilages  are  too  strong  and  too  well 
protected  for  any  fragment  to  be  dislodged  save  by  disorganising  violence. 

^  The  following  classification  may  be  useful  to  a  surgeon  about  to  operate  for  one  of 
these  bodies  :  (1)  A  thickened  or  indurated  synovial  fringe  which  has  become  peduncu- 
lated and  perhaps  detached  ;  (2)  a  fibro-enchondroma  originating  in  those  cartilage  cells 
which  are  naturally  found  in  the  synovial  fringes  ;  (3)  a  portion  of  articular  cartilage 
detached  by  injury.  Years  ago  I  removed  one  of  these  loose  bodies  from  the  knee-joint 
of  a  railway  porter  who  came  to  me  for  sj-novitis,  with  the  history  that  the  attacks  dated 
from  the  time  when  a  cask  which  he  was  moving  had  slipped  and  struck  obliquely  the 
inner  side  of  his  right  knee-joint  (Lancet,  1889,  vol.  ii,  p.  36.3)  ;  (4)  a  bit  of  cartilage 
may,  after  injury,  gradually  become  detached  by  a  process  of  quiet  necrosis  (Paget) ; 
(5)  blood  effused  into  a  synovial  fringe  ;  (6)  a  mass  of  fibrine  ;  (7)  a  detached  osteophyte  ; 
(8)  Mr.  H.  Marsh  {Dis.  of  Joints,  p.  182)  mentions  a  case  of  Mr.  Shaw's,  in  which  a  loose 
body  on  removal  was  found  to  contain  the  point  of  a  needle.  I  have  known  a  tarred 
flint  stone  the  size  pi  a  filbert  removed  six  months  after  a  wound  sustained  by  a  fall. 
The  stone  had  caused  no  inconvenence  for  months  until  the  boy  began  to  play  football. 


888        OPERATIONS  ON  THE  LOWER  EXTREMITY 

Where  one  body  has  been  removed  the  surgeon  must  make  certain 
that  no  others  are  present.  Mr.  R.  Jones  ^  thus  emphasises  this  point  : 
"  I  have  on  three  occasions  had  to  open  up  a  joint  a  second  time  to  remove 
bodies  evidently  present  from  the  first.'" 

The  wound  is  closed  with  interrupted  fine  catgut  for  the  capsule  and  a 
continuous  fishing  suture  for  the  skin.  A  massive  sterile  dressing  is  firmly 
bandaged  from  the  middle  of  the  leg  to  the  middle  of  the  thigh  before  the 
tourniquet  is  removed,  or  when  there  is  likely  to  be  oozing,  drainage 
must  be  provided. 

Xo  splint  is  apphed,  but  the  knee  slightly  bent  is  secured  to  a  soft 
enwrapping  pillow  by  a  few  turns  of  bandage.  The  limb  is  elevated  on 
a  wedge  pillow.  On  the  fourth  day  the  outer  part  of  the  dressing  is 
removed,  and  a  looser  bandage  is  applied.  Movements,  both  active  and 
passive,  are  carried  out  and  gradually  increased  from  this  time.  The 
stitches  are  removed  in  a  week,  and  the  patient  is  allowed  to  walk  with 
the  aid  of  a  stick  on  the  tenth  day,  when  flexion  to  the  right  angle  is 
generally  easy  and  painless.  Massage  of  the  knee  and  especially  of  the 
extensors  of  the  knee  is  carried  out  daily  after  the  wound  has  somidly 
healed. 

DETACHMENT   OF   A  FIBRO-CARTILAGE  AND   OTHER  FORMS  OF 
INTERNAL  DERANGEMENTS  OF  THE  KNEE 

Before  the  question  of  operative  interference  is  considered  the  follow- 
ing remarks,  the  outcome  of  exploration  of  nineteen  cases,  may  be 
useful.  I  shall  divide  the  cases  into  two  groups  :  A.  Where  a  fibro- 
cartilage,  far  more  frequently  the  internal,-  has  been  injured,  and  per- 
haps displaced.  B.  Where  other  conditions  are  present.  A.  These 
fall  into  two  classes,  the  typical  and  at^-pical  ones.  (1)  In  the  latter, 
not  infrequently,  though  the  fibro-cartilage  may  have  been  much  in- 
jured, there  is  little  local  external  evidence,  and  it  is  impossible  to  tell 
accurately  what  the  exact  condition  is  ;  at  the  operation,  marked  mis- 
chief is  found.  (2)  Where  a  fibro-cartilage  has  been  undoubtedly  injured, 
it  is  not  alwavs  easv  at  the  time  of  operation  to  be  certain  as  to  the  nature 
of  the  injury.  In  many  cases  where  the  fibro-cartilage  is  detached  at 
either  end,  or  still  attached  but  torn  through  its  centre,  with  one  or 
more  slips  torn  off,  the  mischief  is  obvious.  But  this  is  not  so  in  other 
cases,  e.g.  where  a  fibro-cartilage,  which  there  is  every  reason  to  believe 
to  be  the  cause  of  the  trouble,  is  found  to  be  in  situ.  Here  its  mobihty 
must  be  determined  ;  if  an  aneurysm-needle  can  be  easily  slipped  under 
the  fibro-cartilage  from  end  to  end.  and,  still  more,  if  it  can  be  readily 
hooked  forwards  or  folded  backwards  into  the  joint,  the  indications  for 
its  removal  are  ob\aous — for  I  am  not  an  advocate  of  suture  {see  helow) — 
but  there  are  other  cases  not  so  easily  cleared  up  and  in  which  a  thought- 
ful surgeon  finds  it  difficult  to  be  certain  as  to  the  exact  degree  of  mischief 
present,  and  this  uncertainty  is  increased  by  the  limited  wound  which 

^   Loc.  infra  cif. 

^  The  greater  frequency  of  displacement  of  the  internal  fibro-cartilage  is  due  to  its 
being  more  fixed  and.  therefore,  to  its  feeling  strains  more,  especially  strains  of  the 
internal  lateral  ligament,  as  when  the  flexed  knee-joint  is  suddenly  rotated  outwards.  The 
internal  fibro-cartilage.  in  addition  to  its  attachments  bj-  the  coronan,'  and  transver.se 
ligaments,  is  fastened  all  along  its  convex  border  to  the  inside  of  the  capsule,  and  to  the 
internal  lateral  ligament,  strongly.  The  external  fibro-cartilage,  on  the  other  hand,  is 
more  weakly  attached  to  the  capsule,  especially  opposite  to  the  poplitcus  tendon,  and  has 
no  attachment  to  the  external  lateral  ligament. 


DETACHMENT  OF  A  FIBRO-CARTILAGE  881) 

it  is  usually  advisable  to  make.  One  of  these  is  a  small  semi-detached 
tongue  projoctiiifT  into  the  joint  fioni  the  posterior  third  of  the  internal 
cartilage.  When  the  internal  cartilage  and  synovial  fringes  are  healthy 
the  external  cartilage  may  be  found  loose.  B.  Often  much  less  typical 
cases,  where  other  conditions  than  injury  to  a  fibro-cartilage  are  present. 
Diagnosis  here  is  often  at  fault ;  even  with  the  great  increase  of  these 
operations,  we  are  not  yet  familiar  with  all  the  difTerent  conditions 
which  may  more  or  less  closely  resemble  a  displaced  fibro-cartilage. 
First  of  course  are  the  "  loose  bodies  "'  of  which  I  have  written  at  p.  887. 
These  may  simulate  the  results  of  injury  to  a  fibro-cartilage  very  closely. 
Of  the  other  much  less  obvious  conditions  which  may  cause  pain,  re- 


FiG.  355.     Exploration  of  the  knee-joint  by  dividing  the  patella  vertically, 

thus  all  the  joint  can  be  thoroughly  examined,  and  the  patella  is  made  secure 

by  plate  or  wire  afterwards. 

current  effusion,  perhaps  locking  and  a  more  or  less  defined  swelling, 
and  cripple  the  joint  to  a  varying  degree,  I  shall  mention  a  few 
with  which  I  am  famihar.  Time  will  bring  to  light  others  which  I  have 
overlooked.  When  a  knee-joint  is  opened  and  the  fibro-cartilages  are 
found  to  be  normal  in  position  and  fixity,  where  no  loose  bodv  is  present, 
the  first  condition  to  think  of  is  (a)  an  altered  condition  of  the  synovial 
fringes,  especially  the  pads,  alaria,  and  mucosum. 

I  have  had  three  cases  in  which  I  believed  this  condition  to  be  the  cause  of  the 
trouble.  All  were  yovmg  adults.  In  none  had  locking  been  a  prominent  feature. 
On  exploration  of  the  synovial  rece.ss  between  the  tibia  and  jDatella,  alarge  reddish 
yellow^  fringe  with  its  margin  much  thickened  in  places  was  found.  In  two  of  the 
cases  it  was  easily  shown  that  the  fringe  passed  during  certain  movements  of  the 
joint  between  the  articular  surfaces  of  the  femur  and  tibia.  In  two  of  the  cases 
the  s\Tiovial  membrane  appeared  generally  injected  ;  in  none  of  them  was  any 
effusion  present.  The  fringes  were  cut  away,  a  ligature  being  applied  in  one  case, 
and  drainage  employed.  All  made  good  recoveries,  but  I  have  not  had  the  oppor- 
tunities needful  to  enable  me  to  state  whether  the  results  were  i^ermanently  good. 
Microscopical  examination  showed  an  ordinary  sjmovial  fringe,  chronicallj'  inflamed 


890        OPERATIONS  ON  THE  LOWER  EXTREMITY 

and  with  ecchymoses  of  different  dates.  Prof.  Annandale,  who  did  most  useful 
pioneer  work  in  the  removal  of  displaced  fibro-cartilages,  was,  I  believe,  the  first 
to  call  attention  to  these  bodies.^  Dr.  C.  P.  Flint,  of  New  York,  has  recorded  three 
cases  in  which  he  operated.^     Excellent  illustrations  accompany  the  paper. 

Mr.  R.  Jones,  of  Liverpool  {infra,  p.  891),  writes  :  "  Hypertrophy  of 
the  synovial  villi  is  frequently  confused  with  a  damaged  semilunar. 
The  condition  is  much  more  common  than  is  usually  suspected,  and  I 
have  frequently  met  with  it  when  exploring  joints."  On  one  occasion, 
failing  to  find  any  injury  to  the  semilunar  in  a  case  with  typical  symptoms, 
Mr.  Jones,  on  enlarging  his  incision,  found  a  ligamentum  alarium  actually 
detached  and  lying  in  the  intercondyloid  notch.  Its  removal  resulted 
in  a  perfect  recovery. 


\^^ 


Fig.  356.     Removal  of  detached  internal  semilunar  cartilage.     A  vertical  in- 
cision 3  inches  long  is  made,  1  incli  internal  to  the  ligamentum  patellae.     The 
tourniquet   is  alwaj's   used,  and  nothing    but  instruments  arc   placed  in  the 
wound  or  knee-joint. 

{b)  While  the  semilunar  cartilage  is  normal  in  position  and  its  attach- 
ments, it  has  been  bruised,  and  the  adjacent  head  of  the  tibia  is  the 
seat  of  osteitis  and  periostitis,  (c)  The  parts  are  normal  save  perhaps 
for  some  injection  of  the  synovial  membrane.  While  making  due 
allowance  for  my  faulty  diagnosis  and  the  limited  access  for  exploration, 
T  am  convinced  that  such  cases  do  occur  in  neurotic  patients,  as  in  some 
other  conditions  submitted  to  frequent  operation  at  the  present  day. 
On  this  subject  and  the  varied  causes  of  recurrent  effusion  into  the  knee- 
joint,  my  readers  should  consult  a  most  instructive  article  by  Sir  W. 
Bennett,  K.C.V.O.'''  Before  leaving  this  part  of  my  subject  I  will  add 
two  cautions,  one,  that  in  cases  where  only  injection  and  other  slight 
changes  in  the  synovial  membrane  are  all  that  can  be  found  it  will  always 
be  well  to  bear  in  mind  the  possibility  of  early  tuberculosis,^  which  com- 
monly begins  in  the  synovial  membrane  near  the  internal  cartilage.     The 

1  Brit.  Med.  Journ.,  1887.  vol.  i,  p.  320. 

~  Ann.  of  Surg.,  September  1905,  p.  4-15.  ^  Lancet,  January  7,  1905. 

*  I  refer  especially  to  those  cases  where  the  synovial  membrane  is  found  generally 
injected,  and  some  effusion  is  present.  It  is  noteworthy  that  in  one  of  Dr.  Flint's  cases 
the  fringe  removed  showed  the  existence  of  tuberculosis.  A  generally  villous  or  pajiillary 
synovitis  would  be,  obviously,  most  suspicious. 


DETACHMENT  OF  A  FIBRO-CARTILAGE  891 

other  is  one  to  which  I  have  drawn  attention  at  p.  887.  This  operation, 
especially  if  followed  by  stiffness  and  the  treatment  necessary  to  meet 
this  condition,  may  lifrht  up,  especially  in  patients  no  longer  young,  a 
tendencv  to  ostco-artlii'itis. 

Indications  for  Operation.  The  chief  of  these  are:  (1)  Confidence 
on  the  part  of  the  surgeon  that,  as  regards  both  himself  and  the  patient, 
he  can  secure  an  aseptic  result  throughout ;  (2)  failure  of  palliative 
treatment,  especially  in  recurrent  cases  ;  (3)  cases  of  especial  expediency, 
e.g.,  where  the  employment  entails  especial  risks,  where  the  patient  is 
likely  to  be  remote  from  surgical  aid,  or  where  a  future  career  or  some 
particular  pursuit  will  be  interfered  with.  Thus  in  a  case  of  Mr.  F.  J. 
Steward's — ■ 

The  patient — a  student— had  suffered  for  over  seven  years  from  repeated  dis- 
placement, latterly  brought  about  by  quite  trivial  movements,  such  as  stepping 
oif  a  kerb.  The  operation  was  performed  in  August  1900  ;  the  cartilage,  which  had 
been  completely  torn  from  its  anterior  attachments,  being  removed.  In  January 
1902  the  patient  was  playing  football  regularly,  and  did  not  notice  the  slightest 
difference  between  his  two  knees. 

Mr.  R.  Jones,  of  Liverpool,  gives  the  indications  for  operation  better 
thus  :  "In  the  first  place,  I  refuse  to  operate  in  any  case  I  see  early, 
the  subject  of  a  first  derangement.  I  discourage  operation  in  those 
recurrent  cases  where  the  symptoms  are  transient  and  not  followed 
by  irritation  of  the  joint.  I  strongly  urge  operation  in  those  cases  where 
a  recurrent  displacement  is  at  times  followed  by  acute  symptoms.  I 
advise  it  in  all  recurrent  cases  where  a  strenuous  athletic  fife  is  a  means 
of  liveUhood  or  a  physical  necessity.  I  think  operation  absolutely 
imperative  in  the  case  of  men  who  work  in  dangerous  places."  As  "of 
two  cases,  carefully  watched,  each  refusing  operation,  one  resulted  in 
rheumatoid  and  the  other  in  tubercular  change,"  Mr.  Jones  ad^dses 
"  that  this  danger  should  be  kept  well  in  view,  and  that  patients  with 
either  a  tubercular  or  rheumatoid  diathesis  subject  to  recurrent  derange- 
ment should  early  be  persuaded  to  have  the  exciting  cause  removed." 

Mr.  Jones's  paper  ^  is  well  worthy  of  a  most  careful  study  from 
the  writer's  well-known  experience,  proved  at  many  points  by  the 
lucid  practical  details,  especially  where  he  is  deahng  with  the  difficulties 
which  at'e  present  in  the  diagnosis  and  treatment  of  "certain  derange- 
ments of  the  knee." 

Operation  for  loose  internal  semilunar  Cartilage.  The  area  ha\ang 
been  carefully  sterilised  and  the  strictest  precautions  taken  in  every 
way,  and  a  tourniquet  applied  very  tightly  round  the  middle  of  the 
thigh,  a  vertical  incision  is  made  nearly  three  inches  long,  three-quarters 
of  an  inch  from  the  inner  border  of  the  patella,  downwards  over  the 
interval  between  the  femur  and  tibia.  If  necessary,  the  incision  can 
be  prolonged  upwards  or  downwards  and  the  capsule  may  be  nicked 
horizontally  backwards  as  far  as  the  strong  and  definite  internal 
lateral  hgament.  The  reason  for  placing  the  incision  at  the  above- 
mentioned  distance  from  the  patella  is  explained  later ;  the  most  im- 
portant internal  lateral  ligament  is  to  be  interfered  with  as  httle  as  possible. 
The  capsule,  together  with  the  sjmovial  membrane,  is  now  incised  in  the 
same  line.  The  condition  of  the  fibro-cartilage  is  now  investigated,  with 
the  joint  flexed  and  extended.  Many  of  the  various  degrees  of  damage 
which  it  may  have  received  and  several  of  the  other  conditions  which 

1  Clin.  Journ.,  May  9,  1906. 


892         OPERATIONS  ON  THE  LOWER  EXTREMITY 

may  be  present  have  already  been  alluded  to.  Where  the  fibio-caitilage 
is  much  damaged  its  removal  is  of  course  indicated  by  dragging  it  for- 
ward with  strong  toothed-forceps,  and  snipping  it  away  with  curved 
blunt-pointed  scissors.  A  tenotomy  l^nife  is  veiy  useful  to  free  the 
posterior  part  of  the  ligament.  Where  its  condition  is  more  doubtful,^ 
i.e.  where  it  is  only  partially  frayed,  I  am  of  opinion  that  its  removal 
is  the  wisest  step.  In  cases  of  doubt  the  longitudinal  incision  must  be 
converted  into  a  flap,  or  a  second  incision  made  on  the  opposite  side. 
Attempts  to  suture  the  fibro-cartilage  are  never  advisable.  This  pro- 
cedure is  difficult  :  the  sutures  are  very  likely  to  give  way,-  and  the  more 
prolonged  rest  now  needed — three  or  four  weeks  instead  of  ten  days — 
will  very  likely  lead  to  after- stiffness.  The  interval  between  the  condyles 
is  always  carefully  examined  for  loose  body ;  a  good  light  is  essential 
for  this,  and  the  tourniquet  by  providing  a  clear  field  is  invaluable.  The 
wound  is  dealt  with,  and  the  after-treatment  conducted,  as  indicated  at 
p.  885.  Suture  of  the  capsule  with  separate  buried  sutures  of  fine  catgut 
is  most  important  here  :  it  promotes  early  union  of  the  deep  parts  of 
the  wound,  thus  at  once  facilitating  the  regaining  of  movements,  and 
shutting  out  the  risk  of  after-infection.  For  the  insertion  of  these  sutures 
the  capsule  must  not  be  divided  close  to  the  patella,  or  there  will  be  no 
edge  to  take  up. 

The  case  that  follows  illustrates  the  liability  of  clamps  to  fail  sud- 
denly after  a  prolonged  period  of  usefulness,  and  the  presence  of  osteo- 
arthritis, in  a  very  marked  degree,  in  a  young  subject. 

R.  C,  aged  35,  had  had  repeated  displacement  of  his  left  fibro-cartilage  since 
a  wrench  of  his  knee  when  17  years  old.  A  clamp  gave  great  relief  for  some  time, 
but  latterly  this  ceased  to  be  any  safeguard.  In  April  1894  I  opened  the  knee- 
joint  by  a  vertical  incision  three  inches  long,  placed  about  an  inch  from  the  inner 
margin  of  the  patella,  and  begiiming  opposite  its  centre.  The  first  thing  to  come 
into  view  when  the  joint  was  opened  was  the  inner  condyle,  with  its  margin  con- 
verted into  a  huge  lip,  everted  and  raised  and  covered  with  a  network  of  many 
minute  vessels.  The  head  of  the  tibia,  as  far  as  seen,  presented  the  same  appear- 
ance along  its  articular  rim.  The  internal  fibro-cartilage  was  found  detached  from 
its  connections  to  the  tibia  and  carried  up  with  the  femur.  It  was  thin,  flaccid, 
and  limp,  flattened  out,  its  circumferential  border  having  lost  its  thickness  and 
convexity.  No  bleeding  followed  on  snipping  through  its  posterior  attachments. 
The  "lipping"  of  the  cartilage  on  the  femur  and  tibia  was  rounded  off  with  a  meta- 
carpal saw,  some  sessile  growths  of  the  synovial  membrane  were  snipped  away,  and 
two  small  osteophytes  removed  from  the  articular  surface  of  the  patella.  The 
imier  aspect  of  the  joint  was  carefully  dried  out  with  aseptic  sponges,  and,  as  much 
oozing  was  expected  from  the  sa^vn  surfaces,  a  drainage-tube  was  passed  into  the 
upper  cul-de-sac  and  brought  out  through  the  wound.  The  wound  healed  quickly; 
a  month  later  the  jiatient  could  walk  across  Hyde  Park,  but  it  was  not  till  nearly 
six  months  after  the  operation  that  flexion  and  extension  were  completely  restored, 
and  the  patient  could  say  that  there  was  "not  much  to  choose  between  the  two 
knees."  I  saw  him  five  years  after  the  operation  ;  he  could  then  use  the  lower 
limbs  with  equal  freedom,  and  the  movements  of  the  left  knee  were  quite  smooth. 
He  was  able  to  walk,  ride,  and  shoot  with  entire  comfort. 

In  closing  this  subject  I  cannot  do  better  than  quote  Mr.  Jones's 
article  ^  on  the  possibility  of  failure  of  operation  :    "Is  operative  treat- 

1  In  all  doubtful  cases,  Mr.  Jones's  advice  (p.  893)  must  be  remembered  as  to  the 
possibility  of  more  than  one  mechanical  factor  existing  in  a  joint. 

2  Mr.  M.  MouUin  [Lancci.  1895,  vol.  i,  p.  1233)  mentions  two  cases  in  which  the  dis- 
placement recurred  after  suture.  In  his  words,  "  sutures  and  adhesions  cannot  make 
it  stronger  than  it  was  before  it  was  hurt,  unless  they  fix  it  so  that  it  is  completely  rigid  ; 
and  if  it  gave  way  before,  it  will  give  way  all  the  more  easily  a  second  time  if  exposed  to 
a  similar  strain." 

2  Loc.  supra  cit.,  p.  976. 


DETACHMENT  OF  A  FIHRO  CARTILAGE  893 

raent  invariably  successful  ?  The  answer  is  emphatically,  No.  In  the 
great  majority  of  cases  a  perfect  recovery  may  be  predicted  ;  in  a 
certain  small  percentage  the  symptoms  recur.  The  recurrences  were 
far  more  numerous  some  few  years  hack,  when  the  cartilages  were  sewn 
to  their  tibial  attachments."'  In  other  cases  "  it  will  be  discovered  that 
the  so-called  recurrence  is  due  to  an  overlooked  accessory  factor  in  the 
production  of  the  symptoms  of  derangement."  Mr.  R.  Jones  illustrates 
this  by  two  cases  : 

In  one  the  anterior  half  of  a  torn  external  semilunar  had  been  removed.  Slipping 
again  oeeuircd  within  a  month,  and,  on  opening  the  joint  on  it.s  inner  side,  Mr. 
Jones  found  a  small  librous  nodule  floating  bj^  a  thin  pedicle. 

In  the  other  ease  the  anterior  part  of  the  internal  semilunar  had  been  found 
abnormally  free  and  removed.  For  some  niont  hs  normal  function  reniained  restored. 
The  troubles  then  reappeared,  with  pain,  referred  again  to  the  inner  side  of  the 
joint.  "  1  followed  the  line  of  the  old  scar  and  searched  for  a  cause.  I  was  almost 
closing  the  wound,  when  internal  rotation  of  the  tibia  dislodged  a  loose  body." 

Operation  for  loose  external  semilunar  Cartilage.  A  similar  incision 
is  made  over  the  outer  side  of  the  joint,  and  the  subsequent  steps 
are  similar  to  those  already  described. 


CHAPTER  XLIII 

LIGATURE  OF  ARTERIES  IN  THE  POPLITEAL  SPACE 

AND  LEG 

LIGATURE  OF  THE  POPLITEAL  ARTERY. 

Indications.  Extremely  few.  (i)  Stab  or  punctured  wound.  Here  the 
surgeon  would  only  resort  to  ligature  ( 1 )  if  pressure  was  unsuitable  ; 
(2)  if  suture  (p.  50)  was  found  impossible  ;  (3)  if  the  patient  insisted 
on  running  the  risk  of  gangrene  ;  (-i)  it  would  be  well,  if  possible,  to 
get  leave  for  immediate  amputation  if  the  vein  was  found  injured  also, 
and  beyond  remedy  by  suture,  (ii)  In  some  cases  of  ruptured  popHteal 
artery  it  will  be  right  to  explore  and  see  if  any  other  complication  exist 
beyond  the  rupture  of  the  artery.  If  there  is  no  injury  to  the  vein, 
nerves,  or  the  joint  (a  very  unlikely  contingency),  the  rupture  should 
be  treated  by  Murphy's  method  of  resection,  if  possible,  and,  this 
failing,  by  double  ligatures.  The  surgeon  must  afterwards  be  prepared 
to  amputate  through  the  lower  third  of  the  thigh  on  the  first  sign  of 
gangrene  appearing.  The  operation  of  ligature  of  the  popliteal  artery 
is  extremely  difficult  here,  owing  to  the  depth  of  the  vessel,  the  strong 
fascia,  the  amount  of  coagulated  blood,  and  the  infiltrated,  obscured 
condition  of  the  parts.  Primary  amputation  will,  as  a  rule,  be  required 
in  cases  of  ruptured  pophteal  artery,  especially  where  skilled  assistance 
and  facihties  for  aspectic  treatment  are  not  at  hand.  A  free  incision 
will  enable  the  surgeon  to  investigate  the  amomit  of  injury,  and  at  the  same 
time  will  reheve  tension  if  an  attempt  be  made  to  save  the  hmb.  This 
incision  may  form  part  of  the  amputation  (p.  862).  (iii)  The  artery 
has  been  wounded  in  the  course  of  an  osteotomy  of  the  lower  end  of  the 
femur,  (iv)  Traumatic  aneurysm  in  the  upper  third  of  the  leg  after 
gunshot  wound.  The  writer  recently  had  a  very  successful  case  of  this 
nature. 

Extent.  From  the  opening  in  the  adductor  magnus  to  the  lower 
border  of  the  popUteus. 

Guides.  Behind  :  A  hue  drawn  from  just  inside  the  inner  ham- 
strings above  to  the  centre  of  the  lower  part  of  the  pophteal  space.  In 
front :  The  tendon  of  the  adductor  magnus. 

Relations  (in  the  popliteal  space)  : 

Behind 
Skin ;     fasciae ;     small    sciatic    nerve    above ;     short 
saphena  vein  and  external  saphena  nerve  below ; 
fat ;    glands. 
Semi-membranosus    above ;       gastrocnemius       plan- 
taris,  soleus,  below. 

894 


LIGATURE  OF  THE  POPLITEAL  ARTERY        895 

Internal  ])()j)liteal  nerve  ;  popliteal  vein,  outside 
above,  inside  below,  exactly  over  the  artery  in 
the  centre  of  the  space. 

Blanch  of  obturator  above. 

Outside  Inside 

Biceps  above  ;    fiastrocneniius  Semi-membranosus    above  ; 

and  plantaris  below.  gastrocnemius  below. 

Popliteal  aftery. 

/n  Front 
Femur. 

Posterior  ligament. 
Pophteus. 

Collateral  Circulation. 

Above  Below 

Anastomotica  magna,  supe-  with  Inferior  articular,  and  re- 

rior  articular,  descending  current     from     anterior 

branch    of    external   cir-  tibial, 

cumfiex. 

Operations.  The  artery  may  be  tied  in  three  places.  A.  At  the 
upper  part  of  the  popliteal  space.  B.  At  the  lower  part  of  the 
popliteal  space.  Q\  At  the  inner  side  of  the  limb.  For  the  sake 
of  experience,  all  should  be  practised  on  the  dead  body. 

A.  At  the  Upper  Part  of  the  Popliteal  Space.  The  patient  being 
rolled  two-thirds  on  to  his  face,  and  the  Hmb  at  first  extended,  a  free 
incision  three  inches  and  a  half  long  is  made,  in  the  line  of  the  vessel, 
along  the  outer  margin  of  the  semi-membranosus,  and  then  downwards 
and  outwards  to  the  centre  of  the  space.  The  small  sciatic  nerve,  if 
seen,  should  be  drawn  to  one  side  ;  the  deep  fascia  is  then  freely  opened 
up,  and  the  pulsation  of  the  artery  felt  for  at  the  outer  margin  of  the 
semi-membranosus.  The  nerve  is  generally  seen  first,  and  this  and  the 
vein  are  to  be  drawn  to  the  outer  side  with  blunt  hooks.  The  needle 
should  be  passed  from  the  vein.  A  good  deal  of  loose  fat  is  usually 
in  close  contact  w^ith  the  vessels,  and  is  liable  to  be  a  source  of  trouble 
wherever  the  artery  is  ligatured,  especially  in  the  dead  subject. 

B.  At  the  Lower  Part  of  the  Popliteal  Space  (Fig.  357).  The  hmb 
being  in  the  same  position,  an  incision  four  inches  long  is  made,  in  the 
line  of  the  artery,  from  the  centre  of  the  pophteal  space  to  the  jvmction 
of  the  upper  and  middle  thirds  of  the  back  of  the  leg.  The  external 
saphena  vein  and  its  nerve  being  avoided,  the  deep  fascia  is  freely  opened 
and  the  limb  flexed.  The  exact  interval  between  the  heads  of  the 
gastrocnemius  is  next  sought  for.  The  following  structures  may  now  be 
met  with  overlying  the  artery,  and  must  be  draw^n  aside,  viz.  the 
plantaris,  the  sural  arteries  which  run  down  on  the  vessel,  and  the  com- 
municans  tibialis  nerve.  The  popliteal  vein  now  lies  to  the  inner  side, 
together  with  the  pophteal  nerve,  which  is  superficial  to  it,  if  this  has  not 
given  off  its  branches.  These  structures  should  be  drawn  to  either  side, 
and  the  needle  passed  as  is  convenient. 


896  OPERATIONS  ON  THE  LOWER  EXTREMITY 


SKT  SAPH£/iOUS    V. 


COMMUfilC-^MS      TIBIALIS 


Fig.  357.     Ligature  of  the  popliteal  artery  from  behind. 


POPLITE/^L     ^. 


/IDD.  /1/I6NUS    TENDON 


Fig.  358.     Relation  of  parts  in  ligature  of  the  popliteal  from  the  inner  side. 


LIGATURE  OF  THE  POPLITEAL  ARTERY  897 

C.  At  the  Inner  Side  (Fig.  358).  This  operation  might  be  useful 
in  cases  where  haemorrhage  recurs  after  osteotomy  at  the  lower  end 
of  the  femur. 

The  following  account  is  taken  from  Sir  Wm.  MacCormac  :  ^  "  Flex 
the  knee  and  place  the  limb  on  the  outer  side.  Make  an  incision  three 
inches  long  immediately  behind  and  parallel  to  the  tendon  of  the  adductor 
magnus  downwards  from  the  junction  of  the  middle  and  lower  thirds  of 
the  thigh.  Divide  the  skin,  superficial  and  deep  fascise  ;  avoid  the  long 
saphenous  nerve  ;  seek  the  tendon  of  the  adductor  magnus  ;  draw  it 
forwards  and  the  hamstring  tendons  backwards.  The  artery  will  then 
be  found  surrounded  by  fatty  areolar  tissue.  The  nerve  and  vein  do  not 
necessarily  come  into  view,  being  on  the  external  aspect  of  the  vessel." 

For  an  account  of  Mata^'s  operatio:i  for  aneurysms,  see  p.  53. 

^  Ligature  of  Arteries,  p.  110. 


SUKOF.RV  1 


57 


CHAPTER    XLIII   (continued) 

OPERATIONS   ON    THE    LEG 

LIGATURE  OF  THE  POSTERIOR  TIBIAL  ARTERY 

Indications.  Very  few.  (i)  Chiefly  wounds.  Mr.  Cripps,^  in  a  very  valuable 
pafK-r.  cli%ides  the  sources  of  hsemorrhage  from  the  upper  two-thirds  of  the  posterior 
tibial  into  (1)  hsemorrhage  after  amputation  ;  (2)  hsemorrhage  from  injury  to  the 
vessels  in  continuity.  (I)  Hsemorrhage  after  amputation.  This  i.s  usually  due 
to  a  diseased  condition  of  the  vessels,  and  to  the  fact  that  the  ves.sels  lying  between 
the  bones  are  now  especially  difficult  to  take  up.  If  from  their  con>stantly  breaking 
away  it  is  found  impossible  to  deal  with  them,  the  limb  should  at  once  be  amputated 
above  the  knee.  If  the  hsemorrhage  occurs  later  on,  well-adjasted  pressure  (p.  843) 
should  be  carefulh'  tried,  aided  or  followed  by  ligature  of  the  femoral  or  by  amputa- 
tion liigher  up.  (2)  Haemorrhage  from  wounds  of  the  tibials  in  continuity.  Three 
chief  causes  may  lead  to  this  :  (a)  An  incised  wound,  (h)  A  punctured  wound. 
(c)  Wounds  other  than  punctured  or  incised.  Four  methods  of  treatment  are  open 
to  the  .surgeon,  viz.  (a)  Pressure  and  bandaging,  (h)  Ligature  of  both  ends  of  the 
vessel,  (c)  Ligature  of  the  femoral,  (d)  Amputation,  (a)  Incised  Wound.  If 
this  is  seen  soon  after  its  infliction,  the  bleeding-point  should  be  sought  for  and  tied, 
the  wound  being  enlarged  if  needful.  If  sloughing  and  extravasation  of  blood 
have  taken  place,  amputation  will  probaVjly  be  the  wLser  course,  though,  if  the 
patient  decide  to  run  the  risk,  an  attemjit  may  be  made  to  save  hLs  limb  by  making 
free  incisions,  providing  drainage,  plugging  the  wound  (rendered,  as  far  as  may  be, 
aseptic  -with  irrigation  and  iodoform)  ^vith  aseptic  gauze,  bandaging  evenly  and 
firmly,  and  tying  the  femoral  in  Hunters  canal,  {h)  Punrlured  Wound.  If  this 
is  deep,  and  the  vessel  injured  uncertain,  the  question  of  treatment  is  a  very  serious 
one.  Mr.  Cripps  shows  that,  in  the  majority  of  instances,  pressure  deserves  a  fair 
and  thorough  trial.  If  it  is  useless,  or  prejudicial  to  other  treatment,  either  the 
femoral  mast  be  tied,  or  the  wound  enlarged  to  secure  the  wounded  vessel.  Between 
these  operations  the  features  of  the  particular  case  must  decide.  If  pre.s.sure  is 
made  use  of,  it  should  be  applied  methodically  and  with  intelligent  purpose,  and 
so  that  it  needs  no  alteration  or  repetition,  (c)  Wounds  other  than  Punrtured  or 
Incised,  viz.  Injury  to  the  Vessel  from  Fracture  or  Gunshot  Wound.  In  many  ca.ses 
conditions  will  be  present  which  will  call  for  amputation,  ^^z.  the  severity  of  the 
crush  ;  the  extent  of  the  comminution  ;  injure*  to  the  nerves  or  to  both  arteries, 
as  evidenced  by  the  condition  of  the  foot ;  and  the  age  or  the  vitality  of  the  patient. 
In  most  of  these  ca.ses,  as  an  attempt  to  find  the  vessel  involves  great  difficulty  and 
danger,  and  the  probabilities  of  success  diminish  as  the  interval  between  the  in- 
fliction and  treatment  of  the  injury  increases,  ligature  of  the  fejuoral  would  be 
less  hazardous  than  anj"  interference  with  the  wound.  But  amputation  will  frequently 
be  needed.  The  above  remarks  apply  to  compound  fracture-s  ;  an  instance  of 
8ucces.sful  ligature  of  a  lacerated  femoral  co-existing  with  a  compound  fracture 
of  the  leg  is  given  at  p.  839.  (u)  Small  traumatic  aneurysms,  (iii)  The  posterior 
tibial  may  be  tied  low  down,  together  mth  the  dorsalis  pedis,  for  certain  wounds  of 
the  sole  or  for  some  valscular  growths  of  the  foot. 

■S'.'.  Birl.  Hasp.  Reports,  vol.  xi,  p.  94  ;  Dirt  of  Surg.,  vol.  ii,  p.  626. 

898 


LIGATITRK  OF  POSTKRTOH  TIBTAI.  ARTERY       890 

Line  and  Guide.  X  line  diawii  Iroiii  u  point  at  the  lower  part  of  tlie 
centre  of  tlie  ])()])Iiteal  space  to  our  midway  between  the  tendo  Achillis 
and  the  iuteinid  inalleohis. 


antehio^    r/eiAL   /iEcuKKMffr- 


POST£AtlOR       T/Bl^i. 


POP-Lir^/^L 


/9NTERJOR.     T/BIAL. 
fOST£Ji>OK.    nB//iL    K£CU/{fi£HT 


xSUPEK'OJZ  r/BUlj^R. 


PER.OM£yiL. 


/NT£KJ^/tL    M/)LL£Oty9R.-  - 

POST.  /NT£RNAL     /^^lL£OJ.AR.--\- 

/f^T£RH^L     PL^ihlT/iR, 

£XT£KN/U.      PLAi/^T/^JZ. 

SCAPHOJD     BOHE. ■ 


/^Nr£P.IOK.    PERONEAL. 
POSTEfVOR.   PEKOHEj^L. 

COMMUNt  C/9  TfNG 


-EyfTERH/^l.    M/^LLEOISR. 


■^S  rPiy^0,^J.  US 


EMTE/SN/il.    C^t.<:y^N£j^N  £R/iNCH 


-C/^±CSNEUM 


Fig.  359.     Arteries  of  the  leg. 

Relations.      These    differ    according    as    the  vessel  is  tied :    A,   in 
the  middle  of  the  leg  ;  B,  in  the  lower  third  of  the  leg ;  C,  at  the  inner 
ankle. 
SURGERY  I  57' 


900       OPERATIONS  OX  THE  LOWER  EXTREMITY 

A.  Relations  in  the  Middle  of  the  Leg  : 

Superficial 

Skin  ;  fascise.;  branches  of  saphenous  veins  and  nerves. 
Gastrocnemius  ;   soleus  ;   plantaris. 
Special  fascia  ;   transverse  branches  of  venae  comites  ; 
tendinous  origin — arch — of  soleus  (above). 


Outside 

Vena  comes. 

Posterior  tibial  nerve 
which  has  crossed 
above  from  the 
inner  side. 


Posterior  tibial. 


Beneath 


Inside 
Vena  comes. 
Posterior  tibial  nerve 
(above). 


Flexor  longus  digitorum. 
Tibiahs  posticus. 

B.  Relations  in  Loiver  Third  of  Leg  : 

Swperficial 
Skin    fasciae  ;  superficial  veins  and  nerves. 


Outside 
Vena  comes. 
Posterior  tibial  nerve. 
Tendo  Achillis. 


Inside 
Vena  comes. 


Posterior  tibial. 


Beneath 


Flexor  longus  digitorum. 
Tibia. 


C.   Relations  at  Inner  Ankle  : 

Superficial 

Skin ;     fasciae ;     branches   of   internal   saphena   vein 

and  nerve. 
Internal  annular  ligament. 


Outside 
VensL  comes. 
Flexor  longus  hallucis. 
Posterior  tibial  nerve. 


Posterior  tibial. 

Beneath 
Internal  lateral  ligament. 


Inside 

Vena  comes. 

Flexor  longus  digi- 
torum ;  tibialis 
posticus. 


Operation  in  Middle  of  Leg  (Fig.  360).  The  parts  having  been 
sterilised,  the  knee  flexed,  and  the  limb  supported  on  its  outer  side,  the 
surgeon,  standing  or  sitting  on  the  inner  side,  makes  an  incision  three 


LIGATURE  OF  POSTERIOR  TIBIAL  ARTERY       901 

and  a  half  inches  long,  parallel  with  the  centre  of  the  iniicr  border  of  the 
tibia,  and  half  or  three-quarters  of  an  inch  l)eiiind  it,  according  to  the 
size  of  the  lind).     This  incision  divides  skin  and  fascia>.     If  the  internal 
saphenous  vein  is  met  with,  it  nuist  be  drawn  aside  ;   any  of  its  branches 
may  be  divided  between  two  ligatures.     The  deep  fascia  is  then  freely 
slit  up,  and  the  inner  edge  of  the  gastrocnemius  defined  and  drawn  back- 
wards. This  will  expose  the  soleus,  the  tibial  attachment  of  which  is  to 
be  cut  through,  any  sural  artery  being  at  once  secured.     The  incision 
through    the    soleus    (Fig.    3(50) 
should  be  three  inches  long  and 
quite  half  an  inch  from  the  tibia  ; 
as  the  fibres  are  divided,  the  cen- 
tral membranous  tendon  will  come 
into  view,  and  must  not  be  con- 
fused with  the  special  deep  fascia 
or  intermuscular  septum  over  the 
deep  flexors.    Usually,  before  this 
comes  into  view,  some  additional 
fibres  have  to  be  divided.   When 
this  is  done,   the  above   special 
fascia  must  be  identified,  stretch- 
ing between  the  bones  {see   Fig. 
360).     The  wound  must  be  care- 
fully dried,  well  opened  out  with 
retractors,   and  exposed  with    a 
good  light  at   this    stage       The 
deep   fascia   being   opened   care- 
fully,  the    nerve    usually   comes 
into  view  first,  the  artery  lying 
a  little  deeper  and  more  external. 
The    vense    comites     should    be 
separated  as  far  as  possible,  but 
rather  than    puncture  them  and 
cause   haemorrhage  at  this  stage, 
or  waste  time,  the  surgeon  should 
tie  them  in       The  needle  should 
be  passed  from   the  nerve.      To 
facilitate    this,   the   knee  should 
be  well  flexed,  and  the  foot  also 
flexed  downwards  so  as  to   relax 

the    muscles   thoroughly.      The   ligature   will    lie   below    the    peroneal 
artery. 

Operation  in  Lower  Third  of  Leg.  The  limb  and  the  operator  being 
in  the  same  position  as  before,  an  incision  two  and  a  half  inches  long 
is  made  through  skin  and  fasciae,  parallel  with  the  inner  border  of 
the  tibia,  and  midway  between  it  and  the  tendo  Achilhs  ;  after  the 
deep  fascia  has  been  opened  another  layer,  tying  down  the  deep  flexor 
tendons,  will  require  division.  The  artery  here  lies  between  the  flexor 
longus  digitorum  and  pollicis,  surrounded  by  venas  comites.  The  needle 
should  be  passed  from  the  nerve,  which  hes  to  the  outer  side.  If  the 
incision  is  made  too  high,  some  of  the  lowest  fibres  of  the  soleus  will 
require  detaching  from  the  tibia  ;  if  too  low,  the  internal  annular  ligament 
would  be  opened.     The  sheaths  of  the  flexors  (their  synovial  investment 

SURGERY  I  57" 


Fig.  360.  Ligature  of  the  posterior  tibial 
at  middle  of  the  leg.  The  soleus  is  divided 
and  retracted  and  the  transverse  deep 
fascia  is  opened  to  display  the  arterj^  and 
its  relations. 


902       OPERATIONS  ON  THE  LOWER  EXTREMITY 

commences  about  an  inch  and  a  half  above  the  internal  malleolus)  should 
not  be  interfered  with. 

Operation  at  the  Inner  Ankle  (Fig.  361).  The  limb  and  operator 
being  placed  as  before,  a  curved  incision,  two  inches  long,  is  made,  three- 
quarters  of  an  inch  behind  the  internal  malleolus.  Skin  and  fasciae  being 
divided,  any  branches  of  the  internal  saphena  vein  tied,  the  internal 
annular  ligament  is  divided,  and  the  artery  found  closely  surrounded  by 
its  veins.  The  nerve  lies  externally,  and  the  needle  should  be  passed 
from  it.  The  artery  is  so  superficial  here  that  the  veins  can  be  easily 
separated.     The  nerve  has  occasionally  bifurcated  higher  up. 


Fig.  361. 

LIGATURE  OF  THE  ANTERIOR  TIBIAL 

Indications.  These  are  very  few,  and  resemble  so  closely  those 
already  given  for  the  posterior  tibial,  viz.  wounds  and  traumatic 
aneurysm,  that  there  is  no  need  to  go  into  them  again  here. 

Line  and  Guide.  From  a  point  midway  between  the  head  of  the 
fibula  and  the  outer  tuberosity  of  the  tibia  to  the  centre  of  the  front  of 
the  ankle-joint ;   the  outer  edge  of  the  tibiahs  anticus. 

Relations : 

Superficial 
Skin ;     fascia3 ;     cutaneous    branches    of    saphenous 
veins  and  nerves,   and   (below)   musculo-cutaneous 
nerve. 
Tibilalis     anticus     and     extensor    longus    digitorum 

(above),  overlapping. 
Tibialis  anticus  and  extensor  longus  hallucis  (below) 
overlapping. 


LIGATURE  OF  THE  ANTERIOR  TIBIAL 


903 


Inside 
Tibialis  anticus. 
Vein. 


Outside  Anterior  tibial  artery. 

Extensor  longus  digitoruni  (above). 
Extensor  longns  hallucis  (below). 
Anterior  tibial  nerve. 
Vein. 

Beneath 

Interosseous  membrane. 

Operation  at  the  Junction  of  the  Upper  and  Middle  Thirds  of  Leg. 

The   knee   being   flexed   and   the    limb   supported  uixjn  its  inner  side, 


/INT.   TI3I/IL.    >;. 


Fig.  362.     Ligature  of  the  anterior  tibial  artery  at  the  junction  of  the  m 

and  upper  thirds. 


iddle 


the  surgeon  having  defined,  if  possible,  the  outer  edge  of  the  tibialis 
anticus,'^  sits  or  stands  on  the  outer  side  of  the  patient,  and  makes 
an  incision  about  four  inches  long  in  the  line  of  the  artery,  beginning 
about  two  inches  below  the  head  of  the  tibia.  This  incision  should  lie 
(if  the  edge  of  the  muscle  has  not  been  marked  out)  three-quarters  to 
one  inch — according  to  the  size  of  the  leg — from  the  crest  of  the  tibia, 
and  should  expose  the  deep  fascia   carefully,  so   that   the  white  line 

1  The  patient  may  put  this  into  action  just  before  the  anaesthetic  is  taken. 


904       OPERATIONS  ON  THE  LOWER  EXTREMITY 

which  marks  the  desired  intermuscular  septum  may  be  looked  for.  This 
line  is  often  whitish-yellow,  and  varies  much  in  distinctness  If  there 
is  any  difficulty  in  finding  it,  any  bleeding-points  must  be  secured  and 
the  deep  fascia  slit  up  over  the  line  of  the  artery,  and  the  finger-tip 
inserted  to  feel  for  the  sulcus  between  the  muscles.  A  third  aid  is  almost 
constant,  and  that  is  a  small  muscular  artery  ^  which  comes  up  between 
the  tibialis  gnd  the  extensor  longus  digitorum.  The  sulcus  being  found 
between  the  muscles  (without  tearing  them),  they  are  separated  with 
the  handle  of  a  scalpel  or  a  steel  director,  and  retractors  inserted,  the 
outer  one  being  hooked  over  the  fibula.  If  the  limb  is  a  very  muscular 
one,  the  deep  fascia  should  be  nicked  transversely  at  the  upper  and  lower 
extremities  of  the  wound,  and  the  parts  more  relaxed  by  bending  the 
knee  more  and  pressing  the  foot  upwards.  The  finger,  now  directed 
towards  the  interosseous  space,  feels  for  the  artery  deep  down  in  the 
bottom  of  the  wound.  The  nerve  should  be  drawn  to  the  outer  side. 
If  much  trouble  is  met  Avith  in  separating  the  vense  comites,  they  may 
be  included. 

Operation  at  the  Junction  of  the  Lower  and  Middle  Thirds  of  Leg. 
An  incision  about  two  inches  and  a  half  long  is  made  in  the  line  of  the 
artery  ;  in  the  upper  part,  this  incision  will  be  about  one  inch  from  the 
tibia.  The  white  line  and  the  interval  between  the  tibialis  anticus  and 
the  extensor  proprius  hallucis  are  both  looked  and  felt  for.  The  deep 
fascia  being  divided  and  the  muscles  relaxed  and  retracted,  the  artery  is 
found  surrounded  by  its  venae  comites.  The  needle  must  be  passed  from 
without  inwards. 

LIGATURE  OF  THE  PERONEAL  ARTERY 

Indications.  As  these  are  extremely  few,  and  as  in  the  case  of  a 
wound  of  the  vessel  (which  is  very  rarely  met  with)  the  best  course  would 
be  to  enlarge  the  wound,  any  formal  operation  for  its  ligature  need  only 
be  very  briefly  described. 

Relations.  The  peroneal  artery  comes  off  from  the  posterior  tibial 
about  one  inch  below  the  popliteus,  descends  at  first  parallel  with  this 
artery  but  separated  from  it  by  the  posterior  tibial  nerve  ;  it  then  passes 
outwards  towards  the  fibula,  and  runs  down  between  this  bone  and  the 
flexor  longus  hallucis.  In  the  upper  part  of  its  course  it  lies  upon  the 
tibialis  posticus,  and  is  covered  by  the  soleus. 

Operation.  To  tie  the  artery  when.no  wound  is  present  to  guide  the 
surgeon,  an  incision  three  inches  long  should  be  made  along  the  posterior 
border  of  the  fibula,  with  its  centre  at  the  junction  of  the  upper  and 
middle  thirds  of  the  leg.  The  gastrocnemius  being  drawn  aside,  and 
the  soleus  separated  from  its  attachment  to  the  fibula,  the  special  deep 
fascia  is  slit  up  and  the  artery  sought  for  close  to  the  fibula. 

1  This  was  pointed  out  by  Mr.  C.  Heath  (Opcr.  Surg.,  p.  47).  I  have  found  the  same 
fact  most  helpful  in  the  ligature  of  the  ulnar  in  the  middle  third  of  the  forearm. 


CHAPTER  XLIV 

AMPUTATION  OF  THE  LEG.  OPERATION  FOR  NECROSIS. 
COMPOUND  FRACTURE.  SIMPLE  FRACTURE  AND 
VARICOSE  VEINS 

AMPUTATION  OF  THE  LEG 

Different    Methods.      (1)  Lateral    Skin    Flaps    at    "Seat   of    Election." 
(2)  Lateral  unequal  Flaps  containing  Muscle.     (3)  Antero-posterior  Flaps. 

Before  amputating  the  leg,  careful  consideration  of  the  level  of  the 
amputation  is  required.  For  a  good  artificial  limb  to  be  fitted  the 
stump  below  the  knee  must  be  at  least  four  inches  long,  a  shorter  stump 
here  is  unmanageable  so  that  an  amputation  through  the  lower  third  of  the 
thigh  is  to  be  preferred  unless  the  patient  is  content  to  use  a  "  peg  leg  " 
for  which  a  very  short  stump  is  desirable  as  it  has  to  be  flexed  into 
the  kneeling  position. 

(1)  Lateral  Skin  Flaps,  with  Circular  Division  of  the  Muscles,  &c. 
This  is  a  satisfactory  method  of  amputation  at  the  "  Seat  of  Election  " 
where  a  '"  peg  leg  "  only  is  to  be  used  as  in  old  patients  of  hospital  class. 
It  is  difiicult  to  fit  a  good  artificial  limb  here  with  a  knee  joint  at  the 
proper  level,  for  the  short  stump  of  leg  is  in  the  way  and  often  unmana- 
geable, as  it  rarely  can  be  fully  extended.  It  will  not  only  be  found 
most  convenient  at  the  time,  but  it  also  gives  very  satisfactory  results 
afterwards.  The  blood-supply  is  well  and  equally  distributed  to  the 
lateral  flaps,  one  can  be  conveniently  cut  longer  than  the  other,  and  they 
are  more  easily  shaped  and  dissected  up  than  antero-posterior  skin-flaps, 
while  no  mass  of  muscle  is  left  to  drag  away  from  and  expose  the  bones, 
as  in  the  antero-posterior  flaps,  with  the  anterior  of  skin  and  the  posterior 
by  transfixion. 

Operation.  The  femoral  artery  having  been  commanded,  the  leg 
brought  over  the  table,  and  the  damaged  or  diseased  parts  bandaged 
in  sterilised  towels — so  as  to  give  the  assistant  a  firm  hold  and  also 
to  prevent  his  soihng  the  flaps  later  on — the  opposite  ankle  is  tied 
to  the  table.  The  surgeon,  standing  to  the  right  of  the  Umb,  places 
his  left  index  on  the  crest  about  an  inch  below  the  tubercle,  and  his 
thumb  at  a  corresponding  point  behind  in  the  centre  of  the  limb. 
Looking  over,  he  inserts  his  knife  close  to  the  thumb,  and  cuts  on 
the  side  of  the  limb  farthest  from  him  a  lateral  flap  broadly  oval  in 
shape  and  three  inches  long,  ending  at  the  index  finger,  from  which 
point,  -R^thout  removing  the  knife,  a  similar  flap  is  marked  out  ending 
on  the  back  where  the  first  began. ^  Flaps  of  skin  and  fascia  are  now 
dissected  up,  and  the  muscles  all  cut  through  with  a  circular  sweep 

^  If  the  condition  of  the  soft  parts  demand  it,  not  only  can  one  lateral  flap  be  shaped 
longer  than  its  fellow,  but  antero- external  and  postero-internal  flaps  can  be  employed. 

905 


90G       OPERATIONS  ON  THE  LOWER  EXTREMITY 

of  the  knife  at  the  intended  point  of  bone-section,  this  sweep  being 
repeated  two  or  three  times  till  the  soft  parts  are  all  cleanly  severed. 
The  posterior  muscles  should  be  cut  a  little  longer  than  those  in  front, 
owing  to  their  greater  retraction.  The  interosseous  membrane  is  next 
divided,  so  that  it  shall  not  be  frayed  by  the  saw,  and  wnth  one  final, 
firmly  drawn,  circular  sweep  the  periosteum  is  grooved  for  the  saw.^ 
This  is  then  applied  with  the  following  precautions.  The  position  of  the 
fibula  behind  the  tibia  and  its  much  smaller  size  must  be  remembered,  lest 
it  be  splintered.  This  may  be  avoided  by  rolling  the  leg  well  over  on  to 
the  inner  side,  and  placing  the  saw  well  down  on  the  outer  side  so  as  to 
start  the  section  of  the  bones  simultaneously,  and  thus  ensure  complete 


Fig.  363. 


AmiJutation  of  the  leg  by  lateral  flaps.     The  muscles  are  cut  obliquely 
and  afterwards  sewn  over  the  bones  as  far  as  possible. 


division  of  the  fibula  before  the  tibia.  This  object  may  also  be  effected, 
if  the  leg  is  held  in  the  ordinary  position,  by  applying  the  saw  to  the 
tibia,  and  remembering,  when  this  bone  has  been  sawn  half  through, 
to  depress  the  handle,  and  thus  complete  the  section  of  the  bones  simul- 
taneously. In  either  case  the  saw  should  be  used  lightly  and  quickly, 
with  the  whole  length  of  the  blade,  and  without  jamming.  As  the  sharp 
projecting  angle  of  the  crest  tends  to  come  through  the  anterior  angle 
of  the  flaps,  this  may  be  sawn  off  obliquely  after  the  bones  are  sawn. 

(2)  Lateral  flaps  of  unequal  length  containing  muscle  are  very 
valuable  for  the  ordinary  amputation  in  the  middle  third  of  the  leg.  It 
is  a  distinct  advantage  to  have  the  scar  away  from  the  end  of  the  stump, 

1  Nowadays,  with  modern  precautions,  the  old  need  of  periosteal  flaps — viz.,  to  keep 
pus,  &c.,  out  of  the  diploe  and  medullary  canal — is  no  longer  present.  Furthermore, 
these  flaps  are  very  difficult  to  raise,  unless  inflamed,  especially  in  the  thin  periosteum 
of  adults. 


SEQUESTROTOMY  907 

and  some  muscle  is  necessary  for  the  vitality  of  the  flaps,  but  tlie  lo^yer 
inch  and  a  half  are  of  skin  and  deep  fascia.  The  site  for  the  division  of  the 
tibia  is  selected  at  least  three  inches  below  the  tubercle  of  the  tibia  and 
from  this  ])oiiit,  lateral  fhi})s  of  unecjual  leni^th  arc  marked.  As  a  rule 
the  external  should  be  about  four  inches  lon<^  and  the  internal  about 
two  and  a  half  inches.  The  skin  and  facia  are  raised  for  an  inch  and  a  half, 
and  the  muscles  are  divided  obliquely  towards  the  bones,  care  being 
taken  not  to  damage  the  anterior  tibial  vessels  in  raising  the  muscles 
from  the  interosseous  membrane. 

Bier's  Osteoplastic  Method  oJ  Amputation.  The  following  advantages 
are  claimed  for  this  procedure  by  the  inventor  ^  J.  H.  Pringle,  of  Glasgow, - 
and  Moscowitz,  of  New  York  :  ^  (1)  The  patient  can  bear  his  whole 
weight  on  the  stump,  whether  this  has  been  made  through  the  bones  of 
the  leg  or  the  femur,  as  well  as  a  patient  can  do  so  after  a  Syme's  ampu- 
tation. (2)  He  can  wear  an  artificial  hmb  earher.  Thus  Mr.  Pringle 
writes :   "At  the  end  of  four  weeks,  as  a  rule,  I  fix  a  wooden  pin- leg  to  the 


Fig.  364.     Teale's  amputation  by  long  anterior  and  short  posterior  flaps. 

stump  by  plaster  of  Paris  bandages,  and  get  the  patient  up."  The 
disadvantages  are  :  (1)  that  the  raising  the  bony  part  of  the  flap  is  not 
easy  :  a  suitable  saw,  e.g.,  a  small  one  of  the  keyhole  pattern  or  a  Gigli's 
saw  set  in  a  frame,  must  be  at  hand.  (2)  This  flap  may  necrose  and  cause 
trouble.     (3)  Longer  time  is  obviously  required. 

Operation.  To  take  the  case  of  the  leg,  flaps  are  marked  out  as 
before,  a  large  antero-internal  or  antero- external  being  preferred  by 
Bier.  Whatever  flaps  are  employed,  great  care  must  be  taken  not  to 
injure  the  periosteum  on  the  inner  side  of  the  tibia.  The  next  step 
is  the  raising  of  the  osteoplastic  flap.  A  rectangular  flap  of  periosteum 
is  marked  out  on  the  inner  side  of  the  tibia.  This  must  be  large  enough 
to  cover  easily  the  sawn  surfaces  of  the  tibia  and  fibula,  and  care  must 
be  taken  to  cut  the  periosteum  longer  than  the  bone,  both  at  the  sides 
and  margin  of  the  flaps,  so  that  it  can  be  sutured  in  place  later  without 
any  tension  on  the  pedicle  of  periosteum  which  remains  attached  to  the 
tibia.  The  cut  edges  of  periosteum  having  been  sufficiently  raised, 
a  thin  bony  flap  is  then  cut  out  from  the  inner  surface  of  the  tibia  partly 
with  one  of  the  saws  mentioned  above  partly,  with  a  chisel.  Its  base 
must  be  either  snapped  through  or  divided  with  a  saw  or  chisel.  Its 
pedicle  must  be  carefully  preserved  intact.     The  soft  parts  are  next 

1  Centr.f.  Chir.,  1897.  Hft.  31,  S.  834. 

2  Lancet,  November  18,  1905.  3  2Ied.  News,  February  1901. 


908      OPERATIONS  ON  THE  LOWER  EXTREMITY 

divjded,  the  bones  sawn  and  the  vessels  secured  at  the  base  of  the  flap 
or  flaps,  great  care  being  taken  not  to  injure  the  flap  of  bone  and  periosteum. 
This  is  now  carried  across  the  sawn  surfaces  of  tibia  and  fibula  and  kept 
place  by  sutures  of  sterilised  silk  which  take  up  the  cut  fascia^,  tendons  and 
periosteum  of  tibia  and  fibula.  If  the  flap  be  not  large  enough  to  cover 
the  cut  surface  of  the  fibula,  this  bone  should  be  divided  again  at  a  slightly 
higher  level.  Actual  bony  miion  does  not  appear  to  be  absolutely 
essential  for  a  perfect  functional  result. 

SEQUESTROTOMY 

As  the  removal  of  necrosed  bone  is  most  frequently  required  in  the 
leg,  the  above  operation  will  be  described  here. 

Indications.  The  question  will  often  arise  as  to  whether  the  case  is 
ripe  for  operation.  The  chief  points  bearing  upon  this  and  the  loose- 
ness of  the  secj^uestrum  are- — (1)  The  time  that  has  elapsed  since  the 
beginning  of  the  illness  ;    thus,  two  to  three  months  will  probably  be 


Fig.  365,     Operation  for  acute  necrosis.     When  pus  has  been  found  in  the  central 
canal  by  drilling,  free  drainage  is  provided  by  making  a  large  opening  into  the 
central  canal  with  the  chisel  or  parting  tool. 

required  in  the  case  of  the  tibia,  but  more  likely  six  in  that  of  the  femur. 
(2)  The  age  and  general  health  ^  of  the  patient.  The  younger  the 
patient,  and  the  more  vigorous  his  vitality,  the  more  rapidly  will  the 
sequestrum  become  detached.  (3)  The  size  of  the  sequestrum.  The 
larger  and  more  tubular  the  sequestrum,  the  slower  will  be  the  process. 
(4)  Radiography  may  show  separation  of  the  sequestrum.  (5)  The 
size  and  amount  of  the  new  shell  of  bone.  The  more  distinct  this  is,  the 
more  probable  is  it  that  the  process  of  separation  is  complete.  (6)  Some- 
times the  sec[uestrum  may  be  felt  with  a  probe  to  be  loose. 

Operation.-  This  should  be  always  conducted  with  strict  antiseptic 
precaution  throughout,  for  these  reasons — (a)  to  prevent  any  risk  of 
setting  up  infective  osteo-myehtis  ;  (6)  to  diminish  the  amount  of  sup- 
puration, and  so  the  risk  of  further  necrosis  after  the  interference  with 
the  involucrum  which  is  entailed  by  the  operation. 

The  hmb,  having  been  rendered  a  vascular  byvertical  elevation 
while  the  patient  is  taking  the  anaesthetic,  and  the  application  of  a  tourni- 
quet round  the  thigh,  is  firmly  supported  on  a  sand  bag,  the  surgeon 
makes  a  vertical  incision  on  the  inner  surface  of  the  tibia  down  to  the 
bone.     If  only  one  sinus  is  present,  this  will  probably  be  taken  as  the 

^  Freedom  from  syphilis  and  phthisis  will  be  noted. 

*  It  is  supposed  here  that  the  sequestrum  is  one  of  considerable  size 


SEQUESTROTOMY 


909 


centre  of  tlic  incision.  This  incision  should  be  made  to  surround  the  sinus 
or  sinuses  so  that  the  edfj^es  of  these  are  removed.  The  soft  parts,  in- 
chidinji  the  periosteum,  are  lefK^cted  with  a  raspatoiy  so  that  the  new 
slieath  of  bone,  spongy  and  vasculai',  is  thorouglily  exposed.  This  is 
then  cut  into  and  suiliciently  removed  with  a  chisel  and  mallet,  to 
expose  its  cavity  completely  from  end  to  end.'^  No  overhanging  edges 
are  left,  for  these  prevent  the  rapid  and  permanent  obliteration  of  the 
cavity  by  the  ingrowth  of  the  lateral  connective  tissues.  The  sequestrum 
is  now  removed  with  secjuestrum  forceps,  or  prised  out  with  an  elevator. 
If  too  large,  it  must  be  divided  with  cutting  forceps.  The  bed  of  ill- 
formed  granulation-tissue  in  which  the  sequestrum  lay  is  then  carefully 
examined  for  any  small  bit  which  may  be  concealed,  and  this  tissue, 
together  with  that  lining  the  sinuses,  is  all  scraped  away  with  a 
sharp  spoon,  and  the  cavity  left  thoroughly  cleansed,  e.g.  with  formalin 
solution  (I  in  250),  or  pure  carbolic  acid.     The  resulting  cavity  is  then' 


GRWtUL^  riOH^ 


StQUESTHUM 


Fig.  36G.  Scquestrotomj-.  When  the  sequestrum  is  removed,  all  the  over- 
hanging edges  of  the  involucrum  are  removed,  so  that  the  soft  parts  can  glide 
in  to  cover  the  shallow  pit  lined  with  granulations  which  ossify  in  due  course. 

carefully  plugged  with  sterilised  gauze  dusted  with  iodoform,  the  dressings 
being  bandaged  firmly  on  w^hile  the  limb  is  elevated,  and  not  till  then  is 
the  Esmarch  bandage  removed.  If  the  bandage  is  removed  before 
the  dressings  are  applied,  such  free  venous  oozing  takes  place  that  the 
plugs  are  at  once  loosened  and  rendered  inefficient,  and  the  wound  has 
to  be  re-dressed  shortly.  The  limb  is  kept  raised  on  a  back  splint  and 
an  injection  of  morphia  given,  if  needed. 

In  order  to  curtail  the  period  of  after-treatment,  which  is  extremely 
prolonged  and  tedious  ownng  to  the  slowness  with  which  healing  takes 
place  in  the  large  cavity  left,  an  attempt  has  been  made  to  raise  a  flap 
which  includes  the  anterior  portion  of  the  involucrum,  by  skin  incisions 
passing  down  to  the  bone,  and  the  latter  then  divided  along  the  lines  of 

^  Sir  H.  Howse  (Brit.  Med.  Joum.,  1874,  vol.  i,  p.  475)  lays  great  stress  on  the  need  of 
this.  The  new  bone  should  bo  removed  as  far  as  the  probe  can  be  passed  upwards  or 
downwards  inside  it,  so  as  to  make  the  whole  easily  granulate  up  from  the  bottom.  Other- 
wise, the  jiart  that  is  not  laid  open  will  very  likely  persist  with  a  sinus.  Furthermore, 
laying  the  whole  cavity  open  not  only  ensures  its  granulating  up  from  the  bottom,  but 
also  allows  of  the  removal  of  all  informed  and  infective  material. 


910       OPERATIONS  OX  THE  LOWER  EXTREMITY 

incision  with  a  sharp  chisel  or  osteotome.  This  having  been  done, 
the  flap  is  prised  up  sufficiently  to  expose  the  cavity  in  which  the  seques- 
trum lies,  and  the  latter  is  then  removed.  All  the  granulation  tissue  hning 
the  cavity  and  the  sinuses  is  now  thoroughly  removed  with  a  sharp  spoon, 
and  the  skin  forming  the  margins  of  the  sinuses  excised.  The  cavity  in 
the  bone,  the  sinuses,  and  the  surrounding  skin  are  now  thoroughly 
cleansed,  the  flap  replaced  and  sutured,  and  the  wound  dressed.  In  a 
few  cases  thus  treated,  where  the  attempt  at  rendering  the  wound  aseptic 
has  been  successful,  rapid  healing  by  organisation  of  blood-clot  may  take 
place.  In  some  cases  a  small  cavity  may  be  filled  with  sterilised  wax. 
It  is  far  better  and  more  radical,  however,  to  remove  the  overhanging 
parts  of  the  involucum  on  one  side  as  shown  in  Fig.  366,  so  that  the  soft 
parts  may  glide  over  the  granulations  which  soon  fill  the  trough  of  in- 
volucrum  left.  Later  all  this  granulation  tissue  ossifies,  leaving  a  firm 
well-healed  limb. 

As  the  formation  of  sequestra  is,  nowadays,  very  largely  preventible, 
I  shall  take  an  opportunity  here  of  making  a  few  practical  remarks  on 
the  disease  which  is  largely  responsible  for  necrosis  of  long  bones,  infective 
juxta-epiphysial  osteo-periostitis.  (i)  Anatomy  of  the  parts  first  affected  ; 
its  hearing  on  the  disease,  [a)  In  a  young  patient,  the  juxta-epiphysial 
area  contains  growing  cellular  tissues  of  much  activity,  delicate,  com- 
phcated  and  unstable,  with  an  equiUbrium  which  is  easily  disturbed, 
and  a  resistance  which  is  often  small ;  (6)  hosts  of  vessel-loops  are  also 
present,  imperfect  in  their  embryonic  structure,  communicating  freely  and 
unable  to  expand  ;  (c)  at  this  age  the  richly  cellular  periosteum  divides  at 
the  above  area  into  two  layers,  one  continuous  with  it,  the  other  descend- 
ing to  blend  with  the  cartilage  of  the  joint.  In  the  above  tissues  some 
slight  injury,  exposure  to  cold  or  an  exanthem  leads  to  the  arrest  of 
the  ordinary  pyo-cocci  which,  if  not  present  in  the  patient,  abound  uni- 
versally wherever  men  congregate.  Results  of  such  arrest  are  \^olent 
inflammation,  haemorrhages,  thrombosis,  suppuration  with  different  hues 
ready  for  this  to  travel  along,  necrosis,  and  many  possibihties  of  auto- 
inoculation,  (ii)  As  the  diagnosis  is  sometimes  far  from  easy,  and  as  this 
most  grave  disease  is  liable  to  be  mistaken  for  acute  rheumatism,  cellu- 
litis, or  an  exanthem,  one  absolute  rule  should  ahvays  be  remembered  in 
acute  pyrexias  of  doubtful  origin  in  young  subjects,  and  that  is  to  remember 
the  presence  of  juxta-epiphysial  areas,  (iii)  With  regard  to  the  nature  of  the 
early  interference  which  is  always  imperatively  called  for,  there  are  two  camps 
of  opinion  as  to  whether  the  periosteum  is  ever  affected  alone,  i.e.  without 
the  medulla.     In  my  experience  it  certainly  is  so  in  the  early  stage. 

This  is  a  question  very  largely  affected  by  the  surroundings.  A 
surgeon  with  a  well-equipped  hospital  at  his  back  is  very  differently 
placed  from  a  general  practitioner  in  the  country.  The  latter  may  feel 
confident  that  a  free  incision  may  be  safely  made  down  to  the  bone,  in 
the  case  of  the  femur  in  either  of  the  sites  given  at  p.  860.  The  following 
would  be  indications  to  my  mind  for  exploring  and  endeavouring  to 
disinfect  the  medulla  itself  :  (1)  gravity  of  the  general  symptoms  from 
the  first ;  (2)  obscurity  of  the  local  symptoms  ;  (3)  failure  of  relief 
after  free  incision  of  the  periosteum  ;  (4)  a  soft  condition  of  the  bone 
when  cut  down  upon,  to  the  finger  or  director. 

Two  more  questions  coimected  with  the  above  disease  require  to  be 
alluded  to  ;  viz.  those  of  amputation  and  the  performance  of  early  sub- 
periosteal resection,  i.e.  as  soon  as   the    bone  is  dead,  and   before  any 


BONE-GRAFTING  911 

new  shell  has  formed  around  it.  The  following  are  some  of  the  conditions 
ill  which  tho  (|nostion  of  amputation  will  arise  :  failure  of  the  above  treat- 
ment, ospi'fially  it'  initiated  late  ;  involvement  of  joints,  especially  if  drain- 
age of  both  knee  and  ankle  has  failed  ;  presence  of  chronic  septica3mia 
or  pyaemia  and  the  existence  of  other  pya?mic  lesions ;  a  patient  with  a 
vitality  so  low  as  to  render  him  unequal  to  meet  further  calls  upon  it. 

Ejrly  subperiosteal  resection.  This  is  so  simple  an  operation  in 
the  case  of  the  tibia,  and  its  advantages  over  the  expectant  treatment  are, 
at  first  sight,  so  great,  that  it  has  frequently  been  performed.  (1)  Thus 
it  removes  what  may  be  the  source  of  dangerous  infection,  and  (2)  it 
avoids  the  need  of  any  operation  for  the  removal  of  a  sequestrum,  and 
the  tediousness  of  waiting  and  of  the  after-convalescence.  The  very 
serious  disadvantage  of  shortening  of  the  limb  which  has  occurred  in 
the  majority  of  cases,  though  the  fibula  is  present  to  act  as  a  stay  between 
the  knee-  and  ankle-joints,  more  than  outweighs  the  above  advantages. 
This  shortening  has  occurred  even  when  the  periosteum  has  been  care- 
fully preserved  and  even  portions  of  the  ends  of  the  diapyhsis  left  to  ensure 
portions  of  the  epiphysial  cartilages  persisting.  While  I  am  aware  that 
successful  cases  have  been  reported,  we  hear  nothing  of  the  unsuccessful 
ones.  The  results  are  extremely  uncertain  owing  to  causes  at  present 
not  definitely  known.  Where  regeneration  of  bone  has  not  taken  place 
the  limb  is  an  extremely  useless  one  (p.  912).  Nowadays  early  diagnosis 
and  early  operation  should  render  these  cases  of  extensive  necrosis 
extremely  rare.  Where  they  occur,  it  is  possible  that  the  Rontgen- 
rays  by  the  information  they  may  give  as  to  the  thickness  of  the  periosteum 
and  the  involucrum  will  very  likely  enable  the  sequestrum  to  be  removed 
at  an  earlier  date. 


BONE-GRAFTING.    FILLING  UP  OF  BONE  CAVITIES 

Sir  William  Macewen  ^  has  done  much  work  on  this  subject,  and 
many  years  ago  succeeded  in  building  up  the  shaft  of  a  humerus  with 
pieces  of  bone  removed  during  osteotomies. 

Friedrich,  of  Griefswald,'-  reported  rapid  healing  and  good  functional 
results  in  two  cases  in  which  the  diaphysis  of  the  tibia  and  femur  had 
been  removed  and  replaced  by  the  corresponding  shaft  from  another 
human  being,  the  bone  used  being  first  deprived  of  its  marrow  and 
sterilised  by  boiling.  In  a  girl,  at  8,  in  which  the  entire  shaft  of  the  femur 
had  been  removed  for  an  endosteal  sarcoma,  a  child's  tibia  was  used. 
Heahng  was  rapid,  and  the  child  was  able  to  run  with  the  help  of  a  splint 
and  cane.  In  another  child  14  cm.  of  the  femur  were  replaced  by  part 
of  the  femur  from  a  woman  who  had  died  of  gastric  cancer. 

A  modification  of  grafting  which  may  be  termed  bone-transference 
may  be  usefully  employed  in  the  case  of  two  contiguous  long  bones. 

Dr.  Huntingdon,  of  San  Francisco,  drew  attention  to  this  common- 
sense  and  useful  principle,^  with  a  successful  case,  though  his  paper 
is  lacking  in  details  of  technique,  where  these  are  most  needed.  Dr. 
Donald,  of  Paisley,"*  successfully  employed  the  same  principle  in  a  boy 
of  five.  As  in  Dr.  Huntingdon's  case,  sub-periosteal  resection  of  the  tibia 
had  been  performed  for  infective  osteo-periostitis,  and  in  each  case  the  limb 

1  Ann.  of  Surg.,  vol.  vi,  No.  4,  p.  301. 

2  Germ.  Con.gr.  of  Surg.,  April  1904. 

^  Ann.  of  Surg.,  February  1905,  p.  249. 
Brit.  Med.  Journ.  May  12,  1906. 


912       OPERATIONS  ON  THE  LOWER  EXTREMITY 

was  useless.  "  An  incision  was  made  in  the  original  scar  in  its  lower  half 
and  the  deeper  tissues  retracted  so  as  to  form  a  suitable  furrow  for  the  re- 
ception of  the  bone-graft.  Another  incision  was  made  over  the  lower  third 
of  the  fibula  and  the  superficial  structures  separated  from  the  bone  and 
periosteum.  A  segment  of  bone,  about  two  inches  long,  composed  of  half 
the  thickness  of  the  fibula  with  its  attached  periosteum,  was  spht  off  by 
a  chisel,  and  laid  in  the  prepared  furrow."  When  the  dressings  were 
first  changed  at  the  end  of  two  weeks,  the  wound  was  found  to  be  sup- 
purating. Small  crumbs  of  bone  came  away,  but  the  wound  gradually 
healed  well.  About  nine  wrecks  after  the  operation  the  tibia  was  rigid  in  its 
whole  length,  and  abnormal  movements  could  no  longer  be  performed. 
Skiagraphs  taken  at  intervals  showed  increasing  thickness  and  density  of 
the  tibia.  Seven  months  after  the  transference  of  bones  the  boy  was  able 
to  walk  quite  well,  although  there  was  some  shortening  of  the  leg.  This 
method  deserves  extensive  trial.  Two  points  especially  need  attention  : 
(1)  Thorough  sterilisation  of  the  bed  for  the  graft ;  (2)  attention  to  the 
position  of  the  foot  and  support  to  the  tibia,  while  this  is  sohdifying. 

Filliig  up  of  bone-civities.  The  following  methods  are  available 
here.  In  all  it  is  absolutely  essential  that  the  cavity  be  devoid  of  in- 
fection of  any  kind.  The  circumjacent  area  must  be  regularly  re- 
sterihsed  from  time  to  time. 

(1  By  detaching  flaps  of  skin  and  soft  parts  and  so  "  papering  "  the 
cavity  which  must  be  first  carefully  freshened.  This  method  ma}  be  aided 
by  skin-grafting.  It  has  been  alluded  to  at  p.  876.  If  any  portion  of  a 
muscle  has  formed  part  of  the  soft  tissues  used,  adhesion  of  this  to  the 
cavity  and  subsequent  interference  with  its  action  must  be  prevented 
by  passive  and  active  movements  being  begun  two  or  three  weeks  later. 
The  limb  should  not  be  used  until  six  or  eight  weeks  have  elapsed. 

(2)  By  the  use  of  decalcified  bone.  The  cavity  having  been  carefully 
refreshed,  and  the  periosteum  if  possible  detached,  the  cavity  is  entirely 
filled  up  with  the  decalcified  fragments  over  which  the  periosteum  and 
soft  parts  are,  separately,  drawn  together,  if  this  be  possible. 

(3)  By  various  "  fillings."  Most  of  these  have  proved  failures.  The 
following  account  of  the  method  of  V.  Mosetig  inserted  by  the  editors. 
Dr.  W.  T.  Bull  and  Dr.  J.  B.  Solley,  in  the  third  volume  of  their  transla- 
tion of  V.  Bergmann's  System  of  Surgery,  p.  703,  is  worthy  of  careful 
attention.  "  The  method  as  reported  by  V.  Mosetig^  before  the  Gesell- 
schaft  flir  Aertze,  in  Vienna  in  January  of  the  same  year,  and  which  he 
had  used  during  the  previous  three  years,  in  over  a  hundred  cases  of 
caries  and  necrosis,  was  as  follows  :  Under  application  of  the  Esmarch 
and  with  strict  antisepsis  the  periosteum  was  lifted  off  and  all  diseased 
tissue  removed  thoroughly  with  sharp  spoon,  &c.,  until  positive  that 
the  cavity  was  aseptic.  The  result  depended  upon  the  latter  condition 
and  the  steriUty  of  the  filhng.  The  filling  consisted  of  iodoform,  60-0  ; 
spermaceti  and  oleum  sesami,  aa  40-0,  heated  slowly  to  100°  C.  in  a  flask 
on  a  water-bath  ;  kept  at  this  temperature  for  fifteen  minutes ;  then 
removed  and  allowed  to  cool  and  solidify,  while  shaking  constantly. 
Before  using,  it  is  melted  and  heated  to  50°  C.  in  a  thermostat  After 
the  cavity  has  been  cleansed  of  all  diseased  tissue,  it  is  washed  out 
thoroughly  with  a  1  per  cent,  solution  of  formalin,  dried  out  with  swabs 
and  then  with  hot  air  and  filled  with  the  melted  mixture.  The  periosteum 
and  skin  are  then  suturedjwithout^drainage  and  a  dressing  applied.     In 

1  Munich.  Med.  ]Yoch.,  1903,  No  2. 


NEW  GROWTHS  OF  FEMUR  AND  TIBIA  913 

fourteen  days  the  dressing  is  changed  and  the  skin  sutures  removed. 
The  course  is  almost  afebrile,  and  there  is  never  iodoform  intoxication. 
The  hardened  filling  is  gradually  replaced  by  granulations  and  new 
bone  as  demonstrated  by  the  X-ray  (Holzknecht).  The  patient  can  be 
about.  The  size  of  the  cavity,  according  to  Silbermach,^  is  no  contra- 
indication, in  some  instances  two-thirds  of  the  shaft  having  been 
removed  and  replaced  by  the  filling.  The  same  author  emphasises  2  the 
importance  of  absolutely  checking  all  bleeding  and  drying  out  the  cavity 
with  hot  air,  and  describes  the  electrical  hot-air  apparatus  used  in 
V.  Mosetig's  cUnic.^  To  check  the  oozing  of  blood  even  more  surely, 
Damianos  *  swabs  out  the  cavity  with  adrenalin  pledgets  after  thorough 
cleansing  and  drying  with  hot  air.  He  cites  150  cases  treated  success- 
fully, and  attributes  the  results  to  extreme  care  in  the  technic  and  in 
determining  the  time  of  operation.  According  to  Damianos  v.  Mosetig 
prefers  a  flap  section  to  direct  incision.  In  chronic  osteo-myelitis  the 
cavity  can  be  plugged  at  once,  but  in  acute  cases  not  until  several  weeks 
after  the  onset." 

NEW  GROWTHS  OF  FEMUR  AND  TIBIA 

Myeloma  has  been  referred  to  in  the  chapter  on  the  surgery  of  the 
bones  of  the  forearm.  In  that  region  resection  was  the  chief  operation 
in  question,  here  it  is  scooping  out  of  the  growth,  scraping  the  wall  and 
filling  the  cavity  after  Mosetig's  method,  or  in  late  cases  with  invasion  of 
the  coverings  of  the  bone,  amputation  may  be  necessary. 

In  the  femur,  periosteal  sarcoma  requires  amputation  at  the  hip- 
joint  by  skin  flaps  and  division  of  all  the  soft  parts  as  high  as  possible 
is  usually  the  only  operation  available.  It  is  possible  that  the  use  of  the 
Rontgen-rays  may  by  rendering  an  earher  diagnosis  possible,  improve 
the  prognosis  which  is  at  present  so  grave  owing  to  the  probable  existence 
of  metastases.  In  the  endosteal  variety  affecting  one  condyle,  scooping 
out  of  the  growth,  resection  of  the  bone  affected  and  excision  of  the  knee 
have  all  been  performed,  but  the  risk  of  reappearance  of  the  disease 
and  the  doubtfulness  as  to  the  utihty  of  the  Hmb  render  amputation 
which  is  usually  sufficient  if  performed  high  up  in  the  thigh  with  careful 
inspection  of  the  medullary  canal,  a  preferable  step.  But  here,  again, 
the  Rontgen-rays  if  employed  early,  and  aided  by  a  free  exploratory  in- 
cision made  without  delay,  may  increase  the  possibihty  of  saving  the 
hmb. 

In  the  tibia  and  fibula,  where  the  growth  is  an  endosteal  myeloma,  from 
the  presence  of  two  bones  and  the  somewhat  simpler  access,  resection  of 
the  bones  and  scooping  out  of  the  growth  have  to  be  considered  as 
well  as  amputation  Mr.  Morton  has  resected  the  knee-joint  in  two 
cases.^  The  after  use  of  the  hmb  was  good.  As  already  stated,  long 
duration,  slow  progress  of  the  growth,  uniformity  of  expansion,  no 
evidence  of  increased  size  of  the  shaft,  indicating  extension  along  the 
medulla,  or  of  escape  of  the  growth  into  the  soft  parts  are  amongst  the 
chief  points  to  bear  in  mind  when  any  of  the  less  radical  operations  are 
performed.  The  Rontgen-rays  may  not  only  be  of  assistance  in  clearing 
up  early  a  doubtful  case,  but  also  in  showing  the  degree  of  thickness  of 
the  bony  capsule  as  indicated  by  a  darker  zone  contrasting  with  the 

1  Miinch.  Med.  Woch.,  1903,  No.  20.  ^  c^ntr.  f.  Chir.,  1903,  No.  25. 

3  Deut.  Zeitsch.f.  Chir.,  Bd.  Ixvi,  p.  589.  *  Centr.  /.  Chir.,  1904,  No.  6. 

6  Brit.  Med.  Journ.,  1898,  vol.  i,  p.  228, 

SURGERY  I  5S 


914       OPERATIONS  ON  THE  LOWER  EXTREMITY 

adjacent  lighter  area,  and  whether  the  growth  has  perforated  exter- 
nally. Egg-shell  crackling  and  pulsation  are  more  often  talked  of  than 
seen. 

In  the  operation  for  scooping  out — it  is  rarely  an  enucleation^ — the 
following  points  may  be  of  service.  The  parts  having  been  duly  sterilised, 
and  the  haemorrhage  controlled  by  an  Esmarch  bandage,  the  growth 
is  exposed  by  a  sufficient  flap  or  longitudinal  incision  on  the  aspect  which 
gives  the  best  access.  If  the  periosteum  be  not  infiltrated,  it  should  be 
raised,  care  being  taken  not  to  rupture  the  capsule.  With  stout  scissors 
or  a  chisel  this  is  next  freely  opened.  If  it  be  possible  the  growth  is  now 
enucleated  entire.  But  its  friability  and  its  adhesions  render  this  rarely 
possible.  The  only  mode  of  removal  is  usually  that  by  sharp  spoons. 
During  their  use  the  capsule  must  not  be  perforated,  and  cavities  accessory 
to  the  main  one  should  be  looked  for.  Hsemorrhage  now  may  cause  much 
trouble. 

In  a  case  operated  upon  by  Dr.  J.  C.  Bloodgood,^  the  shell  was  found  to  be 
perforated  by  25  or  30  vessels  as  large  as  the  temporal  artery.  Each  of  these  oi)en- 
ings  was  plugged  with  Horsley's  wax.  No  retimi  of  bleeding  took  place,  but  it  was 
two  weeks  before  all  the  wax  was  removed.  The  history  of  the  case  is  only  carried 
up  to  three  months  after  the  operation. 

Where  the  result  of  the  scooping  out  appears  doubtful,  the  cautery, 
pure  carbolic  acid,  or  a  strong  solution  of  formalin  should  be  tried.  The 
wound  is  plugged  with  strips  of  gauze.  The  long  process  of  healing  of  the 
cavity  where  this  is  large  may  be  hastened  by  one  of  the  steps  given  at 
p.  912. 

Even  where  there  is  no  local  reappearance,  the  above  operation  may 
fail  owing  to  metastases,  or  to  the  shell  left  being  too  weak  to  support 
the  leverage  of  the  parts  below  or  the  weight  above.  Where  a  free 
exploratory  incision  has  proved  that  the  endosteal  sarcoma  is  a  mixed 
one — and  these  growths  are  by  no  means  always  myelomata — amputation 
through  the  knee-joint  or  the  lower  third  of  the  thigh  is  the  only  course. 
Owing  to  the  agrravated  disappointment  which  attends  a  local  reappear- 
ance after  an  amputation,  I  prefer  the  latter  step.  And  this  operation 
is  the  only  one  in  periosteal  sarcomata  of  the  bones  of  the  leg. 

TREATMENT  OF  COMPOUND  FRACTURES  ^ 

The  following  special  points  for  consideration  arise  here,  viz.  (1)  The 
treatment  of  the  wound  ;  (2)  The  reduction  of  protruding  fragments 
and  the  treatment  of  splinters  ;  (3)  Complications  ;  (4)  The  question 
of  amputation. 

(1)  In  the  treatment  of  the  wound  the  one  great  object  is  to  convert 
the  fracture  as  soon  as  possible  into  a  simple  one.  In  a  few  cases,  seahng 
a  small,  clean  cut  wound,  the  skin  having  been  carefully  washed  with 
acetone,  sterilised  with  tincture  of  iodine  and  at  once  with  dry  gauze,  and 
collodion  and  iodoform,  or  tinct.  benz.  co.,  may  be  sufficient.  The 
fracture  is  set  under  an  anaesthetic  and  while  powerful  traction  is  main- 
tained plaster  bandages  are  applied  in  the  lower  limb  from  the  tuber  ischii 
to  the  toes,  to  maintain  the  fragments  comfortably  in  apposition.  A  gap 
is  left  opposite  the  wound,  for  frequent  dressing.     But  where  the  surgeon's 

^  Johns  Hopkins  Hosp.,  Bull.,  May  1903,  p.  134. 

-  From  the  frequency  with  which  these  occur  in  the  leg  this  subject  will  be  treated 
here. 


TRKATIMFAT  OF  COMPOUND  FRACTURES         915 

surroundings  admit  of  it,  and  where  there  is  reason  to  be  suspicious 
about  the  soil  at  the  spot  where  the  injury  took  place,  it  will  be  better  to 
make  an  incision  and  disinfect  the  ends  of  the  bones.  In  those  cases, 
common  enough  in  large  hospital  practice,  where  the  wound  is  exten- 
sive and  lacerated,  and  accompanied  by  great  contusion  of  the  soft 
parts,  with  abundant  blood  extravasation,  with  much  connninution  of 
fragments  and  injury  to  the  periosteum,  or  where  the  facture  is  com- 
plicated with  a  dislocation,  the  following  method  will  be  found  to  give 
the  best  results. 

(2)  Protrusmi  of  Fragments.  It  is  usually  the  upper  one  which 
protrudes.  The  difficulty  of  reduction  is  in  proportion  to  the  obliquity 
of  the  fracture,  the  length  of  the  protruding  bone,  and  the  amount  of 
spasm.  The  wound  having  been  freely  enlarged,  an  attempt  must  be 
made  by  manipulations  to  bring  the  fragments  into  accurate  apposi- 
tion. This  will  often  be  facilitated  by  means  of  a  strong  elevator  inserted 
between  the  fragments,  and  used  as  a  lever.  Division  of  the  tendo 
AchilUs  or  possibly  of  other  tendons  may  also  be  found  necessary  befoie 
satisfactory  reposition  can  be  accomplished.  Faihng  all  these,  part 
of  the  bone  must  be  removed  with  a  narrow-bladed  saw,  care  being  taken 
to  separate  the  periosteum  first,  and  to  protect  the  soft  parts  with  a  blunt 
dissector  passed  under  the  bone  and  by  retractors.  If  the  bone  is  splin- 
tered, some  judgment  is  required  as  to  what  pieces  to  remove.  Those 
which  are  still  adherent  by  their  periosteum  should  be  left.  Those 
completely  isolated  must  be  removed,  whether  they  carry  their  periosteum 
or  not.  As  to  a  third  set  partly  adherent,  partly  not,  these  are  usually 
left  in  good  position  for  they  are  useful  in  promoting  union  and  our 
knowledge  of  the  value  of  bone  grafts  makes  us  chary  of  sacrificing 
valuable  material.  If  after  reduction  it  is  found  that  there  is  any  con- 
siderable tendency  to  the  reproduction  of  the  deformity,  the  fragments 
must  be  fixed  either  by  means  of  plates  and  screws,  &c.,  as  suggested  by 
Sir  W.  A.  Lane.  If  the  wound  is  likely  to  have  been  infected,  it  is  some- 
times wise  to  be  content  with  cleansing  and  draining  it,  and  to  defer 
plating  until  the  operation  can  be  carried  out  aseptically.  In  most  com- 
pound fractures  the  wound  is  drained  when  plating  is  adopted. 

While  the  anaesthetic  is  given,  the  leg  is  shaved  and  cleansed  with 
a  1  per  cent,  solution  of  iodine  in  petrol.  A  tourniquet  is  applied  after 
the  hmb  has  been  raised.  Any  skin  which  is  much  damaged  or  into  which 
dirt  has  been  ground  is  first  cut  away.  The  wound  having  been  freely 
enlarged  and  all  recesses  well  opened  up,  the  blood-clot  is  washed  away  and 
the  whole  surface  of  the  wound  thoroughly  sponged  over  with  swabs  soaked 
in  hot  carbohc  acid  solution  (1  in  30)  or  biniodide  of  mercury  (1  in  2000) 
or  iodine.  Where  dirt  has  been  ground  into  the  fragments,  this  must  be 
gouged  out  or  shaved  off  with  a  stout  knife.  Pure  carbolic  acid  may  be 
safely  applied  to  any  isolated  area  which  cannot  be  safely  removed. 
The  fragments  are  now  reduced  (care  being  finally  taken  that  nothing 
intervenes)  and  fixed,  if  needful,  as  described  at  p.  920,  and  counter- 
openings  made  for  drainage  as  may  be  found  necessary.  The  tourniquet 
should  not  be  removed  until  there  has  been  time  for  the  antiseptics  used 
to  soak  into  the  parts  ;  all  haemorrhage  being  now  arrested,  and  any  torn 
nerves  pared  and  sutured,  the  recesses  of  the  wound  are  well  dried  out. 
Sterile  dressings  are  apphed  or  a  boracic  acid  fomentation  according  to  the 
confidence  which  the  surgeon  is  able  to  feel  in  the  disinfection  of  the  wound, 
and  the  Mmb  put  up  either  in  a  back  and  two  side  sphnts  with  any  needful 


916       OPERATIONS  ON  THE  LOWER  EXTREMITY 

interruptions,  or,  according  to  Mr.  Croft's  directions,  in  plaster  of  Paris. 
Another  excellent  means  of  using  plaster  of  Paris  is  in  combination  with 
metal  strips  so  as  easily  to  provide  good  access  to  the  injury.  A  sterile 
bandage  is  first  applied  below  and  above  the  wound,  two  to  four  strips 
of  thin  malleable  metal  are  then  applied  antero-posteriorly  and  laterally 
as  well  if  needful,  bent  outwards  over  the  area  adjacent  to  the  fracture, 
their  extremities  being  embedded  in  the  plaster  of  Paris  bandages  as 
these  are  appUed.  Of  the  above  I  prefer  the  first  and  the  third,  in  severe 
cases,  for  the  first  week  ;  infrequent  dressings,  wherever  practicable, 
are  most  essential.  But  in  trying  to  secure  this  end,  the  risk  of  shutting 
in  injection  must  not  be  forgotten. 

(3)  Complications.  My  space  will  only  allow  me  to  enumerate  these. 
They  are  local  and  general.  The  former  include  pruritus,  vesicles, 
ecchymosis,  suppuration,  cedema,  phlebitis,  gangrene,  osteitis,  caries, 
necrosis,  muscular  spasms,  dislocations,  and  imphcation  of  a  neigh- 
bouring joint.  The  general  comphcations  are  such  as  are  common  to 
all  injuries,  viz.  traumatic  fever,  deHrium,  erysipelas,  septicaemia, 
pyaemia,  hectic,  tetanus,  jaundice,  and  retention  of  urine  ;  in  older 
patients  a  tendency  to  hypostatic  congestion  and  broncho-pneumonia, 
and  finally,  in  a  few  cases,  pulmonary  fat- embolism. 

(4)  Question  of  Amputation.  The  following  are  amongst  the  condi- 
tions requiring  primary  amputation  :  (1)  When  a  limb  is  torn  off  by 
a  cannon-ball,  a  portion  of  shell,  or  by  machinery.  (2)  When  the  division 
of  the  soft  parts  is  nearly  complete,  except  in  the  case  of  a  clean  cut 
across  the  phalanges,  metacarpus,  or  metatarsus  ;  even  the  forearm 
may  occasionally  be  saved  under  similar  circumstances.  (3)  When  there 
is  much  actual  loss  of  soft  parts,  as  when  one  side  of  a  limb  is  torn  away, 
or  the  skin  is  extensively  peeled  off.  (4)  When,  with  or  without  great 
comminution  of  the  bones,  there  is  much  bruising  and  laceration  of  the 
soft  parts,  with  protrusion  of  muscular  bellies,  and  extensive  tearing  up 
of  deep  planes  of  areolar  tissue.  (5)  In  some  cases  when  the  principal 
artery  and  nerves  of  the  Hmb  are  both  divided  ;  thus,  in  the  case  of  the 
lower  limb,  primary  amputation  will  usually  be  required.  (6)  In  certain 
cases  of  severe  haemorrhage,  primary  or  secondary.  (7)  Some  cases 
of  compound  fracture  of  large  joints,  viz.  when  one  bone  is  shattered 
or  more  than  one  is  broken  ;  when  there  is  much  laceration  of  the  liga- 
ments ;  when,  in  addition  to  comminution  of  the  bones,  there  is  much 
contusion  of  the  soft  parts,  especially  if  comphcated  with  division  of  an 
artery ;  when  the  foreign  body  which  has  caused  the  fracture  remains 
in  the  joint,  or,  projecting  into  it  from  its  bed  in  the  bone,  cannot  easily 
be  removed,  or  when  there  is  much  damage  to  the  articular  surfaces. 
It  will  be  understood  that  all  these  forms  of  injury  are  most  fatal  when 
affecting  the  knee  or  hip  ;  in  dealing  with  other  joints  much  greater 
latitude  may  be  allowed. 

Finally,  before  deciding  on  amputation,  the  surgeon  must  take  into 
consideration,  in  addition  to  the  above  points  which  concern  the  fracture 
itself,  any  general  information  to  be  gained  about  the  patient  himself. 
Thus,  the  age,  constitution,  habits,  any  sign  of  visceral  disease,  and 
the  appearance  of  the  patient,  are  all  points  of  material  importance  in 
coming  to  a  decision  between  amputation  and  an  attempt  to  save  the 
limb.  Thus,  to  make  my  meaning  clearer,  there  are  no  more  anxious 
cases  than  severe  compound  fractures  in  dwellers  in  large  towns,  who 
are  past  middle  life,  flabbily  fat,  with  dilated  venules  about  the  cheeks 


OPERATIVE  TREATMENT  OF  SIMPLE  FRACTURES   917 

and  nose,  whose  conjunctivae  are  slightly  jaundiced,  the  urine  of  low 
specific  gravity  and  perhaps  albuminous.^  The  surgeon  nuist  here  bear 
in  mind  that  saving  the  patient's  life  is,  after  all,  of  more  importance 
than  the  preservation  of  his  limb. 

In  performing  amputation  in  these  cases  of  compound  fracture  it 
is  always  to  be  remembered  that  the  injury  is  not  so  locaUsed  as 
would  appear  from  the  surface  ;  thus,  in  compound  fracture  of 
the  leg  there  is  often  extensive  loosening  of  the  skin  from  the  deep 
fascia,  and  extravasation  of  blood  into  the  deep  planes  of  connective 
tissue  for  some  distance  above,  the  knee-joint  being  perhaps  full  of 
blood,  and  its  cartilages  bruised.  In  such  cases,  if  amputation  be  per- 
formed just  above  the  injury,  sloughing  and  separation  of  the  flaps 
will  inevitably  follow.  On  the  other  hand,  in  cases  of  severe  com- 
pound fracture  of  the  thigh,  where  amputation  is  required  high  up,  it 
will  be  found  better  practice  to  ampulate,  in  part  at  least,  through  injured 
tissues.  2 

If,  in  addition  to  the  fracture,  there  are  serious  injuries  to  other 
organs,  immediate  amputation  is  useless  or  injurious.  The  only  chance 
of  recovery  here  is  afforded  by  secondary  amputation  after  the  early 
dangers  are  past. 

Secondary  amputation  may  be  required  for  profuse  suppuration  with 
hectic,  for  gangrene,  or  uncontrollable  haemorrhage.  The  decision 
must  here  be  made  according  to  the  needs  of  each  case.  The  surgeon 
must,  if  possible,  wait  till  the  infective  fever  and  constitutional  dis- 
turbance are  subsiding,  till  the  temperature  has  begun  to  fall,  and  till 
all  redness,  erysipelas,  and  sloughing  have  ceased.  On  the  other  hand, 
if  the  operation  be  deferred  till  the  powers  of  the  patient  are  running 
down  from  profuse  suppuration  and  hectic,  and  till  confirmed  asthenia 
has  set  in,  the  period  of  performing  it  will,  very  probably,  have  passed 
away. 

At  a  still  later  period  the  operation  may  be  desired  by  the  patient,  if, 
in  consequence  of  non-union,  incurable  deformity,  or  tedious  bone  disease, 
the  Hmb  has  become  an  encumbrance  to  him.  Some  of  these  conditions 
may,  of  course,  be  treated  by  resection,  osteotomy,  &c. 


OPERATIVE  TREATMENT  OF  SIMPLE  FRACTURES 

The  wider  adoption  of  this  step  has  been  strongly  advocated  by  Sir 
Arbuthnot  Lane,^  on  the  grounds  chiefly  that  (1)  it  is  perfectly  safe 
nowadays,  (2)  that  otherwise  the  results  are  often  bad  and  very  fre- 
quently disabhng,  and  (3)  that  it  saves  time. 

(1)  At  the  present  date  the  opinion  of  most  surgeons  is  that  it  is  only 
in  a  small  proportion  of  cases  of  fracture  of  the  leg  and  Pott's  fracture 
• — conditions  which  will  be  considered  separately — that  operative  inter- 
ference is  justifiable,  for  the  following  reasons.     The  value  of  any  treat- 

1  Note  will  also  be  taken  of  the  occupation,  as  in  brewers'  draymen  and  commercial 
travellers. 

2  Thus,  in  the  case  of  a  young  railway  porter,  whose  thigh  was  smashed  by  a  railway 
accident  at  Epsom,  I  performed  amputation  at  the  level  of  the  lesser  trochanter,  in  pre- 
ference to  the  hip  joint.  The  damaged  flaps  sloughed,  as  I  expected,  but  the  patient 
made  a  good  recovery,  after  the  removal  of  some  dead  bone.  All  the  precautions  which 
may  be  taken  against  shock  before,  during,  and  after  the  amputation,  will,  of  course,  be 
adopted  in  these  cases. 

^  Clin.  Soc.  Trails.,  vol.  xx\ni;    Clin.  Jonrn.,  July  1897,  and  elsewhere. 


918       OPERATIONS  ON  THE  LOWER  EXTREMITY 

ment,  especially  in  a  very  common  injury,  must  be  estimated  by  the 
extent  to  which  it  is  available  by  the  great  majority  of  those  called  upon 
to  employ  it,  or  to  put  the  matter  in  Sir  W.  Bennett's  words  :  ^  "  it  is 
quite  impossible — and  this  is  a  fact  that  cannot  be  too  strongly  insisted 
upon — to  estimate  the  value  of  any  method  of  treatment  upon  the  evidence 
of  the  report  of  the  successful  cases  only.  It  is  equally  impossible  to 
gauge  the  general  value  of  any  method  of  treatment  upon  the  experience 
of  a  few  individuals.  Although  a  certain  number  of  surgeons  may  be 
able,  from  the  circumstances  in  which  they  work,  or  from  special  aptitude 
in  operating,  to  produce  results  which  are  practically  ideal,  it  does  not 
necessarily  follow  that  the  same  result  can  be  achieved  by  the  general 
body  of  those  who  attempt  the  same  method."  I  need  not  point  out  that 
while  the  skin  in  these  cases  of  simple  fracture  of  the  leg  is  unbroken,  it  is 
very  often  in  a  condition  which  renders  it  impossible  to  say  that  operative 
interference  is,  even  nowadays,  without  risk.  At  the  usual  site  of 
fracture  it  is  thin  and  of  little  vascularity,  its  vitality  is  diminished  by 
the  injury ;  blebs  and  extravasation  may  be  present.  The  needed 
thoroughness  of  the  sterihsation  can  only  be  secured  at  the  risk  of  further 
damage.  Moreover,  the  patients  are  often  habitually  inattentive  to 
cleanliness,  and  drunken  habits  may  be  a  further  complication. 

(2)  In  my  opinion  the  proportion  of  cases  in  which  the  use  of  the 
limb  has  been  permanently  impaired  and  the  wage- earning  capacity  of 
the  patient  seriously  diminished  has  been  much  exaggerated.  To  get 
at  the  truth,  I  consider  it  essential  that  in  such  cases  the  patient  should 
be  examined  as  to  the  accuracy  of  his  statements  by  the  surgeon  himself. 
Written  reports  from  patients  have  little  value  in  my  eyes.  The  patient's 
powers  have  to  be  tested  by  experienced  and  watchful  eyes,  and  the  in- 
fluence of  club-money  and  expected  remuneration  from  actions  at  law 
to  be  duly  weighed.  That  the  real  disability  is  small  is  confrmed  by 
such  results  as  Sir  W.  Bennett  -  obtained  from  his  inquiries  amongst 
practitioners  in  mining  and  colliery  districts,  and  those  who  had  to  do 
with  sailors  in  large  numbers  who  have  suffered  from  fractures  at  sea 
and  under  other  disadvantageous  circumstances.  On  this  point  Sir 
William  speaks  as  follows  :  "  The  result  of  my  inquiries  in  this  respect 
is  that  I  find  the  real  disability  following  upon  fracture  is  not  so  great 
as  one  would  be  led  to  suppose  from  recent  writings  on  the  subject."  .  .  . 
"  The  fact  of  the  matter  is,  I  beheve,  as  follows.  In  spite  of  what  may 
be  said  to  the  contrary,  the  disability  following  upon  fracture  is  much 
more  frequently  due  to  matting  of  the  parts  about  the  fracture  and  about 
the  joints  immediately  concerned  than  to  faulty  union  of  the  bones 
themselves."  ...  "I  believe  that  if  in  case  of  fracture  early  passive 
movements  were  methodically  used  so  that  all  chance  of  adhesion  of  the 
parts  is  prevented,  very  much  less  would  be  heard  about  the  disabilities  in 
such  cases  than  we  hear  now."  Mr.  R.  W.  Murray,  Surgeon  to  the 
Northern  Hospital  at  Liverpool  in  a  paper  on  "  The  Ultimate  Results 
of  Eighty-eight  Cases  of  Fracture  of  the  Tibia  and  Fibula,"  ^  writes, 
"  In  the  vast  majority  of  the  cases  of  oblique  fracture  the  men  were 
able  to  resume  their  former  work."  While  the  subject  of  the  function 
of  the  limb  is  being  referred  to,  I  would  remind  my  readers  that  though 
the  functional  results  of  non- operative  treatment  may  be  excellent  the 
Rontgen-rays  may  reveal  the  persistence  of  a  marked  deformity.     As 

^  Treatment  of  Simple  Frrictiirr.9.  p.  16  ;    and  Brit.  Med.  Journ.,  October  7.  1900. 
2  Loc.  supra  cit.,  p.  22.  ^  Brit.  Med.  Journ.,  October  10,  1903. 


OPERATIVE  TREATMENT  OF  SIMPLE  FRACTURES  919 

to  the  gain  of  time  by  operative  treatment  in  simple  fracture  of  the  leg 
this  is  certainly  not  so  marked  as  in  fracture  of  the  patella.  The  plate, 
while  an  excellent  means  of  holding  the  fragments  together,  sometimes 
requires  removal,  and  in  future  as  the  early  use  of  passive  movement, 
which  Sir  W.  Bennett  has  advocated  so  strongly,  becomes  more  general 
the  time  required  before  the  patient's  employment  is  renewed  will  be 
materially  shortened  {see  Fig.  367). 

Indications  for  Operative  Interference  in  Simple  Fractures.  A.  Those 
cases  of  spiral  or  oblique  fracture  in  which  careful  attempts  guided  by 
radiography  have  failed  to  reduce  the  displacement  satisfactorily  ;  or 
where  reduction  is  effected,  but  on  the  patient's  recovering  from  the 
aniBsthetic  the  fragments  shp  apart  into  a  bad  position  as  shown  by 
radiography.  Operation  is  especially  indicated  for  irreducible  fractures 
near  joints,  where  malposition  is  likely  to  interfere  with  movements. 
B.  Some  cases  of  Potts  fracture.     The  general  health,  vitahty,  and 


Fig.  367.     Oblique  or  spiral  fracture  of  the  tibia.     The  bone  is  exposed  for  at 
least  two  inches  above  and  below  the  fracture,  and  the  skin  is  excluded  from 
the  field  of  operation  bj'  attached  gauze  pads. 

habits  of  the  patient  must  be  satisfactory,  and  the  surroundings  such  as 
to  ensure  an  aseptic  result  being  secured.  C.  Most  cases  of  fracture  of 
the  patella  and  olecranon  with  separation  of  the  fragments. 

Operation.  A.  Fracture  of  the  tibia  may  be  taken  as  an  example. 
The  entire  leg,  foot  and  toes  are  most  carefully  prepared  (p  915).  Any 
blebs  should  be  incised  after  painting  with  iodine.  The  sterihsation 
should  be  carefully  repeated  when  the  patient  is  anaesthetised.  The 
fragments  are  best  exposed  by  a  longitudinal  incision  over  the  super- 
ficial aspect  of  the  tibia  :  Aseptic  pads  are  chpped  over  the  edges  of  the 
wound  so  that  no  skin  is  exposed.  Any  intervening  blood  clot  or  muscle 
or  fascia  having  been  removed,  the  fracture  is  reduced,  often  a  matter 
of  much  difiiculty.  While  extension  and  counter- extension  are  made 
by  assistants,  the  surgeon  prises  the  fragments  into  their  correct  position 
by  means  of  a  strong  elevator  and  hon-forceps,  any  comminuted  frag- 
ments which  admit  of  it  (p.  911)  being  accurately  fitted  into  place.  By 
bending  the  hmb  at  the  site  of  fracture,  overlapping  ends  can  be  brought 
together,  when  powerful  traction  has  failed  {see  Fig.  368).  When  the  ends 
are  thus  locked,  the  hmb  is  gradually  straightened  without  reproducing 
the  displacement.  If  it  is  necessary  to  remove  part  of  either  fragment 
the  periosteum  must  be  detached ;  otherwise  this  membrane  is  left 
carefully  in  situ.  While  the  corrected  position  is  maintained  by  Lane's 
forceps,  or  extension  and  counter-extension,  the  fixation  is  carried  out. 
Various  methods  are  used  for  this. 

(1)  Lane's  plates  are  excellent.      They  are  of  vanadium  steel,  very 


920       OPERATIONS  ON  THE  LOWER  EXTREMITY 

strong  and  of  various  sizes,  and  they  are  affixed  by  steel  screws  of  various 
lengths  and  thicknesses.  A  series  of  drills  or  bradawls  should  be  at 
hand,  and  the  one  selected  should  be  sUghtly  smaller  than  the  screw  {see 


Fig.  368.     Oblique  fracture  of  the  tibia  being  reduced  by  angulation  and  leverage. 

Fig.  369).  The  screws  are  held  by  special  forceps  as  they  are  driven  in  by  a 
screw-driver.  Throughout  the  operation  no  hands,  gloved  or  otherwise, 
invade  or  touch  the  wound,  plates  or  screws.     One  or  more  plates  are 


i$ 


Fig.  369.     Oblique  fracture  of  the  tibia  held  in  apposition  by  forceps  while  it  is  plated. 

used  as  required  to  maintain  perfect  apposition.  Bleeding  is  arrested 
and  the  wound  is  closed  with  fine  catgut  for  the  muscles  or  fasciae,  and 
fishing  gut  or  Michel's  chps  for  the  skin. 


OPERATIVE  TREATMENT  OF  SIMPLE  FRACTURES   921 

(2)  Long  screws.  These  are  especially  indicated  where  the  fracture 
is  known  to  be  an  oblique  or  spiral  one.  They  arc  very  valuable  for 
fractures  of  the  neck  of  the  femur,  and  for  vertical  or  oblique  fractures 
of  the  lower  end  of  the  femur  extending  into  the  knee  joint.  Also  for 
Dupuytren's  and  some  Pott's  fractures. 

(3)  Wire.  While  this  material  does  not  give  such  firm  hold  as  plates 
and  screws  and  while,  if  used  in  the  ordinary  way,  it  involves  more  com- 
plete exposure  of  the  fragments,  it  is  always  available  and  easy  of  appU- 
cation,  and  if  it  gives  after-trouble,  it  is  more  easily  removed  than  a 
plate.  It  is  very  valuable  for  fracture  of  the  patella.  One  or  more 
strong  circumferential  silver  wires  are  valuable  and  simple  means  of 
securing  oblique  or  spiral  fractures.  To  prevent  slipping  two  notches 
may  be  made  on  the  bone.  However  the  wire  is  employed,  its  ends 
should  be  well  twisted  and  embedded.  The  wire  should  be  supple.  The 
most  useful  sizes  are  Nos.  5  and  G,  French  gauge. 

(■f)  Dovetailing  or  Mortising  the  Fragments.  Very  occasionally,  the 
condition  in  which  these  are  found  lends  itself  to  cutting  them  into 
step-hke  shape,  or  zig-zag  fashion,  so  as  to  secure  better  interlocking. 
If  necessary  they  are  thus  secured  with  a  plate,  screw  or  wire.  In  one 
case  I  impacted  the  shaft  of  the  radius  into  the  expanded  lower  extremity. 
The  overlapping  fragments  of  the  ulna  were  shortened  and  plated.  The 
result  was  excellent. 

(5)  Gussenbauer's  Staple.  This  very  simple  method  deserves  a  wider 
knowledge  in  this  country.  If  any  sinus  form,  and  the  staple  give 
evidence  of  becoming  loose,  the  adjacent  skin  must  be  kept  sterile. 

Pott's  Fracture.  B.  Pott's  fracture  is  one  of  the  most  troublesome 
fractures  to  set  accurately,  and  the  ultimate  results  of  conservative  treat- 
ment are  in  many  cases  deplorable.  It  is  common  to  find  tahpes  valgus 
when  the  patient  begins  to  walk,  and  this  deformity  gradually  increases 
and  sets  up  arthritis  changes  in  the  ankle  so  that  ultimately  a  rigid  ab- 
ducted and  everted  foot  is  a  common  result.  This  seriously  interferes 
with  the  patient's  activity  and  earning  capacity.  It  is  important  here 
to  consider,  (i)  the  immediate  treatment  of  Pott's  fracture  and  (ii)  the 
correction  of  deformity  and  restoration  of  function  in  late  cases. 

(1)  The  Immediate  Treatment  of  Pott's  Fracture,  (a)  Conservative 
Treatment.  Every  endeavour  should  be  made  to  set  the  fracture 
accurately,  and  for  this  an  ansesthetic  is  absolutely  necessary.  The 
knee  should  be  well  flexed,  and  while  it  is  firmly  held  by  a  strong  assistant 
powerful  traction  is  made  upon  the  foot,  and  the  latter  is  strongly  adducted 
and  inverted  while  the  fragments  are  manipulated  into  position.  In  some 
cases  it  is  necessary  to  divide  the  tendo  Achilles,  flexion  of  the  knee  faihng 
to  afford  a  sufficient  relaxation  of  this  powerful  tendon,  which  is  a  strong 
hindrance  to  reduction.  The  setting  should  be  carried  out  as  soon  as 
possible  after  the  accident,  for  it  is  much  easier  to  get  a  good  position 
before  extravasation  of  blood  and  effusion  into  the  tissues  shorten  the 
muscular  and  other  "  ties "  around  the  ankle.  Whenever  possible, 
the  setting  should  be  actually  guided  by  the  X-rays.  When  this  is  im- 
practicable, the  result  should  be  checked  by  subsequent  screen  examina- 
tions. While  the  foot  is  held  in  a  good  position  at  least  three  wide 
plaster  bandages  are  applied  from  the  knee  to  the  toes,  and  the  correct 
position  is  maintained  imtil  the  plaster  has  firmly  set.  Tahpes  equinus 
is  avoided,  the  ankle  being  dorsi  flexed  to  the  right  angle.  When  there 
is  but  little  swelling  it  is  only  necessary  to  put  a  thin  bandage  under  the 


922       OPERATIONS  OX  THE  LOWER  EXTREMITY 

plaster,  but  when  there  is  much  swelling,  and  especially  if  there  are 
blebs,  the  hmb  is  painted  with  tincture  of  iodine  and  covered  with  a 
layer  of  cotton  wool  of  moderate  thickness  before  the  plaster  bandage 
is  applied.  The  position  of  the  fragments  is  later  ascertained  by  screen 
examinations,  and  if  the  setting  is  not  satisfactory  it  must  be  repeated. 
The  spHnt  is  not  removed  for  ten  days,  but  after  that  time  it  is  taken 
off  daily  for  massage,  movement  and  exercises,  and  it  is  finally  abandoned 
about  five  weeks  after  the  accident,  but  the  patient  is  not  allowed  to 
stand  or  walk  for  two  months,  and  then  the  inner  border  of  his  boot  is 
raised  a  quarter  of  an  inch  to  prevent  the  development  of  abduction  from 
the  gradual  giving  way  of  the  Hue  of  fracture.     Better  still,  a  double 


Fig.  370.  Showing  antero-posterior  dis- 
placement and  overlapping.  Prominent 
lower  end  of  shaft  of  radius  injuring  the 
tendons  and  median  nerve.  Full  supina- 
tion was  impossible. 


Fig.  371.  Rays  passing  antero-posteriorly 
after  plating  ulna,  and  impacting  radial 
shaft  in  the  lower  end  of  the  bone.  The 
hand  was  perfect  with  plate  in  position 
ten  years  later. 


steel  support  with  a  strong  T  valgus  strap  is  supplied  for  nine  months  after 
the  accident. 

(6)  Early  Operation.  When  a  good  position  cannot  be  obtained 
by  the  method  already  described  and  the  patient  is  healthy  and  active, 
when  there  are  no  contra  indications  to  an  operation,  and  the  ser\'ices 
of  a  good  and  aseptic  surgeon  experienced  in  the  operative  treatment  of 
fractures  can  be  obtained,  early  operation,  say  within  a  week  of  the 
accident,  is  strongly  indicated,  for  it  offers  a  very  good  chance  of  a  per- 
fect hmb.  A  tourniquet  is  apphed  around  the  thigh  after  the  limb  below 
the  knee  has  been  elevated  and  most  carefully  sterihsed,  and  a  shghtly 
curved  incision  is  made  over  the  lower  third  of  the  fibula  starting  just 


OPERATIVE  TREATMENT  OF  SIMPLE  FRACTURES  923 

behind  the  bone  at  its  lower  point  of  trisectiou  and  extending  down- 
wards and  slightly  forwards  and  terminating  one  inch  below  the  tip  of 
the  external  malleolus.  All  the  soft  parts  ((own  to  the  periosteum  are 
then  reflected  backwards.  This  flap  method  is  better  than  a  straight 
incision  over  the  line  of  fracture.  Sterilised  pads  are  immediately  and 
accurately  secured  over  the  edges  of  the  wound  with  tissue  forceps  so  that 
no  epidermis  is  exposed.  The  broken  ends  are  isolated  partly  with  the 
knife  and  partly  with  broad  elevators  and  levers.  They  are  then  brought 
into  apposition  by  means  of  Lane's  long-handled  forceps,  and  while  thus 


Fig.  372.     A  typical  Dupuytren's  Fig.  373.     The  contiguous  surfaces  of  the 

fracture  in  a   %ery    heavy    com-  tibia  and  fibula  have  been  pared,  and  a  long 

mercial  traveller.  screw  has  been  passed  horizontally  to  keep 

the  bones  together  until  bony  union  occurs. 

Note    the   good  position  of   the    fibular 

fracture. 

held,  are  fixed  in  position  by  steel  plates,  wire  or  screws.  In  all  cases  the 
inferior  tibio-fibular  joint  is  exposed  near  the  lower  angle  of  the  wonnd, 
and  if  there  is  separation  of  the  two  bones  at  this  point  indicating  Dupuy- 
tren's fracture,  the  simplest  and  most  satisfactory  way  of  correcting  the 
deformity  is  to  chisel  away  the  cartilage  from  the  contiguous  surfaces 
of  the  tw^o  bones,  and  then  pass  a  screw  obliquely  inwards  and  slightly 
upwards  through  the  fibula  and  tibia  a  little  above  the  ankle-joint.  A 
screw  passed  in  a  similar  way  is  very  effective  for  those  common  cases 
of  oblique  fracture  extending  upwards  and  outwards  through  the  fibula 


924       OPERATIONS  ON  THE  LOWER  EXTREMITY 

from  just  below  the  inferior  tibio-fibular  joint.  This  and  the  preceding 
fracture  yield  very  bad  results  with  conservative  treatment,  for  the  upper 
and  outer  edge  of  the  displaced  astragalus  acts  as  the  apex  of  a  powerful 
wedge  which  gradually  increases  the  separation  of  the  bones  at  the  site 
of  injury.  In  many  cases  this  is  all  that  is  required,  for  as  the  screw  is 
driven  home  the  fibula  fragments  become  locked  in  good  position.  When 
this  is  not  so,  a  small  plate  is  applied  over  the  outer  surface  of  the  fibula 
at  the  site  of  fracture,  which  is  generally  about  two  inches  above  the 
malleolus.  When  the  fracture  of  the  fibula  is  obhque  or  spiral,  a  circum- 
ferential wire  is  often  simpler  and  more  efficient  than  a  plate.  Through- 
out the  operation  the  bone,  screws,  wire  or  plate,  or  any  part  of  the  instru- 
ments to  be  inserted  in  the  wound  are  not  touched  even  by  the  gloved 
hand.  This  "  touch-me-not  "  technique  is  of  vital  importance  in  securing 
an  aseptic  union  and  a  perfect  result.  The  wound  is  then  closed  with  a 
continuous  salmon-gut  suture,  and  a  massive  dressing  is  firmly  applied 
before  the  tourniquet  is  removed.  The  tourniquet  allows  far  speedier 
and  more  accurate  work,  and  the  application  of  the  firm  dressing  before 
the  removal  of  the  tourniquet  prevents  extravasation  of  blood  into  the 
tissues. 

(2)  The  Correction  of  Deformity  and  Restoration  of  Function  in  Late 
Cases.  An  attempt  to  restore  the  broken  fragments  to  their  natural 
position  is  not  likely  to  be  successful  later  than  three  months  after  the 
accident,  an  attempt  to  do  this  may  be  a  very  formidable,  difficult  and  some- 
what dangerous  operation,  for  a  good  deal  of  callus  has  formed,  matting 
and  shortening  of  the  soft  parts  have  occurred,  and  above  all  the  frag- 
ments themselves  have  atrophied  and  become  soft  so  that  they  do  not 
hold  a  plate  or  screw  well.  In  these  cases,  it  is  better  to  do  all  we  can 
to  obtain  a  movable  ankle  without  equinus,  and  to  restore  the  proper 
ahgnment  of  the  limb,  and  this  is  safely  and  simply  done  as  follows  : 

When  the  patient  is  under  the  anaesthetic  and  the  hmb  has  been 
carefully  sterihsed,  the  knee  is  bent  and  held  by  an  assistant  while  the 
surgeon  grasps  the  fore  part  of  the  foot  and  moves  the  ankle  freely. 
When  flexion  is  considerably  Hmited  it  is  wnse  to  divide  the  tendo  Achilles 
subcutanesouly.  Stronger  union  is  obtained  in  the  tendon  if  its  two 
lateral  halves  are  divided  at  difi'erent  levels  about  an  inch  and  a  half 
apart.  When  good  movement  has  been  obtained  the  hmb  is  turned  on 
its  outer  edge  on  a  sand  pillow,  and  a  small  longitudinal  incision  is  made 
with  its  centre  three  quarters  of  an  inch  above  the  tip  of  the  internal 
malleolus.  An  osteotome  is  then  driven  transversely  outwards  across 
the  bone.  At  this  level  there  is  no  fear  of  entering  the  ankle-joint.  As 
far  as  possible  the  work  is  done  sub-periosteally.  When  the  bone  is 
almost  completely  divided  an  attempt  is  made  to  snap  the  remainder, 
and  to  bring  the  foot  into  a  good  position.  If  this  fails  the  osteotome 
is  re-inserted  and,  if  necessary,  driven  on  to  notch  or  divide  the  fibula. 
The  deformity  is  shghtly  over- corrected,  the  wound  closed  with  catgut 
and  the  hmb  secured  in  a  good  position  with  plaster  bandages  over  an 
antiseptic  dressing.  The  after-treatment  is  similar  to  that  already 
described  under  conservative  treatment. 


UNUNITED  FRACTURES  925 

UNUNITED  FRACTURES 

Recent  years  have  shown  that  operative  interference  has  made  here 
great  advances.  A  valuable  addition  to  our  knowledge  is  the  informa- 
tion which  the  Rontgen-rays  may  give  as  to  the  condition  of  the  ends 
of  the  bone  or  bones,  the  direction  of  the  line  of  the  fracture,  whether 
obhque  or  transverse,  how  far  they  arc  symmetrical,  the  amount  of  separa- 
tion, and,  especially,  how  far  they  are  normal  or  expanded,  or  atrophied. 
By  the  information  thus  gained  the  surgeon  is  aided  in  his  selection 
amongst  the  different  methods  of  fixation.  The  most  rigorous  asepsis 
is  necessary  for  complete  success  in  these  operations,  which  may  also 
require  great  mechanical  skill,  and  patience.  Careful  after-treatment 
is  also  of  much  importance^ — in  securing  firm  union  without  gradual 
bending,  and  in  restoring  the  movements  and  power  of  the  Umb. 

Operation.  While  the  following  remarks  have  been  inserted  here 
for  the  sake  of  convenience,  they  apply  not  only  to  the  bones  of  the 
leg,  but  also  to  the  humerus  and  femur.  While  the  tibia  offers  a  sub- 
cutaneous surface  on  its  inner  aspect  which  invites  attack,  its  outer 
aspect  can  be  safely  reached  by  working  within  the  detached  periosteum. 
While  this  hint  appHes  to  other  bones  with  important  structures  lying  on 
one  aspect  it  must  not  be  taken  to  sanction  needless  detachment  of  the 
above  membrane.  The  limb  must  be  emptied  of  blood  and  a  tourniquet 
apphed.  In  making  his  incision  the  surgeon  will  be  guided  by  the 
information  given  by  the  X-rays.  A  free  longitudinal  incision  usually 
suffices.  The  remarks  at  p.  919  apply  to  the  exposure  of  the  frag- 
ments. These  are  next  sufficiently  refreshed  by  the  removal  of  any  scar 
tissue,  &c.,  with  a  chisel  and  mallet,  saw,  or  cutting-forceps.  A  thin 
slice  is  thus  removed  from  each  fragment,  and  if  they  lend  themselves  to 
mortising  or  stepping  {vide  infra),  they  are  shaped  accordingly.  They  are 
now  brought  in  apposition,  especial  precaution  being  taken  to  correct 
faulty  rotation  of  the  lower  fragment,  partly  by  extension  and  counter- 
extension,  partly  by  manipulation  with  powerful  elevators  or  forceps. 
Much  difficulty  may  be  met  with  where  one  fragment  is  depressed  and 
firmly  embedded  in  the  soft  parts,  and  the  needful  disturbance  of  these 
may  be  great  in  spite  of  much  ingenuity  and  patience.  Any  tense  bands 
which  interfere  with  the  replacement  must  be  detached  or  divided,  after 
due  examination  of  their  possible  contents.  Thus  in  the  case  of  the 
humerus  the  musculo- spiral  nerve  must  be  remembered.  To  retain 
them  in  place  the  methods  of  fixation  already  mentioned  are  available 
(p.  920). 

Bone- Grafting.  This  subject  has  been  referred  to  at  p.  911. 
Here  the  graft  is  best  taken  from  the  bones  themselves.  In  the  case 
of  a  single  bone  a  portion  covered  with  and  still  connected  with  its 
periosteum,  if  possible,  is  chiselled  off  and  jammed  in  between  the 
freshened  fragments.  This  fixity  is  essential  as  no  wire,  &c.,  can 
usually  be  employed.  In  the  case  of  two  parallel  bones,  hke  the  tibia 
and  fibula,  where  the  intact  condition  of  one  prevents  the  approximation 
of  the  fragments  of  the  other,  the  graft  is  best  taken  from  the  unbroken 
bone  (p.  911).  In  other  cases  the  bone  has  been  taken  from  a 
distance  as  in  Sir  W.  Macewen's  case,  where  the  wedges  removed 
in  osteotomies  were  employed.  As  the  method  of  bone-grafting  is 
chiefly  indicated  in  the  less  promising  cases  where  the  ends  are  much 
atrophied  or  widely  separated,  too  much  must  not  be  expected  from  it. 


926       OPERATIONS  ON  THE  LOWER  EXTREMITY 

Scheuer  has  met  the  difficulty  with  brilliant  success  in  a  severe  case 
of  pseudarthrosis  of  the  humerus  in  a  boy  aged  four.  After  refreshing 
the  ends  of  the  bone  he  implanted  a  flap  from  the  thorax  containing 
a  piece  of  the  fifth  rib.  Bony  union  followed,  and  the  pedicle  was  divided 
fourteen  days  later.^  In  the  case  of  the  lower  extremity,  it  might  be 
possible  to  follow  this  example  by  taking  the  bone  from  the  opposite 
hmb. 

The  question  of  drainage,  and  the  extent  to  which  it  is  advisable 
to  close  the  wound  at  once  with  sutures,  must  depend  on  the  amount 
of  disturbance  inflicted  on  the  parts.  Complete  closure  of  the  wound 
looks  admirable  at  the  time,  but  may  well  entail  too  much  risk.  From 
his  knowledge  of  anatomy  and  the  size  of  any  vessels  divided  the  surgeon 
should  decide  as  to  whether  it  is  safe  to  leave  the  removal  of  the  tour- 
niquet until  the  dressings  are  in  situ,  a  course  always  to  be  followed  if 
possible. 

EXCISION  OF  VARICOSE  VEINS 

This  method,  as  old  as  the  times  of  Celsus,  and  one  which  fell  into 
disuse  from  the  risks  of  pyaemia,  &c.,  was  revived  with  safety  some 
years  ago  by  the  late  Mr.  Davies-Colley,^  when  the  late  Lord  Lister  had 
shown  how  the  old  dangers  might  be  avoided. 

Indications.  Safe  as  this  operation  has  been  made,  it  is  to  be  recom- 
mended with  caution  owing  to  the  great  risk  of  recurrence.  If  this 
operation  is  largely  employed,  and  the  cases  are  carefully  watched, 
it  will  be  found  after  some  years  that  the  amount  of  permanent  benefit 
ensured  is,  in  many  cases,  very  small.  I  allude  especially  to  opera- 
tions performed  below  the  knee  only  {vide  infra),  or  to  those  cases,  often 
of  markedly  diffuse  varicosity,  where  small  multiple  incisions,  thirty  to 
fifty,  are  made  on  the  two  limbs. 

Operative  interference  here  requires  more  discrimination  than  it  has 
received  either  by  surgeons  or  patients.  The  public  look  upon  opera- 
tion here  as  not  only  absolutely  safe,  but  as  equally  certain  to  bring 
about  a  cure.  Any  surgeon  wishing  to  maintain  a  character  for  honesty 
will  consider  this  claim  to  be  a  most  harmful  exaggeration.  While 
careful  operation  in  well-chosen  cases  will  remove  many  discomforts 
and  certain  sources  of  danger,  it  does  not  always  enable  the  patient  to 
dispense  entirely  with  the  need  of  further  attention  to  his  vein. 

Before  the  varices  are  removed  it  must  be  ascertained  that  the  better 
supported  deep  veins,  and  the  large  venous  trunks  through  which  it  is 
intended  that  the  blood  shall  largely  return  after  the  superficial  ones 
are  obhterated,  are  healthy.  A  full,  tumid  condition  of  the  calves,  with 
cramp-like  pains  here,  points  to  a  varicose  state  of  the  sural  veins,  and  is 
against  operation  ;  so  too  is  any  tendency  to  oedema,  or  increase  in 
the  size  of  the  limb  or  dilatation  of  the  superficial  epigastric  veins 
indicating  thrombosis  of  the  femoral  or  ihac  veins.  The  cases  best 
suited  for  operation  are  :  (1)  Where  only  one  vein- trunk  is  involved, 
at  one  or  two  definite  parts  of  its  course.  (2)  Where  both  saphenous 
veins  are  involved,  but  again  definitely  and  locally.  The  more  the  varices 
are  longitudinal,  the  more  they  he  in  the  fines  of  the  trunk,  the  more 
longitudinal  incisions  will  suffice,  the  more  satisfactory  the  operation 
and  the  better  and  more  lasting  the  results.     On  the  other  hand,  where 

^   V.  Bergmann's  Syst.  of  Surg.,  Amer.  Trans.,  vol.  iii,  p.  138. 
^  Guy's  Hospital.  Beforfs,  1875,  p.  431. 


EXCISION  OF  VARICOSE  VEINS  927 

the  enlargement  is  bilateral  and  general,  where  numerous  communi- 
cating veins  between  the  trunks  are  enlarged,  where  the  venous  radicles 
are  becoming  dilated  and  their  ramifications  plexiform,  the  more,  in 
short,  that  the  disease  shows  signs  of  being  a  general  one,  the  more  will 
the  result  be  disappointing.  Finally,  the  soft  parts  near  the  varices 
should  be  in  a  healthy  condition,  free  from  dermatitis,  and  thus  capable 
of  being  rendered  aseptic,  and  of  uniting  quickly  afterwards.  In  a  few 
cases,  though  the  conditions  given  above  as  essential  for  success  are 
absent,  operation  is  still  indicated.  (3)  Where  many  varices  exist,  but 
one  is  especially  troublesome,  as  where  a  very  thin-walled  vein  crosses 
the  tibia  in  an  exposed  position  in  a  young  adult,  to  whom  playing  foot- 
ball, &c.,  means  very  much  ;  or  where  a  varix  is  the  cause  of  an  ulcer 
troublesome  to  heal,  and,  perhaps,  already  the  source  of  dangerous 
bleeding.  (4)  In  some  cases  of  thrombosis.  Where  a  patient  is  the 
subject  of  thrombosis  in  "  the  dangerous  area  "  {vide  infra)  and  the 
thrombus  is  creeping  upwards  a  surgeon  who  can  rely  on  the  case  running 
an  aseptic  course  is  quite  justified  in  placing  a  ligature  on  the  proximal 
side  of  the  thrombus  with  the  view  of  preventing  its  reaching  the  large 
trunks.  How  far  it  is  wise  for  him  to  go  further  and  remove  the  thrombus 
at  the  same  time  or  later  with  the  object  of  preventing  implication  of 
the  deep  veins  and  a  recurrence  of  the  thrombus  must  depened  on  the 
individual  case.  Sir  W.  Bennett  ("  Varix  and  Thrombosis,"  p.  49) 
goes  further  and  considers  that  in  a  certain  number  of  cases  of  thrombosis 
followed  by  embohsm  "  incalculable  good  can  be  done  by  surgical  means 
provided  that  action  is  taken  speedily  and  boldly."  Thus  if  a  thrombus 
in  the  "  dangerous  area  "  {vide  infra)  shows  signs  of  softening,  if  one  or 
two  attacks  of  cardiac  pain  and  dyspnoea  have  occurred,  removal  of  the 
source  of  the  emboli,  or  interruption  by  ligature  of  the  channel  by  which 
they  have  reached  the  central  parts,  and  by  which  they  may  produce 
another  and  a  fatal  attack  is  called  for. 

I  shall  describe  two  operations.  (1)  That  by  which  the  "  dangerous 
area  "  of  Sir  W.  Bennett  is  removed  ;  (2)  that  of  Trendelenberg.  I 
have  used  the  first  largely  and  my  experience  justifies  my  saying  that 
I  consider  it  to  be  the  one  most  suitable  to  the  largest  number  of  cases 
in  which  an  operation  is  justified,  and  one  which  is  least  likely  in  its 
results  to  lead  to  disappointment.  Sir  W.  Bennett,^  has  given  the 
term  "  dangerous  area  "  to  that  part  of  the  inner  aspect  of  the  lower 
limb  "  which  is  marked  off  by  two  transverse  lines,  one  about  the  middle 
of  the  thigh,  and  another  three  inches  below  the  knee-joint,  an  area  in 
which  the  local  conditions  predisposing  to  thrombosis  in  varix  are 
present  in  a  remarkable  degree.  Cysts,  often  of  great  size,  huge,  dilated 
tortuous  vessels,  valveless  and  with  abrupt  bends  are  frequent,  and  are 
constantly  being  subjected  to  the  straining  movements  produced  by 
flexion  and  extension  of  the  knee."  A  little  later  Sir  William  \\Tites  : 
"  Speaking  generally,  if  the  disease  is  confined  to  the  leg,  operation  is 
useless  ;  sometimes  it  is  harmful."  And  again,  "  operative  measures 
confined  to  the  parts  below  the  knee  in  general  varix  are  useless." 

(1)  The  Radical  Operation.  The  skin  of  the  Hmb  or  hmbs  must  be 
first  carefully  shaved  and  sterilised  beforehand,  and  the  varicose  veins 
marked  as  the  patient  stands  in  order  to  distend  them.  Sterilised  carboHc 
acid  fuchsin  solution  is  apphed  either  with  a  sterilised  camel-hair  brush 
or  a  match-stick.     A  steriHsed  dressing  is  then  apphed.    When  the 

^  Loc.  supra  cit.,  p.  18. 


928       OPERATIONS  ON  THE  LOWER  EXTREMITY 

patient  is  under  the  anaesthetic  and  the  limb  has  been  well  elevated 
for  a  few  minutes,  a  sterilised  tourniquet  is  applied  round  the  upper 
third  of  the  thigh.     This  prevents  a  great  deal  of  unnecessary  bleeding, 
and  if  the  veins  have  been  well  marked  there  is  no  disadvantage  in  using 
it.     Moreover  it  prevents  extravasation  of  blood  into  the  tissues.     If  the 
central  end  of  the  long  saphena  vein  is  tied  and  the  dressings  are  firmly- 
applied  before  the  tourniquet  is  removed  there  is  no  fear  of   bleeding 
after  the  operation.     When  it  has  been  impossible  to  mark  the  veins 
accurately  a  tourniquet  is  a  great  disadvantage,  for  the  empty  veins 
are  difficult  to  find.     Under  these  circumstances,  bleeding  can  be  greatly 
diminished  by  commencing  the  operation  near  the  ankle  and  working 
upwards.     As  far  as  possible  longitudinal  incisions  are  used,  for  in  this 
way  the  nerves  are  less  interfered  with  and  after-pains  are  consequently 
less.     There  is  no  advantage  in  removing  any  distended  veins  from  the 
foot,  for  these  are  well  supported  by  the  boot  and  will  greatly  diminish 
if  the  operation  is  thoroughly  carried  out.     Several  longitudinal  in- 
cisions about  two  inches  long  are  required  on  the  inner  side  of  the  leg 
below  the  knee.     In  every  case,  thin  sterilised  pads  are  fixed  with  tissue 
forceps  over  the  edges  of  the  wound.     The  edges  are  held  up  by  the 
forceps,  as  the  vein  is  isolated  and  separated  from  the  internal  saphenous 
nerve.     The  vein  only  is  picked  up  with  two  long  bladed  artery  forceps, 
and  divided  between  them.     As  the  vein  is  liberated  with  a  blunt  dis- 
sector the  forceps  are  rotated  so  that  the  vein  is  wound  upon  it,  the 
winding  proceeding  away  from  the  point  of  the  forceps  to  prevent  the 
coils  slipping.     In  this  way  several  inches  of  the  vein  are  removed,  and 
as  it  breaks  away  very  httle  bleeding  usually  occurs  even  if  no  tourni- 
quet is  used,  and  it  is  easily  stopped  by  pressure  apphed  by  an  assistant 
for  a  few  moments.     Every  lateral  branch  is  clamped  and  treated  in 
a  similar  way.     No  ligatures  are  used  except  for  the  lower  end  of  the  vein 
just  above  the  ankle  and  the  upper  end  just  below  the  saphenous  opening 
for  which  fine  catgut  is  used,  for  otherwise  straining  after  the  operation 
may  induce  bleeding,   especially  from  the  upper  end.     This  method 
was  first  introduced  by  Greig  Smith,  and  is  a  very  valuable,  simple  and 
radical  method  of  removing  the  veins.     Several  incisions  are  generally 
necessary  on  the  outer  side  of  the  leg  and  also  on  the  calf  over  the  short 
saphena  vein.     The  simplest  way  of  doing  this  is  to  get  an  assistant  to 
hold  the  heel  well  up.     As  far  as  possible  incisions  about  the  knee, 
especially  behind  it,  are  to  be  avoided.     In  the  thigh  several  incisions 
are  required  along  the  course  of  the  internal  saphena.     In  stout  patients 
it  is  sometimes  difficult  to  find  the  vein  here,  and  in  them  it  is  an  ad- 
vantage to  make  the  incisions  somewhat  obhque,  for  the  line  of  the  vein 
is  by  no  means  constant.     I  prefer  to  make  the  upper  incision  about 
one  inch  below  the  saphenous  opening,  transverse,  for  this  makes  it  much 
easier  to  find  the  vein  and  the  large  tributary  that  is  commonly  found 
running  obhquely  upwards  and  outwards  from  the  back  of  the  thigh, 
the  removal  of  which  is  essential  for  radical  cure.     This  incision  also 
serves  well  for  the  removal  of  the  large  saphena  varix  sometimes  found 
just  below  the  saphenous  opening.     This  is  commonly  mistaken  for 
femoral  hernia.     The  ligature  at  the  upper  end  of  the  vein  is  apphed 
at  least  an  inch  below  the  saphenous  opening,  but  this  is  not  practicable 
when  there  is  a  high  saphena  varix.     The  wounds  are  sewn  with  fine 
fishing  gut,  and  great  care  is  taken  not  to  insert  the  edges,  and  for  this 
the  button-hole  gtitph  ig  valuable.     The  simplest,  most  secure  and  most 


EXCISION  OF  VARICOSE  VEINS  929 

comfortable  dressine;  is  a  sterilised,  soft  gauze  bandage.  This  is  covered 
by  sterilised  pads  of  wool,  and  a  firm  bandage  is  applied.  Tlie  limbs  are 
afterwards  slightly  raised  on  a  wedge  pillow,  but  no  splint  is  applied. 
A  small  pillow  is  placed  behind  the  knees  to  keep  them  slightly  flexed 
and  prevent  cramp  from  strain  of  the  hamstrings.  When  both  limbs 
are  involved  it  is  a  great  advantage  to  have  two  operators  working  at  the 
same  time,  and  if  the  limbs  are  well  separated,  abducted  and  rotated  out- 
wards this  can  be  conveniently  done. 


Fio.  374.     Excision  of  varicose  veins.     The  veins  are  twisted  round  good 
forceps,  as  they  are  separated  by  blunt  dissection. 

(2)  Trendelenberg's  operation.  Here  about  two  inches  of  the  saphena 
vein  are  resected  just  below  the  saphenous  opening.  This  step  is  only 
indicated  in  those  cases  to  which  Trendelenberg's  test  applies.  The 
limb  having  been  raised  and  emptied  of  much  of  its  blood  the  saphena- 
vein  is  compressed  and  the  limb  lowered.  If  the  blood  can  be  seen  to 
fill  the  empty  vein  immediately  after  the  pressure  is  removed  Treudelen- 
berg  considered  it  proved  that  in  such  a  case  there  was  a  column  of  blood 
reaching  from  the  right  side  of  the  heart  to  the  foot,  unsupported  by 
valves.  The  precaution  mentioned  at  p.  928  must  be  remembered 
here.  Where  there  is  reason  to  suspect  that  the  deep  veins  are  varicose 
this  operation  should  not  be  performed.  The  spine  of  the  pubes  having 
been  identified,  a  line  three  and  a  half  inches  long  is  drawn  from  this 
point  and  an  incision  three  inches  long  made  in  its  lower  half.  By 
some  a  transverse  incision  is  preferred,  for  otherwise  some  difficulty 
may  be  met  in  finding  the  vein  in  fat  patients.  The  saphena  having 
been  isolated  for  two  inches,  this  portion  is  resected  between  two  catgut 
ligatures.  I  need  not  insist  upon  the  absolute  need  of  scrupulous  asepsis 
here.  While  Trendelenberg's  operation  gives  fairly  good  immediate  results 
in  some  cases,  recurrence  commonly  follows  it  in  a  few  years.  For  this 
reason  except  when  there  is  eczema  or  ulceration  of  the  leg,  I  prefer 
the  more  radical  operation  already  described.  Either  operation  may 
be  performed  under  local  or  spinal  anaesthesia  if  the  patient  desires. 


SURGERY  I  59 


CHAPTER   XLV 
OPERATIONS  ON  THE  FOOT 

LIGATURE  OF  THE  DORSALIS  PEDIS  (Fig.  375) 

Indications.  Very  rare.  (1)  Wounds.  (2)  Together  with  the  posterior 
tibial  in  the  lower  third,  for  hemorrhage  from  punctured  wounds  of  the 
sole  resisting  other  treatment.  (3)  For  some  vascular  growths  of  the 
foot. 

Line.  From  the  centre  of  the  ankle-joint  to  the  upper  part  of  the 
first  interosseous  space. 

Guide.     The  above  line  and  the  adjacent  tendons  of  the  great  and 
second  toe. 
Relations : 

In  Front 
Skin,  fasciae  ;   branches  of  saphenous  veins,  and  of  musculo- 
cutaneous and  anterior  tibial  nerves. 
A  special  deep  fascia  continuous  with  the  sheaths  of  the 

adjacent  tendons. 
Extensor  brevis  (innermost  tendon). 

Outside  Inside 

Vein  Dorsalis  pedis     Vein. 

Anterior  tibial  nerve.  artery.  Extensor    longus    hallucis. 

Extensor  longus  digitorum. 

Behind 
Astragalus  ;  scaphoid  ;  middle  cuneiform. 

Operation  (Fig.  375).  The  foot  ha\ang  been  cleansed,  an  incision 
about  an  inch  and  a  half  long  is  made  in  the  line  of  the  artery,  in  the 
lower  part  of  its  course,  commencing  about  an  inch  and  a  half  below  the 
ankle-joint.  .Skin  and  fa.scia3  being  cut  through,  and  any  superficial 
veins  tied  with  fine  catgut  or  drawn  aside,  one  of  the  long  extensors  is 
found  (its  sheath  is  not  to  be  opened),  and  the  strong  fascia  given  ofE 
from  them  opened.  If  the  extensor  brevis  cross  the  artery  at  this  spot 
it  must  be  drawn  aside.  The  hgature  should  be  passed  from  without 
inwards. 

SYME'S  AMPUTATION   (Figs.  376  to  378) 

An  amputation  at  the  ankle-joint  by  a  heel-flap,  with  removal  of  the 
malleoli. 

Operation.  The  thick  skin  of  the  heel  requires  careful  steriHsing. 
Haemorrhage  having  been  controlled,  any  sinuses  present  scraped  out 

930 


SYMF/S  AMPUTATION 


931 


and  disinfectcMl,  and  tli<>  foot  hold  at  right  angles  to  the  leg,  the  surgeon, 
standing  a  little  to  the  right,  but  so  as  easily  to  face  the  sole,  marks 
out  the  points  mentioned  below  with  the  index  finger  and  thumb.  He 
then  makes,  with  a  short,  strong  knife,  an  incision  (in  the  case  of  the 
left  foot)  from  the  tip  of  the  external  malleolus  to  a  point  half  an  inch 
below  ^  the  internal  one,  this  incision  not  going  straight  across  the  sole 
as  in  Pirogoff's  amputation,  but  pointing  a  little  backwards  towards 
the  heel.'-  The  horns  of  this  incision  are  then  joined  by  one  passing 
straight  across  the  joint,  and  severing  everything  at  once  down  to  the 


AHT.  TIBIAL.    At. 


..Aht.  tibial 


W 


FiQ.  375. 


Ligature  of  the  anterior  tibial  in  its  lower  third,  and  of  the 
dorsalis  pedis. 


ankle-joint.  The  foot  being  now  strongly  bent  downwards,  the  lateral 
ligaments  are  severed,  and  the  joint  thus  fully  opened.  The  foot  being 
slightly  twisted  from  side  to  side,  the  tendons  and  soft  parts  on  either 
side  are  carefully  divided,  the  knife  being  kept  closely  in  contact  with 
the  bones.     Especial  precautions  must  be  taken  on  the  inner  side  to 

1  The  directions  usually  given  are  to  go  behind  this  point  as  well  as  below  it,  but  by 
following  the  above  course  the  posterior  tibial  is  more  likely  to  escape  section  before  its 
time,  and  the  flap  will  be  found  sufficiently  symmetrical. 

2  If  the  foot  is  small,  and,  still  more,  if  the  parts  on  the  dorsum  are  damaged,  the 
plantar  incision  should  run  straight  across.  On  the  other  hand,  the  more  prominent  the 
heel,  the  more  should  the  flap  point  backwards.  This  will  facilitate  turning  the  flap  over 
the  heel. 


932       OPERATIONS  ON  THE  LOWER  EXTREMITY 

cut  the  posterior  tibial  artery  as  long  as  possible  (to  ensure  getting  below 
the  internal  calcanean)  and  not  to  prick  it  afterwards. 

As  the  operation  proceeeds  the  flap  is  partly  pressed  back  by  the 
thumb,  partly  pulled  back  and  so  saved  from  damage  by  the  knife.  The 
chief  difficulty  is  met  with  at  the  prominence  of  the  heel. 

The  foot  being  still  more  pressed,  the  upper  non-articular  surface 
of  the  OS  calcis  comes  into  view,  and  then  the  tendo  Achilhs.  This  is 
severed,  and  the  heel-flap  next  dissected  ofE  the  os  calcis  from  above 
downwards,  special  care  being  taken  to  cut  this  flap  as  thick  as  possible, 
not  to  score  or  puncture  it,  but  rather  to  peel  if  off  the  bone  with 
the  left  thumb-nail  kept  in  front  of  the  knife,  aided  by  touches  of 
this.i 

The  foot  having  been  removed,  the  soft  parts  are  carefully  cleared  off 
the  malleoli,  and  a  shce  of  the  tibia  sufficiently  thick  to  include  these 


Fig.  376.     Incisions  and  application  of  Lj'nn-Thomas's  forceps-tourniquet  in 
Syme's  or  Pirogofi's  amputation. 

prominences  removed.  This  slice  should  in  any  case,  to  avoid  shortening, 
be  the  thinnest  possible.  Prof.  Macleod  -  has  recommended  to  remove 
only  the  malleoli,  leaving  the  cartilage  on  the  under  surface  of  the  tibia. 
Prof.  Macleod's  advice  entails  less  shortening  of  the  hmb  and  does 
away  with  the  risk  of  infective  phlebitis,  which  may  be  brought  about 
by  opening  the  cancellous  tissue.  If,  on  the  other  hand,  the  lower 
end  of  the  tibia  is  diseased,  it  must  be  removed  and  the  sawn  surface 
gouged  or  treated  with  a  sharp  spoon.  If  the  cartilage  is  only  slightly 
diseased,  it  may  be  sliced  oft'  with  the  knife,  and  gouged  here  and 
there. 

Tendons  are  now  cut  short,  sinuses  thoroughly  scraped  out  and  disin- 
fected, and  the  vessels  secured.  Free  oozing  is  often  present  in  tuberculous 
cases,  or  where  the  periosteum  has  been  left  in  the  heel-flap.     It  is  best 

^  If,  in  a  young  subject,  the  epiphysis  comes  away  in  the  heel-flap,  it  may  remain  there 
if  the  parts  are  healthy.  The  same  course  may  be  followed  with  the  periosteum,  if  it  is 
found  loose  and  peels  easily  away.  Mr.  Johnson  Smith,  when  amputating  both  feet  for 
frost-bite,  left  the  periosteum  on  one  side.  On  the  other  no  attempt  was  made  to  save  it. 
The  first  stump  was  much  larger  than  the  other,  harder,  and  more  rounded ;  more  like 
that  of  a  Pirogofl's  amputation. 

2  Brit.  Med.  Journ.,  1869,  vol.  ii,  p.  239. 


SYME'S  AMPUTATION 


933 


Fig.  377.     Syme's  amputation. 


TIBIALIS    AITICUS     TCNDON 


CX7CI^30/^     UONQ.     Hy^LLUCIS 


^hlT.  TIBIAL      A 


TIBIALIS     POSTICUS 


P03~.  TIBIAL    ^■-■ 
P03T.   TIBIAL      A/. — 


ANT    TIBIAL     V 


PEKOHEUS    BKE.VIS 
PER.OHEUS    LOHOUS 


•4m-TEHOO   ACHJLLIS 


Fig.  378.     Syme's  amputation.     Showing  the  positions  of  the  important 
structures  in  the  flaps. 

SURGERY  I  59' 


9.34       OPERATIONS  ON  THE  LOWER  EXTREMITY 

treated  by  firm  pressure  with  dry  dressings,  and  elevation  of  the  stump. 
Drainage  having  been  provided  through  the  cup-hke  heel-flap  if  no 
sinuses  are  conveniently  placed,  interrupted  fishing-gut  sutures  are 
inserted.  They  should  be  passed  at  such  a  depth  and  distance  from 
the  edge  of  the  heel-flap  to  ensure  their  holding  this  up  well.  Where 
many  sinuses  have  been  present  along  ^  the  line  of  the  incision,  it  is  no 
good  uniting  the  wound  closely. 

While  the  success  of  a  Synie's  amputation  depends  chiefly  on  the 
care  with  which  the  heel-flap  is  raised,  later  on  attention  must  be  given 
from  the  first,  and  often  for  some  weeks,  to  apply  the  bandages  so  as  to 
hold  the  heel-flap  up  well  and  meet  its  tendency  to  glide  downwards, 
and  afterwards  to  hasten  the  moulding  of  it  into  good  shape.  As  soon 
as  the  stum])  is  healed,  the  patient,  if  his  occupation  require  it,  can  get 


A.  B. 

Fig.  379.     Roux'h  amputation.      The  incisions  shown  from  the  outer  (A.) 
and  the  inner  side  (B.)     (Stimson.) 


about  on  a  knee-rest.     In  about  eight  weeks  he  will  be  able  to  bear 
weight  on  the  stump. 

Roux's  Modification  of  Syme's  Amputation  (Figs.  379  A  and  B).  In 
cases  where  a  satisfactory  heel-flap  cannot  be  obtained,  an  efficient 
substitute  can  be  got  by  a  large  internal  flap. 

The  incision  is  commenced  at  the  apex  of  the  outer  malleolus,  and  carried  half 
across  the  front  of  the  ankle-joint,  from  whence  it  should  run  inwards  in  an  oblique 
direction  over  the  astragalo-scaphoid  joint,  then  pass,  in  a  curved  manner,  down- 
wards and  backwards  to  the  middle  line  of  the  sole  of  the  foot,  and,  running  along 
the  under  surface  of  the  heel,  ascend  the  posterior  aspect  of  that  part,  and  terminate 
at  the  outer  malleolus,  where  it  commenced.  The  ankle-joint  should  be  opened 
at  its  upper  and  outer  part,  the  os  calcis  dissected  from  its  connections,  the  malleoli 
and  a  slice  from  the  articular  surface  of  the  tibia  removed,  and  the  operation  will  be 
comjolete. 

Causes  of  Failure  after  Syme's  Amputation.  (1)  Sloughing  of  the 
heel-flap.  This  is  nearly  always  due  to  faulty  operating,  to  scoring 
or  "  button-holing  "  the  flap,  or  to  dividing  the  posterior  tibial  high 
up.-     (2)  Persistence  of  sinuses  and  tuberculous  disease.     If,  in  spite 

^  iSinuscs  which  have  been  scraped  out  will  give  good  drainage  if  enlarged.  If  any 
puncture  has  been  made  in  the  heel- flap,  it  should  be  utilised  for  the  same  purpose. 

2  If  possible,  the  cut  ends  of  the  two  plantar  arteries  should  always  be  seen,  and  not 
the  single  mouth  of  the  posterior  tibial.  In  the  former  case  the  surgeon  is  certain  that  the 
main  vessel  is  divided  below  the  internal  calcanean  branch. 


PIROGOFF\S  OPERATION  935 

of  repeated  sciaping  out  with  the  aid  of  ana'stlictics,  this  coiiditioii 
recurs  inveteratcly  and  spreads  aloii<i;  the  sheaths,  the  limb  must  l)e 
amputated  higher  up.  'J'liis  will,  liowever,  be  rarely  called  for  with 
perseverance  on  the  part  of  the  surgeon  to  treat  this  condition  as  a  kind 
of  malignant  disease.  If  one  or  two  sinuses  remain,  and  look  likely 
to  persist,  scraping  out  should  be  resorted  to  at  once.  (3)  Caries  in  the 
tibia.     (4)  Death  of  the  tendo  Achillis. 

Tliis  rare  se<iiU'Ia  occurred  to  iiic  in  ISDO.  The  ])aticiit  was  an  aged  inmate  of  the 
Cambei'well  Jnlirmary.  A  bluish  undermined  pati'h  being  laid  open  on  tlu;  back 
of  the  ankle  some  weeks  after  the  amputation,  the  tendon  was  found  to  have  died  up 
to  its  junction  with  the  calf  muscles.     After  its  removal  the  parts  healed  soundly 


PIROGOFF'S  AMPUTATION 

An  amputation  at  the  ankle-joint,  in  which  the  posterior  part  of  the 
OS  calcis  is  retained  and  united  to  the  sawn  surface  of  the  tibia. 

Question  of  the  Value  of  this  Operation  especially  as  compared  with 
Syme's  Amputation.  Disadvantcujes  :  These  have  been  put  prominently 
forward  by  Scotch  surgeons.  (I)  The  amputation  is  not  suited  for 
cases  of  disease,  except  of  distinctly  traumatic  origin  in  young  healthy 
subjects.  (2)  Occasionally  the  sawn  os  calcis  fails  to  unite,  causing 
either  a  kind  of  movable  joint  or  necrosis.  (3)  It  is  said  by  some  that 
the  stump  is  more  difficult  to  fit  with  an  artificial  foot.^  The  first  two 
objections  are  undoubted,  but  I  think  that  they  are  cj^uite  outweighed 
by  the  Advmitaijes  :  ( 1 )  No  dissection  of  the  heel- flap  is  needed.  (2)  The 
blood-supply  is  less  interfered  with.  (3)  The  stump  is  firmer  and  more 
solid.  (4)  The  stump  is  longer  by  one  inch  or  one  inch  and  a  half,  often 
more. 2  (5)  The  stump  does  not  go  on  wasting,  as  is  the  case  after 
Syme's  amputation.^ 

Operation.  The  position  of  the  patient's  foot  and  the  surgeon  being 
as  at  p.  931,  an  incision  is  made,  straight  across  the  sole,  from  the  tip 
of  the  external  malleolus  to  a  point  half  an  inch  below  the  internal  one.^ 
This  incision  goes  right  down  to  the  bone.  Its  horns  are  then  joined  by 
a  transverse  cut  across  the  front  of  the  ankle.  The  lateral  ligaments 
are  now  severed,  care  being  taken  to  cut  inside  the  malleoli  and  to  divide 
the  posterior  tibial  artery  as  long  as  possible,  i.e.  below  its  origin  into 
the  two  plantar,  and  not  to  prick  it  after  it  is  divided.  With  a  few 
touches  of  the  knife  at  either  side  of  the  astragalus,  aided  by  twisting  of 
the  foot  from  side  to  side  and  forcible  bending  of  it  downwards,  the  non- 
articular  part  of  the  upper  surface  of  the  os  calcis  comes  into  view. 
A  groove  is  now  cut  through  the  fatty  tissue  and  the  periosteum,  and 
the  saw  apphed  just  in  front  of  the  tendo  Achilhs,  obHquely  down- 
wards and  forwards,  care  being  taken  to  bring  it  out  through  the 
incision  in  the  heel.     The  foot  being  removed,  the  soft  parts  around 

1  Prof.  Macleod  thinks  that  the  presence  of  the  heel  is  here  "  a  great  drawback,  and 
that  the  back  of  the  heel,  not  the  firm  plantar  pad,  is  what  comes  in  contact  with  the 
ground."     See  the  remarks  p.  937. 

2  Dr.  Hewson  {loc.  infra  cit.)  gives  the  shortening  after  a  Pirogoff's  amputation  aa 
from  one  to  two  inches  ;   that  after  Syme's  operation  as  two  and  a  half  to  three  inches. 

3  'Phc  continuance  of  this  wasting  is  shown  by  the  hospital  patient  being  for  some 
time  oliliged  to  stuff  the  socket  of  his  elephant-boot  with  a  sock.  It  is  not  intended 
by  this  to  depi'cciate  the  value  of  a  Syme's  stump.  Every  surgeon  knows  how  much 
good,  lifelong  work  the  heel-flap  is  capable  of,  however  much  it  shrinks,  so  long  as  it 
has  healed. 

I.e.,  not  pointing  backwards. 


936       OPERATIONS  ON  THE  LOWER  EXTREMITY 

the  bones  of  the  leg  are  carefully  cleared  to  a  level  just  above  the  tibial 
articular  surface  and  the  malleoH,  where  the  saw  is  next  applied,  and 
the  bones  divided  with  a  similar  slight  obliquity,  from  before  backwards 
and  downwards. 

The  vessels,  the  tibials,  anterior  peroneal,  and  perhaps  one  or  both 
malleolar  having  been  secured,  the  tendons  cut  square,  the  bony  surfaces 
are  placed  in  contact,  and,  if  needful,  drilled  and  united  with  a  screw  or 
wire.^ 

If  it  is  found  advisable  to  convert  the  Pirogof!  into  a  Syme,  all  that 
is  needed  is  to  divide  the  tendo  Achillis  and  to  dissect  out  the  part  of 
the  OS  calcis,  keeping  the  knife  close  to  the  bone. 


Fig.  380.     Incisions  for  Pirogoff's  amputation. 

Modifications  of  Pirogoff's  Amputation.  One  of  the  chief  of  these  is  that  intro- 
duced by  Dr.  E.  Watson.-  He  claims:  (1)  That  it  is  shorter  and  easier,  the 
trouble  of  disarticulation  being  avoided.  (2)  That  it  is  less  likely  to  damage  the 
posterior  tibial  arter3\  (3)  That  it  does  away  vvith  one  of  the  chief  diflficulties 
in  a  Pirogoff's  amputation  for  injury,  viz.  the  want  of  purchase  over  the  smashed 
parts  while  the  os  calcis  is  being  sawn  through. 

Operation.  The  operator,  standing  as  before,  having  cut  across  the  sole  from 
the  tip  of  one  malleolus  to  the  corresponding  point  (p.  935)  dowii  to  the  bone, 
introduces  a  small  Butcher's  saw,  or  one  with  a  narrow  blade,  into  this  wound,  and 
saws  off  the  posterior  part  of  the  os  calcis  by  carrying  his  section  upwards  and 
backwards.  This  and  the  heel  being  now  retracted  by  an  assistant  the  surgeon, 
resuming  his  knife,  cuts  upwards  behind  the  ankle-joint  between  the  sawn  bones. 
The  ends  of  the  first  incision  are  now  joined  by  one  jjassing  between  them,  the  skin 
being  pulled  up  a  little  and  the  tendons  and  vessels  severed  down  to  the  tibia  and 
fibula  just  above  the  ankle-joint.  Lastly,  these  bones  are  sawn  through  in  a  slanting 
maimer  by  directing  the  saw  from  before  backwards  and  do^vnwards.3  While  the 
bones  of  the  leg  are  being  sawn,  the  heel-flap  should  be  held  well  up  against  the 
back  of  the  leg  to  keep  it  out  of  the  way. 

^  If  the  patient  is  young  and  healthy,  and  if  there  be  no  tension  on  the  piece  of  os 
calcis  as  this  is  brought  forwards,  this  step  is  not  absolutely  needful.  I  would  recommend 
it  in  other  cases.  Thus  I  have  made  use  of  it  in  a  Pirogoff's  amputation  for  inveterate 
infantile  paralysis,  with  excellent  results.  The  wire,  cut  short,  should  be  well  hammered 
down  and  deeply  embedded. 

-  Lancet,  1859,  vol.  i,  p.  577. 

3  It  will  be  noticed  that  the  direction  of  the  bone-section  here  given  by  Dr.  Watson 
is  contrarv  to  that  usuallv  taught. 


SUB-ASTRAGALOIl)  AMPUTATION 


937 


Modifications  by  Sedillot,  Gunther,  and  Le  Fort.  In  order  to  facilitate  the 
fitting  easily  of  the  sawn  surfuees  of  os  ealcis  and  til)ia  and  (o  niininiise  any  re- 
sistance to  this  stej).  Sedillot  and  Gunther  have  advis('<l  the  very  ol)lique  section 
of  the  bones  shown  in  Figs.  381  and  ;}82.  Pasquier  Le  Fort  goes  still  farther  and 
saws  through  the  os  ealcis,  horizontally,  parallel  to  its  articular  surface,  the  bones 
of  the  leg  being  also  sawn  horizontally. 

From  my  experience  Pirogoff's  operation  gives  excellent  results  if 


Figs.  .381  and  382. 


Modifications   of  Pirogoff's  amputation   by  Sedillot  and 
Gunther.     (Farabeuf.) 


performed  in  suitable  cases  where  the  os  ealcis  and  the  soft  parts  are 

both  sound.     One  difficulty  may  be  met  with  in  cases  of  severe  injury 

where    the    parts    are    badly   smashed, 

and  that   is   the   want   of   the  desired 

purchase   while  the  os   ealcis   is  being 

sawn  through.     The  modification  of  Dr. 

E.  Watson  will  meet  this. 

Operators  sometimes  make  another 
difficulty  for  themselves  by  leaving  too 
large  a  portion  of  the  os  ealcis.  Tension 
is  then  unavoidable  when  the  fragment 
is  brought  upwards  and  forwards. 

SUB-ASTRAGALOID  AMPUTATION 

This  operation  consists — the  soft 
parts  being  divided  as  at  Fig.  383 — in 
opening  the  astragalo-scaphoid  joint 
from  the  dorsum,  and  the  astragalo- 
calcanean,  of  which  the  interosseous 
ligament  can  only  be  divided  by  intro- 
ducing the  knife  point  from  the  outer 
side.  The  whole  foot  is  then  removed 
in  one  mass  with  the  exception  of  the  astragalus,  which  is  left  mortised 
in  between  the  tibia  and  fibula. 

This  amputation  has  been  rarely  practised  in  England,  partly  because 
most  surgeons  have  found  that  those  of  Syme  and  PirogofE  give  good 
results,  partly  because  the  technique  of  the  sub-astragaloid  method  is 
more  complicated  to  remember,  and  also  because  this  method  requires 


Fig.  383.      The    incisions 
astragaloid  amputation, 
chinson.  jun.) 


0.38       OPERATIONS  OX  THE  LOWER  EXTREMITY 

that  the  soft  parts  of  the  sole  should  be  sound  as  far  forwards  as  the 
base  of  the  fifth  metatarsal  bone.  Finally,  Farabeuf,  a  high  authority, 
states  that  the  stump  is  liable  to  be  pulled  up  by  the  tendo  Achillis  taking 
on  a  firm  attachment,  which  brings  the  weight  of  the  body  upon  this 
bone  and  the  neighbourhood  of  the  cicatrix. 

Mr.  J.  Hutchinson,  jun.,  in  a  paper  ^  which,  hke  all  his  writings,  is 
lucid  and  instructive,  strongly  advocates  the  sub-astragaloid  method, 
claiming  the  following  advantages  over  that  of  Syme,  of  which  his  experi- 
ence, necessarily  a  large  one  at  the  London  Hospital,  has  not  been  satis- 


FiG.  384.     Sub-astragaloid  amputation  (right  foot)  by  large  internal  and 
plantar  flap. 

factory  :  (1)  The  stump  is  some  two  inches  longer ;  (2)  it  gives  a 
broader  base  of  support ;  (3)  the  elasticity  due  to  the  ankle  movements 
is  a  marked  advantage  in  walking ;  (4)  the  pad  at  the  end  of  the  stump 
is  much  thicker  ;  (5)  the  arterial  supply  is  better  and  runs  less  risk 
during  the  operation ;  (fj)  an  artificial  foot  can  be  better  fitted  to  the 
stump. 

Operation  (Figs.  383  to  385).  The  following  account  is  taken,  in 
part,  from  Dr.  Stimson's  Manual  of  Operative  Surgery,  p.  US.  The 
chief  guides  are  the  external  malleolus  and  head  of  the  astragalus.  The 
parts  having  been  carefully  sterilised,  especially  the  thick  skin  about  the 
heel,  the  outside  of  the  foot  is  presented  to  the  surgeon  as  at  Fig.  383.    The 

Brit.  Med.  Journ.   October  20,  1900. 


EXCISION  AND  ERASION  OF  THE  ANKLE         \m) 

incisiou  commences  at  tlie  outer  border  of  the  tendo  Acliillis  on  a  level 
of  above  three-quarters  of  an  inch  below  the  external  malleolus,  and  is 
continued  straight  forwards  below  this  prominence  to  the  base  of  the 
fifth  metatarsal.  It  is  thence  carried  across  the  dorsum,  slightly  convex 
forwards,  to  the  base  of  the  first  metatarsal.  It  next  passes  over  the 
inner  side  of  the  foot  and  across  the  middle  of  the  sole,  again  convex 
forwards.  P'rom  the  centre  of  the  sole  it  is  carried  on  to  the  outer  border, 
which  it  gains  just  behind  the  base  of  the  fifth  metatarsal.  Some  opera- 
tors make  it  join  the  first  incision  at  the  calcaneo-cuboid  joint,  others 
carry  it  onwards  and  backwards  over  the  outer  aspect  of  the  foot  as  far 
as  the  outer  tuberosity  of  the  os  calcis,  whence  it  curves  upwards  over 
the  back  of  the  heel  to  join  the  first  at  the 
tendo  Achillis. 

The  incision  is  made  throughout,  down  to 
the  bones,  all  the  tendons  met  with  being 
severed  at  once.  The  soft  parts  are  separated 
from  the  os  calcis  and  cuboid  on  the  outer 
side,  and  on  the  dorsum  dissected  back  to  the 
head  of  the  astragalus.  The  interosseous  liga- 
ment is  then  reached  by  depressing  the  front 
of  the  foot,  passing  the  knife  between  the 
astragalus  and  scaphoid,  and  cutting  back- 
wards and  inwards  along  the  under  surface  of 
the  former.  The  soft  parts  are  next  separated 
on  the  inner  side  from  the  os  calcis,  injury 
to  the  vessels  being  avoided  by  keeping  very 
close    to    the    bone,   the   foot   depressed,   and 

the    tendo    Achillis    divided.      The    posterior  Fig.    385.      Sub-astragaloid 
tibial  nerve  should  be  dissected  out  and  cut  imputation  (left  foot,  outer 

1       ,  aspect). 

short. 

M.  Farabeuf  advises  an  internal  and  plantar  flap,  whose  nutrition 
is  guaranteed  by  a  very  large  base. 


EXCISION  AND  ERASION  OF  THE  ANKLE 

These  may  be  considered  together.  The  operation  performed  is 
usually  a  combined  one,  and  is  not  very  often  called  for,  and  the  principles 
which  should  guide  the  surgeon  in  selecting  one  or  the  other  have  been 
fully  given  at  p.  864. 

Indications.  These  will  be  considered  chiefly  as  they  relate  to  cases 
of  :  A.  Disease  ;  more  briefly  under  the  heading  of  B.  Injury. 

A.  Disease.  The  objections  made  to  operations  on  the  ankle-joint 
are  :  (1)  The  frequency  with  which  the  other  tarsal  bones  are  involved, 
the  depth  to  which  the  astragalus  itself  is  affected,  and  the  poor  vitality 
usually  present  in  the  patients.  As  regards  the  astragalus,  the  whole 
bone  should  always  be  removed,^  and  this  meets,  in  part,  another  reason 

^  Mr.  Holmes,  whose  experience  of  this  operation  was  a  large  one,  advised  [Brit.  Med. 
Journ.,  1878,  vol.  ii,  p.  875)  that  the  whole  of  the  astragalus  should  always  be  removed, 
for  these  reasons  :  (1)  As  it  is  often  softened  to  a  considerable  depth,  mere  removal  of  its 
articular  surface  will  often  leave  disease  behind  ;  (2)  in  patients  of  poor  vitality  the 
violence  done  by  the  saw  may  prove  the  starting-point  of  renewed  caries  ;  (3)  the  bones 
of  the  leg  unite  sufficiently  firmly  to  the  exposed  cartilaginous  surfaces  of  the  os  calcis  and 
scaphoid  ;  (4)  the  shortening  is  not  appreciably  increased ;  (5)  the  difficulty  of  the 
operation  is  lessened. 


940       OPERATIONS  ON  THE  LOWER  EXTREMITY 

brought  forward  by  Prof.  Syme  for  preferring  amputation  at  the  ankle- 
joint,  viz.  the  fact  that  in  disease  of  the  astragahis  the  joint  between 
it  and  the  os  ealcis  is  often  involved.  (2)  The  difficulty  of  free  exposure 
of  the  parts  to  be  dealt  with.  With  the  advantages  of  modern  surgery 
this  objection  has  lost  some  of  its  weight.  (3)  Amputation  at  the  ankle- 
joint  affords  a  better  chance  of  radical  cure,  and  also  a  most  excellent 
stump.  This  may  be  imperilled  by  previous  operations  on  the  ankle- 
joint.  It  is  only  in  patients  with  good  reparative  power,  with  disease 
hmited  to  the  ankle-joint  and  the  astragalus,  and  of  traumatic  origin, 
e.g.  following  a  sprain,  with  no  evidence  of  other  tuberculous  disease  or 
syphilis,  that  operations  on  the  ankle-joint  are  to  be  preferred  to  ampu- 
tation. (4)  The  difficulty  of  securing  a  sphnt  which  will  combine 
(a)  sufficient  rest,  and  (6)  sufficient  exposure  for  the  needful  dressings. 
A  simple  method  is  the  anterior  flat  bar  of  malleable  iron  moulded  to 
the  dorsum  of  the  foot  and  front  of  leg  and  knee-joint,  covered  with 
india-rubber,  supplied  with  hooks  for  suspension,  and  secured  by  plaster 
of  Paris.  This  gives  admirable  access,  and  saves  any  pressure  on  the  heel. 
The  fitting  of  this  splint,  which  can  be  done  on  the  sound  hmb,  requires 
the  careful  attention  of  the  surgeon  himself  beforehand,  especially  as  to 
the  angle  over  the  instep  by  which  the  foot  is  kept  in  right  position. 
Another  method  is  that  with  plaster  of  Paris  and  windows.  When 
the  patient  can  get  up  he  can  use '  a  leg-rest  for  some  months.  In 
those  cases  where,  in  addition  to  a  large  cavity  to  fill  up,  any  tendency 
to  oedema  exists,  a  back  and  two  side-splints — all  being  interrupted — 
may  be  preferable  for  the  first  week  or  ten  days.  The  side-splints  should 
be  boiled  after  removal. 

B.  Injur  If.  In  a  young,  healthy  patient,  where  the  vessels  and 
nerves  are  mainly  intact,  where  the  mischief  is  limited  to  the  ends 
of  the  bones,  an  attempt  to  save  the  limb  by  excision,  partial 
or  complete,  is  abundantly  justified.  The  steps  given  at  p.  915  for 
the  antiseptic,  treatment  of  compound  fractures  should  be  carefully 
attended  to,  as  to  the  preservation  of  periosteum,  the  due  providing  of 
drainage,   &c. 

As  to  gunshot  injuries.  Dr.  Otis  ^  thought  that  "the  substitution  of  excision  of 
the  ankle-joint  for  amputation  effected  no  saving  of  life,"  formal  excisions  being 
rarely  successful.  The  experience  in  later  wars  appears  to  be  similar.  Mr.  Makins, 
C.B.,^  writes  :  "  The  ankle-joint  maintained  the  undesirable  character  which  it  has 
always  held  as  a  subject  for  gunshot  injuries.  This  is  entirely  a  question  of  sepsis, 
and  in  great  measure  depends  on  the  fact  that  the  foot,  as  enclosed  in  a  boot,  is 
invested  with  skin  particularly  difficult  to  cleanse  thoroughly  ;  while  the  socks  are 
an  additional  source  of  infection  before  the  patients  come  under  proper  treatment. 
Of  seven  cases  of  suppurating  ankle-joint  of  which  I  have  notes,  only  two  retained 
the  foot,  and  one  of  these  after  a  very  dangerous  illness." 

Operation.  The  necessary  exposure  may  be  secured  either  by  two 
lateral  incisions  or  by  a  transverse  one,  dividing  the  tendons  in  front, 
some  of  which  are  sutured  afterwards.  Of  these  the  first  is  preferable, 
theoretically,  owing  to  the  smaller  injury  inflicted  upon  the  soft  parts. 
For  myself,  considering  that  a  stable  and  sound  foot  is  the  first  desidera- 
tum, and  that  in  most  hands  a  transverse  incision,  prolonged  laterally 
as  freely  as  is  needful,  gives  the  best  exposure,  and  thus  facilitates  the 
eradication  of  all  the  diseased  parts,  which  is  so  essential  in  dealing  with 

1  Med.  and  Surg.  Hist,  of  the  War  of  the  Rebellion,  Part  iii,  p.  610. 
*  Surgical  Experiences  in  Sotith  Africa,  1899-1900    p.  239. 


EXCISION   AND    ERASION   OF   THE  ANKLK       941 

tuberculous  disease,  I  have  generally  employed  this  method.  If  the 
suturing  of  the  chief  tendons  is  not  successful — and  this  is  a  matter  of 
difficulty  with  the  usually  small  tendons— the  subse(£uent  stiffness  of  the 
toes  is  partly  made  up  for  by  the  mobility  gained,  in  young  subjects, 
at  the  medio-tarsal  joint. 

Lateral  Incisions.  There  are  numerous  modifications  of  these,  but 
tli(>  chief  point  to  remember  is  to  make  them  freely  from  a  point  about 
two  inches  above  the  malleoli  to  one  about  the  centre  of  the  lateral 
aspects  of  the  foot.  The  parts  having  been  carefully  sterilised,  and 
a  tourni(iuet  a])plied,  the  foot  is  laid  upon  its  inner  side,  and  firmly 
supported  by  a  sand  pillow.  A  shghtly  angular  incision  is  then  made 
from  a  point  two  inches  above  the  external  malleolus  behind  this  pro- 
minence to  one  within  an  inch  of  the  base  of  the  fifth  metatarsal.  The 
external  saphena  vein  is  drawn  aside  or  secured  between  two  ligatures. 
The  two  peronsei  tendons  are  carefully  preserved.  The  wound  being 
protected  with  sterile  gauze,  the  foot  is  turned  over  and  a  similar  angular 
incision  is  made  on  the  inner  side  forwards  and  downwards  as  far  as  the 
projection  of  tlie  internal  cuneiform.  In  the  centre  of  the  incisions  the 
operator  should  work  down  to  the  capsule  of  the  joint ;  the  ends  are 
made  free  in  order  to  give  room,  and  also  to  admit  of  identification  and 
displacement  of  the  tendons.  Thus  the  peronei  on  the  outer,  and  the 
tibialis  posticus  and  flexor  longus  digitorum  on  the  inner  side,  must  be 
carefully  but  sufficiently  displaced  from  their  connection  with  the  fibula 
and  tibia,  or  difficulty  will  be  met  with  in  adequately  displacing  the  foot 
inwards  or  outwards.  The  capsule  being  identified,  by  means  of  a 
periosteal  elevator  the  structures  in  front  of  the  joint,  tendons,  vessels 
and  nerves  are  raised  en  masse  by  pushing  inwards  and  outwards  from 
the  lateral  incisions  and  up  and  down  as  well.  As  much  of  the  anterior 
part  of  the  capsule  as  possible  is  then  snipped  away  in  one  piece.  The 
next  step  is  removal  of  the  astragalus.  The  joint  between  it  and  the 
scaphoid  is  first  opened,  and  its  connections  with  the  os  calcis  taken  next.  By 
alternate  eversion  and  inversion  of  the  foot  the  lateral  hgaments  are  divided, 
with  the  help  of  an  elevator  and  sequestrum- forceps  the  astragalus  is  raised 
and  drawn  in  difterent  directions  as  the  hgamentous  fibres  are  divided 
with  strong  blunt-pointed  curved  scissors.  The  interosseous  ligament 
is  next  severed  ;  if  disease  be  present  here  it  must  be  thoroughly  treated 
with  a  gouge.  The  difficult  removal  of  the  astragalus  must  be  efi'ected 
gradually,  and  without  any  needless  bruising  of  the  adjacent  bony  and 
cartilaginous  surfaces.  The  presence  of  the  flexor  longus  hallucis, 
posteriorly,  must  be  remembered.  The  articular  surfaces  of  the  tibia 
and  fibula  are  next  scrutinised,  by  thrusting  them  through  one  of  the 
lateral  incisions.  If  they  appear  healthy  the  cartilage  should  be  well 
rubbed  with  sterile  gauze  to  ensure  the  removal  of  any  tuberculous 
material.  Any  disease  present  must  be  removed  by  shaving  ofi'  the  carti- 
lages, or  by  a  gouge.  Removal  of  either  malleolus,  even  subperiosteally, 
and  in  a  young  subject,  is  likely  to  interfere  with  the  after- stability  of  the 
foot.  Free  access  having  been  thus  attained,  any  remnants  of  the  synovial 
membrane  at  the  back  and  postero-lateral  aspects  of  the  joint  are  removed, 
and  sterilised  iodoform  or  emulsion  of  iodoform  and  glycerine  (10  per  cent.) 
apphed  to  the  cavity  left.  As  this  must  in  any  case  be  a  considerable 
one,  I  recommend  that  the  needful  drainage  be  secured  by  only  suturing 
the  upper  extremities  of  the  incisions,  and  shnging  the  foot  for  the  first 
few  days  laterally,  so  that  one  of  the  incisions  is  kept  facing  down- 


942       OPERATIONS  OX  THE  LOWER  EXTREMITY 

\A'ards.  After  the  deeper  dressings  have  been  secured  by  a  few  figure-of-8 
turns  the  bandage  should  be  carried  firmly,  beginning  at  the  roots  of  the 
toes  (this  area  having  been  sterilised)  from  below  upwards,  so  as  to 
prevent  any  oedema  of  the  foot.  As  the  only  arteries  cut  are  small 
ones,  branches  of  the  peroneal  and  malleolar,  the  Esmarch  bandage  need 
not  be  removed  until  the  dressings  are  in  situ. 

To  secure  a  good  result  much  care  is  needed  afterwards  to  meet 
the  tendency  to  displacement,  which  is  two-fold  :  (a)  pointing  of  the 
foot  downwards ;  (6)  a  lateral  displacement.  While  here,  as  after 
other  erasions,  it  is  not  always  needful  to  disturb  the  deepest  dressings, 
it  is  well  to  re-apply  the  bandage  at  short  intervals  to  promote  early 
consolidation  of  the  deeper  parts  of  the  wound,  and  aid  in  the  obliteration 
of  any  infective  material.  After  three  weeks,  if  the  wound  be  healed, 
active  and  passive  movements  may  be  gently  begun.  No  weight  is  to 
be  borne  on  the  foot  for  two  months.  A  boot  with  lateral  supports 
will  be  required  for  some  time. 

A  Transverse  Incision.  After  the  full  account  given  above  it  is 
needless  to  go  into  details  here.  In  my  opinion  this  method  is  especially 
indicated  in  doubtful  cases,  where  the  surgeon  has  the  probability  of 
amputation  being  required  strongly  before  him.  it  being  now  very  easy 
to  proceed  to  removal  of  the  foot  by  Prof.  Symes  method. 

The  parts  having  been  sterilised  and  rendered  evascular  as  before, 
a  transverse  incision  between  the  malleoh  is  made  down  to  the  tendons. 
Before  these  are  severed  guiding  sutures  of  sterihsed  silk  are  placed  in 
the  tibialis  anticus,  extensor  propriiis  hallucis  and  digitorum,  and  the 
anterior  tibial  nerve.  All  the  structures  in  front  of  the  joint  are  then 
severed,  the  joint  opened,  and  the  operation  completed  on  the  hues 
already  given.  It  is  always  well  to  remove  the  astragalus,  in  order  to 
secure  better  access  to  the  diseased  structures. 

G.  A.  Wright,  of  Manchester,  who  gave  such  a  healthy  impetus  to 
erasion  of  joints,  thus  describes  a  case  operated  on  as  long  ago  as  1882.^ 

The  child  was  8  years  old.  The  joint  was  opened  by  a  transverse  incision  across 
the  front  of  the  joint,  dividing  all  the  extensors,  &c.  ;  tuberculous  synovitis  existed 
with  subchondral  caries,  all  the  diseased  tissue,  as  well  as  the  loosened  cartilage,  were 
removed  as  far  as  possible.  The  tendons  were  stitched  together  with  catgut  and 
the  woimd  closed.  No  attempt  was  made  to  unite  the  nerve ;  the  anterior  tibial 
artery  was  twisted.  The  wound  was  very  slow  in  healing,  but  three  years  later  the 
child's  condition  was  as  follows  :  "  Foot  sound  and  well,  but  the  toes  are  somewhat 
pointed,  and  he  '  throws  '  the  foot  in  walking.  He  gets  about  well  with  a  boot  and 
without  any  support.  A  good  deal  of  new  bone-formation  about  line  of  incision, 
but  some  mobility." 

Those  interested  in  erasion  of  this  joint  should  refer  to  a  paper  by 
Sir  W.  A.  Lane,-  in  which  a  very  free  extension  of  the  transverse  in- 
cision is  advocated  ;  and  one  by  the  late  Mr.  Glutton,^  in  which  four 
vertical  incisions  are  made,  one  in  front  and  one  behind  each  malleolus, 
and  the  tendons  and  ligaments  ahke  avoided.  The  disease  is  removed 
by  the  sharp  spoon  and  irrigation,  aided  by  the  finger.  As  stated  by  Mr. 
Clutton,  an  exactly  similar  method  was  described  by  Bruns.'* 

^  Diseases  of  Children,  Ashby  and  Wright,  p.  633. 
-  Clin.  Soc.  Trans.,  vol.  xxvii,  p.  15. 
3  Trans.  Med.  Chir.  Soc,  vol.  Ixxvii,  p.  101. 
*  Munch.  Med.  Woch..  1891. 


EXCISION  OF  BOXES  AXD  JOIXTS  OF  TARSUS    943 


EXCISION  OF  BONES  AND  JOINTS  OF  THE  TARSUS 

Before  coiisideriiitr  these  separately,  I  would  invite  attention  to  the 
following  practical  points  : 

(i)  Those  cases  are  the  least  hopeful  in  which  there  is  no  history  of 
injury,  in  which  there  is  e\'idence  of  a  tuberculous  constitution,  or  perhaps 
of  disease  dating  to  an  exanthem  and  coupled  with  the  above  constitu- 
tion ;  cases  in  which  the  patient 
is  wan  and  sickly  with  long- 
lasting  pain  and  sleeplessness ; 
those  in  which  the  parts  are 
much  swollen,  dusky  red,  and 
glossy,  with  sinuses  numerous  or 
excavated,  all  points  denoting  a 
disease  that  is  not  limited  to  one 
joint  or  to  few  bones,  (ii)  Mere 
laying  open,  and,  still  more,  in- 
jection of  sinuses  where  there  is 
disease  of  the  tarsus  is  absolutely 
useless  in  most  cases,  (iii)  When 
a  patient  is  imder  care  for  caries 
of  the  foot,  his  lungs  should 
always  be  carefully  examined 
before  operative  treatment  is 
undertaken.  (iv)  When  the 
amoimt  of  disease  present  is 
being  estimated,  it  must  be 
remembered  that  patients,  espe- 
cially children,  will  often  use 
their  feet  with  much  freedom, 
limping,  even  bearing  their  weight 
on  their  toes  with  the  aid  of 
a  crutch,  though  all  the  time 
extensive  disease  is  present 
(v)  That,  before  an  operation,  the 
parts  should  always  be  rendered 
absolutely  avascular  by  elevation 
and  a  tourniquet,  and  that  thus 
the  limit  of  the  disease  should  be 
defined  as  accurately  as  possible, 
(vi)  Subperiosteal  excision  is  in 
my  opinion  rarely  ad\'isable  in 
tuberculosis.      It  is  here  a  step 

full  of  risk  and  does  not  offer  any  sufficiently  compensatory  advan- 
tages except  in  the  os  calcis  which  is  important  as  the  insertion  of  the 
powerful  tendo  Achillis.  (vii)  Strict  antiseptic  precautions  should  be 
made  use  of  wherever  this  is  possible,  because — {a)  Prolonged  suppura- 
tion will  exhaust  a  patient  whose  powers  are  already  sufficiently  handi- 
capped by  disease  and  operation  ;  (6)  Suppuration  will  cause  destruction 
of  the  periosteum,  and  thus  fresh  caries  and  necrosis  ;  (c)  Interference 
with  inflamed  bones  may,  if  infection  result,  easily  cause  osteo-myehtis 
and  pyaemia,  f^^ii)  When  the  question  arises  between  excision  and  am- 
putation, if  the  powers  of  repair  have  been  duly  considered,  the  question 


Fig.  386.     To  show  the  arrangement  of  the 
tarsal  svno^^al  membranes.     (MacCormac. ) 


944       OPERATIONS  ON  THE  LOWER  EXTREMITY 

of  time  and  the  rank  of  life  should  also  be  remembered.  Thus,  after  an 
extensive  excision,  six  months  will  probably  be  required  before  the  foot 
can  be  used,  but  only  three  months  after  an  amputation.  The  time  in 
the  first  case  may  after  all  be  wasted,  a  point  of  much  importance,  when 
the  question  of  schooling,  learning  a  trade,  &c.,  have  to  be  considered, 
(ix)  No  use  of  a  foot  can  be  permitted  after  an  operation  till  firm  con- 
solidation is  obtained,  (x)  If  tuberculous  mischief  persist  after  an  opera- 
tion, the  sharp  spoon  must  be  freely  used,  together  with  laying  open 
sinuses,  snipping  away  of  undermined  skin,  &c.  If  all  carious  bone 
has  been  removed,  the  above  steps  may  be  repeated  here,  as  in  the  knee, 
with  ultimate  success,  if  good  general  health  be  maintained. 

EXCISION  OF  THE  ASTRAGALUS 

Indications.     These  will  be  for  A.  Disease,  B.  Injurij. 

A.  Disease.  (1)  Claries  of  the  bone,  especially  when  comparatively 
recent  and  of  traumatic  origin  in  a  young  and  healthy  patient,  and 
when  the  disease  is  found  to  be  hmited  to  the  upper  surface.  (2)  In 
disease  of  the  astragalo-calcanean  joint,  where  it  is  thought,  from  the 
position  of  the  sinuses,  &c.,  to  be  more  advisable  to  expose  this  joint 
by  removing  the  astragalus  than  the  os  calcis. 

B.  Injur ij.  (1)  Primarily,  (o)  In  simple  dislocation  of  the  astragalus 
not  reducible  with  the  aid  of  anaesthetics  and  tenotomy  of  the  tendo 
Achillis  and  the  tibials  or  extensors,  if  it  seem  hkely  that  the  skin  will 
slough.  (6)  In  compound  dislocation  of  the  astragalus  when  the  bone 
is  too  far  displaced  or  comminuted  to  admit  of  replacement,  and  when 
the  condition  of  the  soft  parts,  vessels,  and  tendons  does  not  call  for 
amputation.  (2)  Secondarily,  when  the  foot  is  useless  and  painful. 
In  these  cases,  especially,  strict  antiseptic  precautions  must  be  taken 
and  free  drainage  provided. 

Operation.  This  may  be  performed  by  two  lateral  or  a  transverse 
incision,  with  subsequent  suture  of  the  tendons,  as  already  described 
(p.  942).  In  tuberculous  cases,  especially  where  amputation  may  be 
found  needful,  I  prefer  the  freest  exposure.  In  some  cases  where  a 
sequestrum  is  found  on  the  upper  surface,  the  removal  of  this  and  the 
use  of  the  gouge  is  all  that  is  required.  More  usually  the  bone  needs 
removal  and  its  articulation  with  the  scaphoid  and  the  os  calcis  requires 
attention.  The  necessary  steps  and  the  after-treatment  have  been  fully 
described  at  p.  942. 

EXCISION  OF  THE  OS  CALCIS 

Practical  Remarks.  Disease  here  is  not  very  infrequent,  and  often 
remains  limited  to  this  bone  for  a  long  time.  It  may  commence  in 
one  of  three  sites,  viz.  (a)  the  posterior  epiphysis,  which,  not  appearing 
until  the  tenth  year,  does  not  unite  till  between  the  fifteenth  and  nineteenth 
years  ;  {h)  the  body  of  the  bone  ;  (c)  the  calcaneo-astragaloid  joint, 
de  novo,  or  as  an  extension  from  the  astragalus.  The  diagnosis  of  primary 
disease  in  this  joint  is  often  difficult ;  thus  the  swelling  and  position  of  the 
sinuses  recall  disease  of  the  ankle-joint.  The  pain  is  usually  greater 
than  in  ordinary  disease  of  the  os  calcis  itself,  and  the  foot  is  sooner 
disabled.  With  the  X-rays,  and  an  anaesthetic,  the  ankle-joint  is  found 
free,  and  probes  introduced  by  sinuses  may  pass  towards  the  level  of  the 


EXCISION  OF  THE  OS  CALCIS  945 

upper  surface  of  the  os  calcis  (known  by  the  tubercle  for  the  extensor 
brevis). 

Operation.  The  parts  having  been  sterilised  and  rendered  evascular, 
and  the  foot  tirnily  supported  on  its  inner  side  at  the  edge  of  the  table, 
an  incision  ^  is  made  with  a  strong-backed  scalpel,  commencing  at  the 
inner  edge  of  the  tendo  Achillis,  and  passing  along  the  upper  border 
of  the  OS  calcis  {vide  supra)  at  the  outer  border  of  the  foot  as  far  as  the 
calcaneo-cuboid  joint,  which  lies  midway  between  the  outer  malleolus 
and  the  fifth  metatarsal  bone.  This  incision  should  go  down  at  once 
upon  the  bone,  so  that  the  tendon  should  be  felt  to  snap  as  the  incision 
is  commenced.  Another  incision  is  then  to  be  drawn  vertically  across 
the  sole,  commencing  near  the  anterior  end  of  the  first,  and  terminating 
just  short  of  the  inner  surface  of  the  os  calcis,  beyond  which  it  should  not 
extend  for  fear  of  wounding  the  posterior  tibial  vessels.  The  bone 
being  now  exposed  by  throwing  back  the  flap,  the  calcaneo-cuboid  joint  is 
first  found  and  opened.  The  peronei  must  be  dissected  out,-  and  drawn 
aside  with  a  blunt  hook.  The  astragalo-calcanean  joint  is  next  attacked  ; 
and  the  close  connnection  between  the  bones  at  this  point  constitutes  the 
principal  difficulty  of  the  operation,  unless  the  Hgaments  have  been 
destroyed  by  disease.  This  difliculty  can  best  be  met  by  grasping  the 
bone  firmlv  "with  lion-forceps,  and  wrenching  it  backwards  and  outwards, 
aided  by  levering  movements  of  an  elevator,  and  a  knife-point  kept 
very  close  to  the  bone.  Especial  care  must  be  taken  on  the  inner  side 
to  avoid  the  vessels.  The  bone  being  removed,  the  gap  is  hghtly  plugged 
with  gauze,  and  the  dressings  apphed  before  the  tourniquet  is  removed. 

The  question  of  preserving  the  periosteum  has  already  been  referred 
to  (p.  943).  I  have  found  subperiosteal  excision  of  the  tuberculous  os 
calcis  a  good  operation,  and  a  healthy  new  bone  of  good  size  has  usually 
resulted. 

OPERATIONS  FOR  MORE  COMPLETE  TARSECTOMY 

It  is  scarcely  worth  while  to  give  directions  for  the  removal  of  other 
single  bones,  e.g.  the  scaphoid  and  cuboid,  as  these  are  rarely  diseased 
alone,  and,  if  this  should  be  so,  their  removal  is  easy. 

The  operation  of  Dr.  P.  H.  Watson  will  be  described  to  meet  those 
cases  where  more  extensive  disease  is  present,  and  where  the  patient's 
age  and  condition  justify  a  trial  of  these  severe  operations  instead  of 
amputation.  In  the  very  few  cases  which  call  for  these  operations 
Watson's  is,  in  my  opinion,  to  be  preferred,  as  it  leaves  a  foot  at  right 
angles  vdth.  the  leg. 

Operation  of  Watson.  This  is  adapted  to  ca.ses  where  the  medio-tarsal 
articulation  is  involved,  the  importance  of  which,  from  the  number  of  bones  and  the 
complicated  s^^lo^^al  membrane,  is  well  kno'ma  (p.  94.3).  In  other  words,  the 
disease  should' be  situated  between  the  bases  of  the  metatarsal  bones  in  front  and 

1  The  above  incision  is  taken  from  Mr.  Holmes"  article  {Syst.  of  Surg.,  vol.  iii,  p.771). 
A  still  better  one  is  that  advised  by  Farabeuf  {Man.  Oper.,  p.  759)  : — A  horseshoe- shaped 
incision  is  made  round  the  heel,  beginning  at  the  calcaneo-cuboid  joint,  di\-iding  the 
tendo  Achillis,  and  ending  on  the  inner  aspect  of  the  foot,  external  to  the  posterior  tibial 
vessels  and  nerves.  To  this  incision  a  short  vertical  one  is  added,  running  up  along  the 
outer  side  of  the  tendo  Achillis.  By  turning  aside  the  flaps  thus  marked  out  the  bone  is 
most  thoroughly  exposed. 

2  5Ir.  Holmes  {loc.  sitpra  cit.)  says  that  he  has  always  divided  these  without  ill  effect. 
Care  must  be  taken  in  drawing  the'm  aside,  for,  if  this  is  done  too  vigorously,  one  may 
slough,  as  happened  to  me  in  one  of  my  cases. 

SURGERY  I  6o 


946       OPERATIONS  ON  THE  LOWER  EXTREMITY 

the  OS  calcis  and  the  astragalus  behind.  The  parts  being  rendered  avascular,  inci- 
sions three  to  four  inches  long  are  made,  on  the  outer  side  from  the  centre  of  the  os 
calcis  to  the  middle  of  the  fifth  metatarsal  bone,  and  on  the  inner  from  the  neck  of 
the  astragalus  to  the  middle  of  the  first  metatarsal.  The  soft  parts  are  carefully 
dissected  off  from  the  dorsal  and  plantar  aspects  of  the  foot  by  means  of  these  inci- 
sions, the  left  thumb  being  kept  between  the  point  of  the  knife  and  the  soft  parts. 
With  a  curved  probe-pointed  bistoury  the  joints  between  the  astragalus  and 
scaphoid,  and  os  calcis  and  cuboid,  are  oj^ened  up,  and,  a  saw  being  passed  between 
the  plantar  soft  parts  and  the  metatarsal  bones,  these  are  cut  through  from  below 
upwards.  The  diseased  bones  being  removed,  the  wound  is  firmly  plugged  and 
pressure  applied  with  gauze  pads  and  bandages  before  the  tourniquet  is  removed. 
That  this  operation,  though  little  knowii,  is  an  excellent  one  in  Dr.  Watson's  hands 
is  shown  by  the  fact  that  five  out  of  his  six  cases  did  well.  It  must  be  remembered 
that  it  is  an  operation  in  the  dark,  and  one  that  may  involve  a  good  deal  of  damage 
to  soft  parts,  owing  to  the  amount  of  disease  which  has  to  be  removed  by  somewhat 
limited  incisions. 

CHOPART'S  AMPUTATION  (Fig.  387) 

In  this  medio-tarsal  amputation  only  the  astragalus  and  the  os  calcis 
are  retained,  disarticulation  being  effected  through  the  joints  between 
the  above  bones  and  the  scaphoid  and  the  cuboid. 

Value  of  the  Operation.  This  has  been  a  good  deal  disputed.  The 
following  objections  have  been  raised  to  it  : 

(1)  That  the  tendo  Achillis,  no  longer  counterbalanced  by  the  extensor 
muscles,  which  have  now  lost  their  attachment,  draws  up  the  heel,  tilting 
down  the  scar,  which  now  becomes  tender  and  irritable  (Fig.  388).  (2)  In 
the  normal  foot  the  weight  of  the  body  is  transmitted  through  the  astra- 
galus to  the  other  bones  of  the  tarsus  and  metatarsus.  When,  as  in 
this  amputation,  these  bones  have  been  removed,  the  weight  of  the 
body  tends  to  thrust  forward  the  astragalus,  no  longer  supported 
by  the  elastic  bones  in  front,  against  the  scar,  and  thus  renders  this 
tender  and  cripphng.  The  above  objections  apply  to  the  operation  per- 
formed for  injury  or  disease,  the  next  to  amputation  for  the  latter 
only.  (3)  If  the  operation  be  made  use  of  in  caries,  this  disease  is  likely 
to  recur  in  the  two  bones  left.  In  answer  to  the  first  two  of  the  above 
objections  it  may  be  said  that  this  tendency  to  tilting  upwards  of  the 
heel  and  downwards  of  the  scar  may  be  met  :  (a)  By  stitching  the 
anterior  tendons,  e.g.  tibialis  anticus,  extensor  proprius  hallucis,  and 
some  of  the  tendons  of  the  extensor  communis,  into  the  tissues  of  the 
sole-flap  with  catgut,  so  as  to  give  them  a  fixed  point  by  which  they 
may  counterbalance  the  tendo  AchilHs  ;  ^  (6)  by  cutting  the  plantar 
flap  sufficiently  long,  and  securing  firm  primary  union  ;  (c)  by  division 
of  the  tendo  Achilhs.  This,  however,  is  only  of  fugitive  value  ;  {d)  wearing 
a  wedge-shaped  pad  in  the  boot  to  raise  the  front  of  the  stump. 

The  third  objection  is  answered  by  only  performing  this  operation 
for  caries  when  the  disease  is  limited  to  the  front  of  the  foot,  is  of  dis- 
tinctly traumatic  origin,  and  occurs  in  a  healthy  patient. 

Operation  (Figs.  387  to  389).  A  tourniquet  being  apphed,  and  the 
foot  supported  at  a  right  angle  over  the  edge  of  the  table,  the  surgeon, 

1  We  owe  this  ingenious  precaution  to  Mr.  Delegarde,  of  Exeter.  Till  it  is  more 
frequently  made  use  of,  and  a  larger  number  of  cases  are  collected,  the  value  of  this 
amputation  must  remain  somewhat  undecided.  I  have  operated  on  five  occasions— one  a 
severe  crush,  another  for  the  results  of  perforating  ulcer,  and  in  three  for  caries  of  the 
front  of  the  foot ;  in  all  this  precaution  was  taken,  and  the  stumps  proved  sound  and 
useful.  One  of  these  cases  of  Mr.  Jacobson  was  seen  bj'  me  thirty  years  later.  She 
had  an  excellent  stump.  The  writer  has  seen  similar  good  results  years  after  intra-utcrine 
amputations. 


CIIOPART'S  AMPUTATION 


947 


standing  to  the  right  side  of  the  foot,  and  so  that  he  can  easily  face  the 
sole,  places  {e.(j.  on  the  right  side)  his  left  index  and  thumb  iinmediately 
above  the  tubercle  of  the  scaphoid  and  the  c()iresj)()iidiiig  p(jint  on  the 
outer  side,  viz.  the  calcaneo-cuboid  joint,  wliicli  lies  midway  between 


Fig.   387.     Choparfs  amputation.     The   dorsal   flap   has  receded  due  to  the 
extreme  plantar  flexion. 

the  external  malleolus  and  the  base  of  the  fifth  metatarsal  bone.  He 
then  joins  these  points  by  a  shghtly  curved  incision  crossing  the  tarsus, 
and  dividing  everything  down  to  the  bones.  The  foot  being  flexed 
upwards,  a  plantar  flap  is  then  marked  out  by  an  incision  running  from 
the  outer  extremity  of  the  first  up  the  outer  side  of  the  little  toe,  then 
across  the  sole  on  a  fine  just  short  of  the  balls  of  the  toes,  and  then  down 
the  inner  side  of  the  great  toe  to  join  the  inner  extremity  of  the  first.^     The 


Fig.  388.     Stump  after  Chopart's 
amputation.     (Fergusson.) 


Fig.  389.  Stump  stated  by  Farabeuf 
to  be  often  met  with  after  Chopart's 
amputation,  showing  its  shape,  the 
position  of  the  bones,  and  the  influence 
of  the  tendo  AchiUis. 


flap  thus  marked  out  is  raised  with  the  same  precautions  given  at  p.  949. 
It  is  then  held  out  of  the  way,  and  the  anterior  half  of  the  foot  being 
strongly  depressed,  disarticulation  is  efl'ected  by  passing  the  knife  above 
the  tubercle  of  the  scaphoid  between  this  bone  and  the  astragalus,  and 

1  The  flap  should  be  a  full  inch  shorter  than  that  in  Lisfranc's  operation  (p.  949),  if 
the  tissues  are  sound.  An  unduly  long  and  large  plantar  flap  will  here,  as  after  a 
Lisfranc's  amputation,  form  an  unwieldy  pocket  (Treves). 


948       OPERATIONS  OX  THE  LOWER  EXTREMITY 

then  between  the  concavo-convex  surfaces  of  the  calcaneo-cuboid  joint. 
In  effecting  this  the  position  of  the  joints  and  the  shape  of  the  astraga- 
lus must  be  remembered,  and  Mr.  Skey's  words  borne  in  mind  :  "  The 
joints  should  be  opened  with  tact  and  not  by  force  :  if  the  knife  be 
apphed  to  the  right  surface,  it  will  pass  without  effort  into  the  articula- 
tion ;  if  in  the  wrong  direction,  no  force  will  effect  it." 

The  anterior  tibial  and  plantar  arteries  are  then  secured,  and,  on 
removal  of  the  tourniquet,  any  other  vessels  which  require  it.     The 

flap  is  then  folded  up  over  the 
bones,  but  without  any  forcible 
bending,  which  might  interfere 
with  the  blood-supply.  While  it 
is  held  in  this  position,  before  any 
sutures  are  inserted,  the  extensor 
tendons  {vide  supra)  should  be 
carefully  stitched  with  sufficiently 
stout  silk  into  the  fibrous  tissues 
which  abound  in  the  plantar  flap, 
care  being  taken,  in  so  doing,  not 
to  puncture  the  external  plantar 
vessels,  but  at  the  same  time  to 
secure  a  sufficient  hold. 

AMPUTATION    THROUGH    THE 
TARSO-METATARSAL  JOINTS 

(Figs.  390  and  391) 

This,  though  usually  spoken 
of  as  Hey"s  or  Lisfranc's  ampu- 
tation, includes,  accurately  speak- 
ing, the  following  operations  : 
(1)  Lisfranc's.  Amputation  by 
disarticulation  through  all  the 
o«M     Tt       ■  ^  <-•        Tu^  ^r.^      joints.    (2)  Hey's.   This  is  usually 

Fig   3fl0.     Lisfranc  s  amputation,     ine  vcn-      J  mi  •         i_  i, 

tral  flap  extends  to  the  bases  of  the  toes  and     described  as  amputation  here  by 
includes  nearly  all  the  soft  parts  below  the       sawing  through  the  bases   of  the 

metatarsal  bones.  metatarsals.       In    reality.    Hey 

seems  to  have  disarticulated 
through  the  outer  four  joints,  and  sawn  off  the  projecting  internal 
cuneiform.^  (3)  Skey's.  Disarticulation  through  the  outer  three  and 
the  first  joints,  the  second  metatarsal  being  sawn  through. - 

Indications.  Few.  (1)  Limited  crushes  in  which  the  sole  is  sound. 
(2)  Disease  hmited  to  the  front  of  the  foot.  (3)  Inveterate  bunion,  with 
persistent  sinuses  and  recurrent  attacks  of  cellulitis  (-4)  Perhaps 
perforating  ulcer.     (5)  Some  cases  of  frost-bite. 

Owing  to  the  complexity  of  the  synovial  membrane  here  (Fig.  386), 
any  disease  which  has  invaded  the  synovial  membrane  between  the 
second  and  third  metatarsals  and  the  second  and  third  cuneiforms,  has 
also  spread  to  that  between  the  scaphoid  and  three  cuneiforms.  This, 
though  of  small  moment  in  cases  of  injury,  should  put  this  amputation 
aside  in  most  cases  of  disease. 

1  Observations  in  Surgery,  third  edition,  p.  552. 

2  Oper.  Surg.,  p.  406. 


TARSOMETATARSAL  JOINTS  949 

Lisfranc's  Amputation  (Fit^s.  .'590  and  391).  The  preliminaries  are 
the  same  as  in  C'hoparts  amputation.  The  surgeon,  standing  to  the 
right  side  of  either  foot,  and  so  as  easily  to  face  the  sole,  places  his  left 
index  and  thumb  on  the  bases  of  the  little  and  great  toe  metatarsals 
respectively.  The  first  of  these  can  always  be  found  by  pressure,  even 
if  swelling  is  present ;  if  there  be  any  difficulty  with  the  latter,  it  will 
be  found  a  full  inch  in  front  of  the  readily  detected  tubercle  of  the  scaphoid. 
Those  two  points  thus  marked  out  are  joined  by  a  slightly  curved  dorsal 
incision  with  its  convexity  forwards.  As  a  rule,  if  the  tissues  in  the 
sole  are  sound,  no  dorsal  flap  should  be  made,  the  above  incision  being 
kept  close  to  the  line  of  the  joints  through  which  disarticulation  is  to  be 
performed. 

The  foot  being  now  flexed  upwards,  the  surgeon,  looking  towards 
the  sole,  marks  out  a  plantar  flap  by  an  incision  running  from  the  outer 
extremity  of  the  first  cut  (for  the  right  foot)  up  the  outer  side  of  the 
foot,  then  across  the  heads  of  the  metatarsals,  and  down  the  inner  side,  so 
as  to  join  the  inner  extremity  of  the  dorsal  incision.  This  flap  should  be 
made  a  little  longer  on  the  inner  than  on  the  outer  side  of  the  foot,  so  as 
to  cover  the  additionally  projecting  bones  on  this  side.  Its  cut  edge 
being  taken  firmly  between  the  finger  and  thumb,  the  flap  is  then  dissected 
up  as  thickly  as  possible,  /.e.  containing  all  the  tissues  possible  in  the  sole. 
In  keeping  the  knife  close  to  the  bones  some  of  the  metatarso-phalangeal 
joints  will  probably  be  opened.  Below  these  the  flap,  if  steadily  pulled 
upon,  will,  with  fight  touches  of  the  knife,  readily  separate  from  the 
metatarsal  bones.  The  flap  should  be  raised  evenly,  and  without  scoring 
or  any  button-holes.  The  prominent  bases  of  the  first  and  fifth  meta- 
tarsals being  laid  bare,  a  few  strong  touches  of  the  point  of  the  knife  may 
be  required  to  separate  part  of  the  tibiahs  anticus  and  peroneus  longus 
from  the  base  of  the  former.  The  anterior  part  of  the  foot  is  now  strongly 
depressed  so  as  to  stretch  the  dorsal  figaments,  and  the  knife,  having 
been  thoroughly  carried  round  the  base  of  the  fifth  metatarsal,  is  drawn 
obfiquely  forwards  and  inwards  so  as  to  open  the  joints  of  the  outer 
three  metatarsals  \nth  the  cuboid  and  the  external  cuneiform.  The 
joint  between  the  first  metatarsal  and  the  internal  cuneiform  is  next 
opened,  and  lastly,  the  second  metatarsal  is  freed  as  follows  :  The  knife 
being  held  firmly  in  the  fist,  its  point  is  inserted  between  the  first 
two  metatarsal  bones,  and  the  knife  carried  backwards  and  forwards 
in  an  antero-posterior  direction  in  the  long  axis  of  the  foot.  The 
same  is  then  done  between  the  second  and  third  metatarsals,  and,  the 
lateral  ligaments  being  thus  divided,  the  joint  between  the  second 
metatarsal  and  the  middle  cuneiform  is  found  and  opened,^  this  being 
facilitated  by  strongly  depressing  the  foot,  care  being  taken  not  to  do 
this  so  violently  as  to  separate  the  second  metatarsal  from  its  upper 
epiphysis,  or  to  fracture  the  bone.^  A  few  remaining  touches  of  the 
knife,  aided  by  a  t\visting  movement,  will  then  suffice  to  separate  the 
foot. 

The  method  by  disarticulation  may  be  a  useful  test  of  a  candidate's 
knowledge  and  skill  at  an  examination.     In  practice,  sa^^^ng  through 

1  The  position  of  this  joint  must  be  remembered,  and  the  -way  in  which  the  base  of  the 
second  metatarsal  bone  is  locked  in  between  its  fellows  and  the  cuneiform  bones.  Its 
base  projects  upwards  between  a  third  and  a  quarter  of  an  inch  above  the  others. 

~  While  the  surgeon  is  disarticulating  the  metatarsal  bones  the  plantar  flap  must  be 
held  well  out  of  the  way  to  prevent  its  being  punctured. 


950      OPERATIONS  ON  THE  LOWER  EXTREMITY 


the  metatarsals  just  below  their  bases  may  nearly  always  be  substituted, 

as  giving  equally  good  results  with  a  great  saving  of  time  and  trouble. 

The  truth  of  this  I  have  per- 
sonally tested. 

This  method  of  cutting 
the  plantar  flap  before  any 
attempt  is  made  to  disarti- 
culate is  strongly  recom- 
mended in  preference  to 
disarticulating  immediately 
after  making  the  dorsal  in- 
cision by  passing  the  knife 
behind  the  bones  and  cutting 
the  flap  from  within  out- 
wards. In  thus  disarticula- 
ting before  making  the  plan- 
tar flap,  it  is  quite  possible 
to  puncture  the  tissues  in 
the  sole,  and  perhaps  to 
wound  the  external  plantar 
artery.  Again,  passing  the 
knife  behind  the  metatarsal 
bones  often  leads  to  a  hitch , 
especially  with  the  project- 
ing fifth. 

The  dorsahs  pedis  and 
the  external  plantar  artery 
are  now  secured  with  any 
smaller  vessels  which  need 
it.  Tendons  are  cut  square, 
nerves  shortened,  drainage 
provided,    and  the  plantar 

flap  then  brought  up  and  secured  in  accurate  position. 

Owing  to  the  thickness  of  the  plantar  flap  and  its  tendency  at  first 

to  unfold  itself  downwards,  numerous  points  of  suture,  of  sufficiently 

stout  wire  or  silkworm-gut,  must  be  made  use  of. 


Fig.  391.     Lisfranc's  amputation.      The  internal 
cuneiform  is  sawn  across  to  make  an  even  stump. 


AMPUTATION  OF  THE  TOES 

Practical  Points.  (1)  Any  plantar  scar  is  to  be  avoided.  (2)  The 
line  of  the  metatarso-phalangeal  joints  lies  a  full  inch  further  back  than 
the  inter-digital  folds  of  the  skin  (Holden).  (3)  Partial  amputations 
(save  in  the  case  of  the  great  toe)  are  very  seldom  advisable,  the  stumps 
left  being  of  little  use,  and  inconvenient  owing  to  their  liabiHty  to  project 
upwards. 


AMPUTATION  THROUGH  THE  PHALANGES  OR  THE 
INTERPHALANGEAL  JOINTS 

These  operations  are  not  recommended,  for  the  reasons  just  given. 
If  a  patient  insist  on  having  one  performed,  the  directions  already  given 
for  the  fingers  will  be  found  sufficient. 


AMPUTATION  OF  TIIK  TOES 


951 


AMPUTATION  OF  ANY  OF  THE  FOUR  SMALLER  TOES 
AT  THE  METATARSO-PHALANGEAL  JOINTS 

This  aniputcition  is  peiforiued  much  as  in  the  case  of  the  fingers 
(chap,  iv.),  but  the  following  points  must  be 
remembered  : 

(1)  The  line  of  the  joint  lies  a  full  inch 
above  the  web.  (2)  The  head  of  the 
metatarsal  bone  is  not  here  removed,  so  as 
to  leave  the  supporting  power  of  the  foot 
undiminished.  (3)  It  is  most  important  to 
avoid,  as  far  as  possible,  any  scar  on  the  sole. 

The  scar,  a  simple  antero-posterior  one, 
is  well  protected  by  the  adjacent  toes.  The 
incision    should    always    be    begun    on    the 

dorsum,  even  in  the  case  of  the  Uttle  toe,  so     ^^^  3,^2.    Amputation  of  tba 
as  to  avoid  friction  of  the  boots.  little  toe. 


AMPUTATION  OF  GREAT  TOE  AT  THE  INTER- 
PHALANGEAL  JOINT 

This  is  usually  performed  with  a  plantar  flap  (chap.  iv.). 


AMPUTATION  OF  GREAT  TOE  AT  THE  METATARSO- 
PHALANGEAL JOINT  (Fig.    393) 

This  is  performed  by  the  methods  described  in  chap.  iv.  The  following 
points  must  be  borne  in  mind  : 

(1)  Owing  to  the  large  size  of  the  head  of  the  metatarsal  bone,  the 
flaps  are  often  cut  of  insufficient  length.  The  incision  must  be  begmi 
an  inch  and  a  quarter  above  the  joint,  and  carried  well  on  to  the  phalanx, 
one  flap  being  cut  longer  than  the  other  if  needful.  (2)  The  sesamoid 
bones  must  be  left  in  connection  with  the  head  of  the  metatarsal  bone, 

as  any  attempt  to  dissect 
them  out  is  hkely  to  imperil 
the  vascularity  of  the  flaps, 
especially  after  middle  life. 

In  all  other  details  the 
steps  of  this  amputation  are 
very  similar  to  those  already 
given  in  chap.  iv. 

Though  it  is  recom- 
mended by  some  excellent 
surgeons  to  remove  the  head 
of  the  metatarsal  bone  either 
transversely  or  obliquely 
from  within  outwards,  this  step,  narrowing  as  it  does  the  treading 
width  of  the  foot,  is  not  advisable,  unless  the  condition  of  the  skin 
is  such  as  to  render  it  impossible  to  obtain  sufficient  flaps  to  cover  the 
entire  head. 


Fig.  393.     Amputations  of  the  great  toe   at  the 
interphalangeal  and  metatarso-phalangeal  joints. 


952       OPERATIONS  ON  THE  LOWER  EXTREMITY 

AMPUTATION  OF  THE  GREAT  TOE,  TOGETHER  WITH 
REMOVAL  OF  ITS  METATARSAL  BONE 

This  may  be  performed  by  a  modification  f)f  the  oval  method  as 
described  for  the  fingers  in  chap.  iv. 

Hammer  Toe.  In  cases  requiring  operation  the  choice  hes  between 
excision  of  the  head  of  the  first  phalanx  and  ajnputation,  the  former  is 
nearly  always  adopted  and  gives  good  results. 

Ingrowing  toe-nail.  Operation  is  the  best  treatment  of  cases  of 
any  severity  of  this  incorrectly  named  condition.  Many  methods  have 
been  described  ;  the  following  is  simple  and  efficient.  It  may  be  per- 
formed under  local  analgesia  and  the  aid  of  an  improvised  tourniquet 
round  the  base  of  the  toe.  If,  as  is  usually  the  case,  an  ulcerated  and 
infected  condition  of  the  soft  parts  be  present,  this  must  be  first  dealt 
with  by  the  use  of  boracic  acid  or  dilute  formalin  fomentations,  pure 
carbolic  acid,   &c. 

From  a  point  at  least  a  quarter  of  an  inch  above  and  a  little  to  the 
outer  side  of  the  inner  angle  of  the  nail-fold,  a  curved  incision  is  carried 
through  sound  skin  to  a  corresponding  point  below  the  nail,  to  reach 
which  the  incision  is  curved  outwards.  From  the  starting-point  a 
straight  incision  is  then  made  between  these  two  points,  directly  for- 
wards, through  the  nail  and  its  bed.  The  included  nail,  skin,  nail-bed 
and  angles  of  the  nail-fold  are  then  completely  excised.  The  edge  of 
the  skin,  carefully  dissected  free  if  needful,  is  then  brought  into  contact 
with  the  edge  of  the  nail  and  there  kept  in  position  by  circular  strips 
of  gauze  not  applied  too  tightly.  The  tourniquet  is  then  removed  and 
a  larger  dressing  apphed,  if  needful.  The  foot  should  be  kept  well 
elevated.  The  patient  can,  usually,  get  about  in  ten  days,  especially  if 
a  leg-rest  is  used  at  first.  After-attention  to  well-fitting  boots,  and  to 
cleanliness  of  the  toes  and  the  way  in  which  the  nails  are  regularly 
trimmed,  must  of  course  be  enforced. 


CHAPTER  XLVI 

OSTEOTOMY 

OSTEOTOMY  OF  THE  FEMUR  FOR  ANKYLOSIS  OF  HIP-JOINT 
OR  FOR  COXA  VARA.  FOR  GENU  VALGUM.  OSTEOTOMY  OF 
THE  TIBIA.     OSTEOCLASIS  AND  MANUAL  REDUCTION 


FOR  ANKYLOSIS  OF  HIP-JOINT 

This  includes  Adams'  operation  of  division   of  the  neck   of  the  femur 
and  Gant's  operation  of  division  of  the  shaft  of  the  femur  just  below 
the  trochanters.  The  latter  being  much  the  simpler, 
and  giving  excellent  results,  should,  I  think;  replace 
the  former. 

Indications.  Cases  in  which  the  hip-joint  is 
permanently  flexed  and  stiff,  and  the  patient  ac- 
cordingly crippled,  either  from  old  hip  disease,  or 
from  ankylosis  after  rheumatic  fever,  pyaemia,  or 
the  neck  of  the  femur  is  bent  as  in  coxa  vara,  &c. ; 
cases  in  which  extension  has  failed,  together  with 
trials  of  straightening  the  limb  with  the  aid  of 
anaesthetics. 

Adams'  operation  divides  the  neck  of  the 
femur  subcutaneously  within  the  capsule.  It  is 
best  suited  for  those  cases  in  which  the  neck  re- 
mains unabsorbed,  as  in  ankylosis  after  rheumatic 
fever,  and,  much  more  rarely,  pyaemia.  A  long 
tenotome  or  a  straight  narrow  bistoury  is  entered 
about  one  inch  above  the  top  of  the  great 
trochanter,  and  carried  on  the  flat  downwards  and 
inwards  over  the  anterior  aspect  of  the  neck  (p. 
820).  The  edge  is  then  turned  towards  the  bone, 
and  by  cutting  deliberately  and  freely  on  this,  a 
passage  is  made  for  the  saw.  The  knife  being 
withdrawn,  the  excellent  saw  which  bears  Mr. 
Adams'  name  is  passed  along  the  wound  made 
down  to  the  neck  of  the  bone,  which  is  then 
sawn  through.  After  sawing  for  about  four  or  five 
minutes  the  limb  should  become  movable.  If 
this  is  not  the  case,  the  section  has  been  made, 
not  through  the  neck  itself,  but  through  the  junc- 
tion of  the  neck  and  shaft.     Where  the  surgeon 

remains  in  doubt  ho  should  remove  the  saw  and  convert  his  wound  into 
an  open  one,  and  make  sure  of  his  path  by  means  of  a  sterilised  finger. 

953 


Fig.  394.  Osteotomy  of 
the  femur.  Usuall}^  the 
methods  of  Gant  and 
Macewen  are  the  best  at 
the  upper  and  lower  end 
of  the  femur.  Adams' 
operation  is  sometimes 
useful  for  adolescent 
coxa  vara. 


954       OPERATIONS  ON  THE  LOWER  EXTREMITY 

In  order  to  bring  down  the  limb  completely,  the  contracted  tendons 
of  the  adductor  longus,  sartorius,  and  perhaps  the  rectus,  will  probably 
require  subcutaneous  division. 

The  limb  is  strongly  abducted  and  extended  and  fixed  in  this  corrected 
position  in  a  plaster  sphnt  extending  from  the  waist  to  the  toes. 

This  operation  gives  good  results,  though,  as  stated  below,  I  prefer 
Gant's  owing  to  its  greater  simplicity.  For  there  is  no  doubt  that  if 
the  bone  is  dense  from  previous  inflammation,  and  if  the  section  trenches 
upon  the  shaft  instead  of  going  through  the  neck  only,  the  sawing  may  be 


Fig.  395.     Osteotomy  for  contracted  ankj-losed  hip  to  correct  flexion,  adduction 

and  shortening. 


very  tedious.  Thus,  I  have  seen  two  cases  in  which  this  took  over  half  an 
hour. 

A  case  is  mentioned  in  a  report  from  a  committee  of  the  Belgian 
Academy  of  Medicine,  in  which  a  patient  who  had  been  submitted  to 
Adams'  operation  insisted  on  getting  up  on  the  twentieth  day.  Haemor- 
rhage came  on  from  the  fragments  wounding  the  femoral  vessels  or  some 
large  branch.  The  femoral  was  tied  just  below  Poupart's  ligament ; 
the  hsemorrhage  ceased,  but  free  incisions  were  recjuired  for  suppuration. 
The  patient  ultimately  recovered.  The  same  connnittee  reported  a  death 
from  hsemorrhage,  and  one  from  purulent  infiltration.  No  bad  results 
have,  as  far  as  I  am  aware,  followed  in  England. 

Gant's  operation.  Here  the  shaft  of  the  femur  is  divided  just  below 
the  trochanters. 

Advantages.  The  operation  is  a  simpler  one  than  that  just  given, 
as  the  shaft  is  more  readily  reached  and  divided  than  the  neck.  More- 
over, it  is  an  operation  of  ^^^der  apphcability,  for  it  is  suited  to  all  cases, 
not  only  those  in  which  a  neck  remains,  but  those  more  common  cases 
of  ankylosis  after  hip-disease,  in  which  repair  has  taken  place  with  partial 
displacement  of  the  head,  or  what  remains  of  it.  In  these  cases  there  is 
next  to  no  neck  of  femur  to  be  divided  by  Adams'  method. 

A  transverse  incision  one  inch  long  is  made  just   below  the  base 


OSTEOTOMY  FOR   GENU  VALGUM  955 

of  the.  great  trochanter.  The  osteotome  is  then  introduced  obliquely 
downwards  and  inwards  well  down  to  the  bone,  and  the  outer  two-thirds 
of  this  divided,  the  rest  being  effected  by  snapping  the  bone  by  lateral 
movements.  The  tendons  mentioned  above  will  probably  require 
division. 

The  limb  is  fixed  in  a  plaster  splint  extending  from  the  epigastrium 
to  the  toes  in  the  over-corrected  position  for  three  months.  Then  a 
Hessing's  splint  is  applied.  This  conducts  vdl  the  weight  from  the 
pelvis  and  tlius  prevents  strain  at  the  fractures  until  all  risk  of  bending 
has  passed. 

OSTEOTOMY  FOR  GENU  VALGUM 

I.  Division  of  the  Shaft  of  the  Femur  from  the  Outer  Side  (Fig. 
39(>).  The  limb  being  supported,  with  the  knee  flexed,  on  a  sand-bag, 
an  incision  about  an  inch  and  a  half  long  is  made  at  a  right  angle  to  and 
down  to  the  bone  on  its  outer  side,  about  three  inches  above  the  external 
condyle.  The  knife — a  narrow,  straight  bistoury —  should  go  down  to 
the  bone  deliberately,  and  cut  firmly  and  strongly  on  it,  enlarging  the 
wound  slightly  as  it  emerges,  in  order  that  the  soft  parts  may  not  be 
damaged  if  the  heel  of  the  saw  is  depressed,  and  that  there  may  be  no  Up 
of  tissues  to  hinder  the  escapes  of  discharges.  The  saw  or  chisel  is  then 
introduced,  and  the  bone  divided  for  its  outer  two-thirds.  As  the  thicker 
part  of  the  bone  is  on  the  outer  side,  as  soon  as  this  is  divided  the  inner 
third  usually  gives  wa}^  readily  on  carrying  the  knee  and  leg  from  without 
inwards.  But  the  operator  should  continue  the  division  of  the  bone 
till  he  can  feel  certain  that  two-thirds  are  divided,  for  if,  after  dividing 
only  half,  he  tries,  especially  in  the  case  of  a  dense  bone,  to  fracture 
the  rest  and  straighten  the  Hmb,  either  great  or  prolonged  force 
must  be  made  use  of,  leading  possibly  to  damage  of  the  vessels  and 
other  soft  parts;  or  the  saw  or  chisel  must  be  re-introduced,  a  point 
to  be  always  avoided  if  possible,  as  the  difficulty  which  is  usually  met 
with  in  hitting  off  the  original  track  will  be  hkely  to  lead  to  the  above 
drawbacks. 

The  advantages  claimed  of  the  above  method  are  (1)  that  as  the  femur 
is  divided  at  a  much  narrower  part  than  in  the  supracondyloid  operation 
of  Macewen,  it  is  more  easily  and  quickly  done.  (2)  The  bone  section 
is  farther  away  from  the  epiphysis  and  the  hne  of  the  synovial  membrane. 
(3)  There  are  no  important  blood-vessels  near. 

1  do  not  hke  the  method,  for  it  does  not  treat  the  deformity  at  the 
best  spot,  and  the  shaft  being  small,  firm  union  takes  some  time  and 
gradual  bending  at  the  fracture  is  not  uncommon  later  on. 

II.  Division  of  the  Lower  End  of  the  Femur  from  the  Inner  Side,  just 
above  the  Epiphysial  Line  (supracondyloid  of  Macewen  ^)  (Fig.  394).  The 
knee  being  flexed  and  supported  firmly  on  a  sand-pillow^  by  the  hands  of 
an  assistant  grasping  the  middle  of  the  thigh  and  leg,  the  skin  resterilisedj 
the  position  of  the  adductor  magnus  tendon  and  its  tubercle  is  defined, 
and  a  longitudinal  incision  about  an  inch  long  (a  Httle  longer  than  the 
breadth  of  the  chisel  to  be  used)  is  made  down  to  the  bone  at  a  point 
one  inch  above  and  in  front  of  the  adductor  tubercle  .  The  scalpel  goes 
at  once  down  to  the  bone.  Superficial  veins  may  be  cut,  but  no  artery 
normally  distributed,  as  the  incision  is  below  and  anterior  to  the  anasto- 

^  Osteotomy,  p.  120. 


956       OPERATIONS  ON  THE  LOWER  EXTREMITY 

inotica  magna  and  above  the  superior  internal  articular.  Before  with- 
drawing the  knife,  the  osteotome  is  introduced  by  its  side  down  to  the  bone 
in  the  same  way  as  the  knife,  i.e.  parallel  to  the  long  axis  of  the  limb, 
is  then  turned  at  a  right  angle  to  it,  and  the  inner  tw^o-thirds  cut 
through.  The  direction  of  the  hone-incision  is  most  important.  The 
surgeon  must  cut  transversely  across  the  femur  on  a  level  with  a  line 
drawn  half  an  inch  above  the  top  of  the  external  condyle.  This  incision 
will  avoid  the  epiphysis  and  synovial  membrane.  The  line  of  the  former 
may  be  usually  represented  by  one  crossing  the  femur  at  the  level  of  the 
highest  point  of  the  femoral  articulating  surface,  and  running  through 
or  just  below  the  adductor  tubercle,  so  that,  the  incision  being  an  inch 
above  the  tubercle,  the  epiphysis  will  be  cleared.  The  only  part  of  the 
syno\dal  membrane  which  is  as  high  as  the  bone  incision  is  that  under 
the  quadriceps,  which  may  reach  in  the  adult  as  high  as  two  inches 
above  the  trochlear  surface.  There  is  generally  a  quantity  of  fat  between 
it  and  the  bone.  The  spot  selected  by  Sir  W.  Macewen  for  his  incision 
is  posterior  to  this  point.  As  in  a  valgous  limb  the  whole  internal 
condyle  is  lowered,  a  line  drawn  transversely  from  the  adductor  tubercle 
might  land  the  operator  low  down  in  the  external  condyle.  The  osteo- 
tome, placed  against  the  inner  edge  of  the  bone,  must  be  driven  at  first 
from  behind  forwards  and  to  the  outer  side  ;  it  is  then  made  to  move 
forwards  along  the  inner  border  until  it  comes  to  the  anterior  surface, 
when  it  is  directed  from  before  backwards  and  towards  the  outer  posterior 
angle  of  the  femur.  By  keeping  on  these  lines  there  is  no  fear  of  injuring 
the  artery.  The  hard  external  surface  usually  resists  the  osteotome, 
especially  in  adults,  but  the  surgeon  will  soon  recognise  by  touch  or 
sound  when  his  osteotome  ^  meets  this  layer.  It  is  the  inner  border 
and  the  anterior  aspect  of  the  bone  which  it  is  essential  to  divide  thoroughly 
if  the  reintroduction  of  the  instrument  with  the  difficulties  of  ensuring 
its  entering  the  old  groove,  and  the  risks  of  infection  are  to  be  avoided. 
If  it  be  thought  desirable  to  penetrate  the  outer  dense  part,  it  must  be 
done  very  steadily,  so  as  to  check  any  undue  impetus  on  the  part  of 
the  osteotome.  A  sterile  pad  having  been  secured  over  the  wound,  the 
surgeon,  pressing  the  thigh  down  on  the  table  with  his  left  hand,  and  taking 
the  limb  low  down  with  his  right,  gives  it  a  quick  jerk  outwards,  this  being 
repeated  if  needful.  If  it  be  necessary  to  reinsert  the  osteotome,  care 
must  be  taken  to  get  it  into  the  groove  again,  and  to  use  it  coolly  and 
methodically  in  accordance  with  the  above-given  directions. 

Mr.  Keetley  thus  writes  ^  on  "  cases  in  which  the  surgeon  has  almost 
entirely  failed  to  get  the  improvement  possible  from  the  operation. 
Such  cases  are  often  supposed  to  be  cases  of  recurrence,  but  they  are 
really  only  examples  of  bad  management.  The  points  to  attend  to  are  : 
(1)  Correct  the  deformity  while  the  limb  is  in  a  position  of  extreme 
extension  at  the  knee.  The  shghtest  flexion  of  the  joint  hides  the  deformity 
and  deludes  the  surgeon  into  a  false  sense  of  satisfaction.  (2)  The  exact 
amount  of  looseness  of  the  knee-joint,  if  any,  should  be  noted  before 
the  bone  is  di\dded,  and  allowed  for  in  putting  up  the  limb.     To  this 

1  The  osteotomes  must  be  bevelled  on  both  sides,  wedge-like,  and  sufficiently  trust- 
worthy for  hardness  and  toughness,  points  only  to  be  secured  by  getting  them  of  first-rate 
and  painstaking  makers.  Sir  W.  Macewcn's  test  is  as  follow.s  :  If  the  instrument  will 
neither  turn  nor  chip  in  penetrating  the  thigh-bone  of  an  ox.  it  is  well  suited  for  cutting 
human  bones.     Its.  edge  should  be  sharp  enough  to  pare  easily  the  finger-nail  (Keetley). 

2  Orthofcelic  Svrg.,  p.  33. 


OSTEOTOMY  FOR  GF.XU  VALGUM  957 

end  the  adjustment  will  sometimes  have  to  be  a  position  of  distinct 
varum.  (3)  A  certain  amount  of  spring  in  the  bones  and  extensibility 
in  the  ligaments,  especially  in  the  case  of  children,  nnist  be  allowed  for  in 
the  same  way."' 

III.  Division  of  Tibia  as  well  as  Femur.  The  division  of  the  tibia 
(and  the  fibula  also)  as  well  as  the  femur  has  been  advocated  by  Mr. 
Barwell  and  others.  In  the  majority  of  cases,  though,  at  first  sight, 
there  may  seem  to  be  one  striking  curve  localised  to  one  spot,  a  closer 
examination  shows  tliat  in  reality  several  curves  are  present,  and  often 
of  different  kinds,  antero-posterior  as  well  as  lateral,  diffused  over  the 
whole  shaft  rather  than  limited  to  one  end.  In  these  cases,  rectifying 
one  curve  often  makes  the  others  more  prominent.  Multiple  osteotomies 
are  required  here,  the  femur  and  the  tibia  each  requiring  division  in 
two  places.  In  one  very  aggravated  case  of  genu  varum,  in  which  the 
limbs  (when  the  ankles  were  placed  together)  formed  a  circle,  Sir  W. 
Macewen  performed  ten  osteotomies  at  one  time.^  In  such  severe  cases 
most  operators  will  prefer  to  straighten  one  side  at  a  time. 

Operation.  A  vertical  incision  is  made  over  the  inner  surface  of 
the  tibia  just  below  its  tubercle,  and  the  bone  di\'ided  with  an  osteo- 
tome or  saw  from  within  outwards.  The  tissue  on  the  anterior  part 
just  below  the  tubercle  is  much  the  densest.  The  di\'ision  is  commenced 
at  the  posterior  part  of  the  tibia  and  made,  at  first  from  behind  forwards, 
and  then  before  backwards.  The  section  of  the  tibia  should  be  made 
on  the  same  occasion  as  that  of  the  femur. 

The  wounds  are  closed  with  fine  catgut. 

Sir  W.  Macewen  uses  a  splint  consisting  of  a  long  outside,  and  a 
short  back,  with  a  foot-piece. ^  I  have  usually  preferred  plaster  of  Paris, 
applied  by  Mr.  Croft's  method,  for  children,  amongst  whom  my  experi- 
ence has  mainly  been.  It  makes  even,  steady  pressure  upon  the  muscles 
around  the  wound,  keeping  them  and  it  at  rest,  and  it  allows  the  patient 
to  be  more  easily  moved,  especially  when  both  limbs  have  been  operated 
on.  The  outer  piece  of  flannel  should  be  brought  high  up,  to  the  level 
of  the  iliac  crest,  so  as  better  to  command  the  muscles  which  disturb  the 
upper  fragment.  In  all  cases  of  osteotomy,  a  long  outside  splint  should 
be  apphed  at  first.  However  the  hmb  is  put  up,  the  bandages  must  be 
applied  firmly  and  evenly,  but  without  undue  tightness.  The  condition 
of  the  toes,  as  to  colour  and  movement,  must  be  carefully  watched. 
When  the  dressings  are  removed  at  the  end  of  ten  or  fourteen  days  I 
hke  to  have  an  anaesthetic  given  if  necessary,  and  to  rectify  any  slight 
remaining  deformity. 

The  spHnts  or  plaster  of  Paris  should  be  continued  for  six  weeks, 
when  the  Mmb  may  be  only  supported  with  sand-bags  if  the  union  is 
firm.  Passive  and  active  movements  are  now  allowed.  In  about 
three  months  the  patient  may  be  got  up,  AA^th  a  stick,  under  observa- 
tion. From  an  earlv  date,  care  should  be  taken  that  he  can  bend  his  knee 
well. 

1  Loc  supra  cit..  Figs.  40  and  41. 

2  Sir  W.  Macewen  advises  the  use  of  a  mattress  consisting  of  four  parts,  the  two  centre 
pieces  corresponding  to  the  gluteal  region,  and  being  easilj-  removed  to  admit  of  the  intro- 
duction of  the  bed-pan. 


958       OPERATIONS  ON  THE  LOWER  EXTREMITY 

GENU  VARUM 

As  the  tibia  is  usually  the  boue  which  is  most  at  fault,  the  directions 
for  its  osteotomy  given  below  will  suffice.  When  the  femur  is  also 
much  concerned  it  must  be  divided  by  means  analogous  to  those  given 
for  genu  valgum.  And,  as  in  this  condition  if  the  lower  third  of  the 
tibia  be  also  curved,  osteotomy  of  this  bone  and  the  fibula  {vide  infra) 
will  be  required.     Division  in  two  places  may  be  necessary. 

OSTEOTOMY  OF  THE  TIBIA 

This  may  be  (A)  Simple  Division  or  (B)  Cuneiform,  i.e.  the  taking 
out  oJ  a  wedge  of  bone.  The  former  of  these,  a  very  simple  operation, 
will  suffice  for  the  ordinarily  curved  tibiae,  where  the  bone  is  bent  laterally 
and  the  bend  is  most  marked  at  the  j miction  of  the  middle  and  lower 
thirds.  Cuneiform  osteotomy  will  be  required  when  the  bending  is  not 
only  lateral,  but  antero-posterior  as  well. 

A.  Simple  Osteotomy  of  the  Tibia.  The  parts  being  sterilised,  and 
the  limb  resting  on  its  outer  side  on  a  firm  sand-pillow,  the  surgeon 
notes,  at  the  anterior  and  inner  margins  of  the  tibia,  the  spot  where  the 
curve  is  sharpest.  Opposite  this  a  longitudinal  incision  half  an  inch  long 
is  made  just  external  to  the  anterior  border  of  the  tibia.  The  periosteum 
is  di\'ided  over  the  crest,  and  separated  from  the  internal  surface  of  the 
bone.  A  fine  Adams'  saw  is  now  introduced  in  the  same  way  as  the 
knife,  carried  horizontally  down  to,  but  not  through,  the  puncture  through 
the  skin  of  the  inner  border  of  the  tibia.  The  left  index  finger  keeping  guard 
over  the  tibial  artery,  the  saw  is  turned  towards  the  bone  and  cuts  through 
the  inner  two-thirds  of  it.  The  entrance  of  the  saw  into  cancellous  tissue 
can  be  known  by  the  diminution  of  resistance  and  the  increased  bleeding 
which  often  occur,  but  the  best  test  of  the  depth  to  which  the  operator 
has  arrived  is  the  depth  of  the  groove  in  which  the  saw  has  smik.  If 
it  be  preferred  a  sufficient  wound  is  made,  and  a  narrow  osteotome  em- 
ployed. When  the  bone  is  divided  sufficiently,  a  sterile  pad  is  placed  on 
the  wound,  and  the  surgeon,  firmly  placing  his  two  hands,  close  together, 
immediately  above  and  below  the  wound,  sharply  carries  the  lower 
fragment  outwards.  If  the  saw  has  been  sufficiently  used,  the  tibia 
snaps  distinctly,  while  the  fibula  yields  with  a  "  greenstick"  sensation. 
But  if  there  be  any  difficulty  here,  this  bone  must  be  divided  through  a 
second  incision.  Great  care  must  be  taken  to  exert  the  force  just  on  the 
sawn  portion,  or  the  ligaments  of  the  ankle  or  the  superior  tibio-fibular 
joint  may  be  strained  and  damaged.  Attention  has  already  been  drawn 
to  the  need  of  using  the  saw  sufficiently,  otherwise  the  parts  will  be  bruised 
and  damaged  in  the  futile  attempts  at  fracture. 

B.  Cuneiform  Division  of  the  Tibia.  Removal  of  a  Wedge.  I  have 
not  found  the  plan  of  estimating  the  size  of  the  wedge  to  be  removed 
by  first  making  an  outline  on  paper  of  much  service.  The  parts  being 
duly  sterilised,  an  incision  is  made  along  the  crest  of  the  tibia  equal 
to  the  base  of  the  wedge  which  is  going  to  be  removed.  It  need  not  be 
longer,  as  the  skin  can  be  pulled  up  and  down  if  needful.  The  periosteum 
is  then  di"vdded  cleanly  and  separated  from  the  tibia  with  curved  scissors. 
This  membrane  being  held  out  of  the  way  with  retractors,  a  wedge  is  next 
removed  with  an  osteotome  or  a  narrow  and  sharp  chisel  but  little  bevelled. 
The  gap  can  then  be  enlarged  by  removing  from  either  side  further  shces 


OSTEOTOMY  OF  THE  TIBIA 


959 


as  required.  Occasionally  free  haemorrhage  takes  place  from  the  medul- 
lary artery,  but  this  soon  stops  with  firm  pressure.  The  limb  is  now 
straightened  by  bending  the  lower  fiaginent  upwards^  so  as  to  bring 
the  surfaces  of  the  gap  in  contact.  Difhcultics  which  may  be  met  with 
now  are  usually  due  to  the  wedge  removed  being  inadequate  in  size 
or  in  shape.  A  sharp  pair  of  bone-forceps  may  now  be  useful.  The 
resistance  of  the  periosteum  at  the  back,  or  of  the  tendo  Achillis  are  also 
factors.  The  former  may  require  the  removal  of 
more  bone,  the  latter  division.  The  periosteum 
at  the  upper  and  lower  angles  of  the  wound  may 
be  closed  with  catgut  sutures.  In  some  cases 
accurate  and  firm  apposition  can  only  be  secured 
by  means  of  a  plate  and  screws.  The  wound  is 
closed  with  catgut.  In  this  and  the  preceding 
operation  sufficiently  thick  dressings  should  be 
applied  to  meet  any  oozing  from  the  bone. 
Plaster  of  Paris  or  back  and  side  sphnts  should 
be  applied. 

Causes  of  trouble  after  Osteotomy.  (1)  In- 
fective troubles.  iSucli  a  case  will  be  found  pub- 
lished in  the  Clin.  Soc.  Trans.,  vol.  xii,  p.  27.  It 
is  too  probable  that  other  operators  have  not 
been  so  candid.  (2)  HceniorrJiage.  At  least  one 
case  has  occurred  of  haemorrhage  from  the 
femoral  and  one  from  the  anastomotica  after 
division  of  the  femur.  I  have  also  heard  of  a 
case  in  which  the  posterior  tibial  was  injured 
in  osteotomy  of  the  tibia. 

(3)  Division  of  the  tibialis  anticus  tendon. 

This  occurred  in  an  osteotomy  of  the  tibia  performed 
by  one  of  my  dressers,  who  forgot  how  close  the  tendon 
lies  to  the  outer  side  of  the  crest.  The  cut  ends  were 
joined  by  cliromic  catgut,  and  the  action  of  the  muscle 
was,  afterwards,  luiimpaired. 

(4:)  Non-union.  I  have  never  seen  a  case, 
but  though  extremely  rare,  its  occasional  oc- 
currence ^  should  be  a  warning  against  needless 
removal  of  bone,  and  any  neglect  of  strict  asepsis. 

Treatment  of  severe  curvatures  of  the  tibia  by  manual  osteoclasis. 
Mr.  Openshaw  thus  describes  his  method  :  ^  "  With  the  child  fully 
anaesthetised,  the  leg  is  encased  in  cotton-wool  and  bandaged.  The 
child  is  then  turned  over  so  that  the  leg  which  is  to  be  broken  lies  upon 
its  outer  side.  A  wedge-shaped  block,  seven  inches  by  three  inches  at 
the  base  and  six  inches  high,  is  used.  The  upper  edge  of  this  block 
is  about  one  inch  wide  and  four  inches  long  and  is  covered  with  thick 
india-rubber.  The  block  is  put  underneath  the  leg  transversely  at  the 
centre  of  the  curve.  The  operator  with  one  hand  grasps  firmly  the  foot, 
ankle  and  lower  part  of  the  tibia,  and  with  the  other  hand  the  upper 
part  of  the  tibia,  the  hands  of  the  operator  being  two  to  three  inches 


Fig.  396.  Manual  osteo- 
clasis of  the  left  tibia  for 
bow- leg.  The  figure  was 
di'awn  from  a  skiagram. 
A  greenstick  fracture  of 
the  tibia  has  occurred,  but 
the  fibula  has  merely  bent. 
The  deformity  was  com- 
pletely corrected. 


1  Aided  by  movements  in  the  opposite  direction,  and  from  side  to  side  if  needed, 
fibula  should  always  in  these  cases  be  also  divided  to  secure  exactitude. 

2  Little,  Traiifi.  Med.  Chir.  Soc,  1891. 

3  Lancet,  March  4,  1905. 


The 


960       OPERATIONS  ON  THE  LOWER  EXTREMITY 

apart.  With  the  block  resting  quite  firmly  upon  a  firm  table,  and  the 
child's  leg  on  the  rubber- covered  edge  of  the  block,  with  a  steady  and 
increasing  pressure,  the  bones  are  snapped  across  and  the  leg  can  then 
immediately  and  easily  be  made  to  assume  a  straight  position.  In  a  few- 
instances  the  fibula  can  be  heard  to  crack  first,  but  in  the  majority  the 
fibula  is  simply  bent,  and  the  tibia  alone  is  broken."  In  some  forty  cases 
thus  operated  on,  Mr.  Openshaw  has  met  with  no  untoward  result.  The 
limb  is  put  up  in  two  lateral  well-padded  splints,  and  the  child  sent  home. 
It  must  be  brought  for  inspection  the  next  day,  when  a  skiagraph  can  be 
taken.  The  child  is  able  to  walk  in  three  or  four  weeks.  It  is  necessary 
that  the  tibia  should  be  actually  fractured.  The  two  legs  are  dealt  with 
at  different  times.  In  Mr.  Openshaw's  opinion  the  leg  of  any  child  under 
ten  can  be  dealt  with  in  this  manner.  One  of  us  has  treated  a  great  many 
children  under  five  in  this  way  in  the  out-patient  department,  with 
excellent  results.  Only  a  "  greenstick  "  fracture  of  the  tibia  is  produced, 
a  wedge-shaped  gap  appears  at  the  hollow  of  the  curve  of  the  bone, 
and  is  well  shown  by  radiograms.  The  periosteum  on  the  outer  side 
is  not  torn,  so  that  overlapping  is  impossible.  In  children  over  five  the 
writer  often  finds  it  easier  to  use  a  small  osteotome  at  the  postero-internal 
aspect  of  the  tibia  to  cut  through  a  part  of  the  bone,  the  remainder 
being  snapped.  The  limb  is  immediately  secured  in  good  position  by 
plaster  bandages. 


CHAPTER  XLVII 

TENOTOMY  AND  TENDON  LENGTHENING.  SYNDESMOTOMY. 
TENOTOMY  OF  THE  HAMSTRING  TENDONS.  TENO- 
TOMY OF  THE  STERNO-MASTOID.  TREATMENT  OF 
SEVERE  TALIPES 

TENOTOMY  OF  THE  TENDONS  ABOUT  THE  FOOT 

DIVISION  OF  TIBIAL  TENDONS. 

Tibialis  Anticus.  This  is  usually  divided  where  it  is  crossing  the  ankle- 
joint  from  without  inwards,  a  little  above  its  insertion  into  the  internal 
cuneiform.  It  has,  here,  the  dorsalis  pedis  vessels  on  its  outer  side,  but 
separated  from  it  by  the  extensor  proprius  hallucis. 

The  surgeon  usually  stands  on  the  outer  side  of  the  leg,  while  the 
assistant  stands  opposite  to  him,  grasping  the  foot  with  one  hand  and  the 
leg  with  the  other.  The  position  of  the  tendon  is  made  out  by  making 
it  tense  by  abducting  and  plantar- flexing  the  foot,  or  by  the  voluntary 
contraction  of  the  muscle  when  the  patient  is  conscious,  a  local  anaesthetic 
only  being  used.  It  is  rarely  necessary  to  give  an  anajsthetic  to  an  infant, 
as  the  operation  is  so  trivial  and  is  over  in  a  few  seconds.  The  danger 
and  after- effects  of  an  anaesthetic  are  thus  avoided  and  the  tendon  can 
be  accurately  localised  as  the  child  moves  his  foot.  The  surgeon  notes 
the  position  of  the  anterior  tibial  vessels,  defines  exactly  the  width  of  the 
tendon,  and  places  the  tip  of  his  index  finger  exactly  on  the  side  of  the 
tendon  farthest  from  him.  He  then  inserts  the  tenotomy  knife  vertically 
close  to  the  outer  side  of  the  tendon  so  as  to  avoid  the  vessels ;  sinks  it  lightly 
till  he  feels  sure  it  is  on  a  level  lower  than  that  of  the  tendon ;  then  sends  it 
horizontally  across  till  he  feels  its  point  just  under  his  index  finger,  and, 
having  turned  its  edge  upwards,  finally,  by  a  series  of  light  levering  or 
sawing  movements,  cuts  through  the  tendon.  The  assistant  relaxes  the 
foot,  i.e.  adducts  and  bends  it  upwards,  when  the  knife  is  first  introduced, 
but  places  it  on  the  stretch  at  a  signal  from  the  surgeon.  Finally,  as  soon 
as  the  completion  of  the  creaking  sound  and  the  sudden  snap  denote  the 
division  of  the  tendon,  the  foot  is  again  relaxed.  A  small  pad  of  sterile 
gauze  being  at  once  applied,  the  foot  is  put  up  in  the  everted  position. 
For  this  purpose  nothing  is,  to  my  mind,  so  simple  and  efl&cient  as  a  well- 
padded  splint  of  the  proper  width,  with  two  notches  at  its  lower  end,  the 
upper  end  being  just  below  the  knee  in  infants,  and  the  lower  projecting 
two  inches  and  a  half  below  the  foot.  The  splint  is  applied  to  the  outer 
side,  the  leg  being  first  rolled  in  a  flannel  bandage  to  prevent  pressure-sores. 
Tibialis  Posticus.  It  is  usually  recommended  to  divide  this  an  inch 
and  a  half  or  two  inches  above  the  internal  malleolus.^  The  tendon  is 
^  The  tendon  is  here  rather  farther  from  the  artery,  and  the  surgeon  will  be  above 
the  commencement  of  its  synovial  sheath,  in  which  it  traverses  the  internal  annular 
ligament. 

SURGERY  I  961  6l 


962       OPERATIONS  ON  THE  LOWER  EXTREMITY 

here  separated  from  the  posterior  tibial  vessels  by  the  flexor  longus 
digitorum. 

The  surgeon  and  his  assistant  occupying  positions  as  above,  the 
exact  site  of  the  tendon  is  defined,  if  possible,  by  abducting  and  bending 
down  the  foot.  In  fat  infants  it  is  often  quite  impossible  to  feel  the 
tendon,  and  in  these  cases  a  spot  midway  between  the  anterior  and  internal 
borders  of  the  leg  will  be  the  best  guide,  as  denoting  the  inner  margin  of 
the  tibia.  The  surgeon  then  introduces  a  sharp  tenotome  so  as  just  to 
touch,  if  possible,  the  inner  margin  of  the  tibia,  taking  care  to  sink  the 
blade  sufficiently  to  open  the  sheath  freely.  This  being  done,  a  blunt- 
pointed  tenotome  is  introduced  through  the  same  opening,  and  pushed 
under  the  tendon  ;  the  edge  being  then  turned  towards  it,  and  the  tibia 
used  as  a  fulcrum,  the  tendon  is  severed,  together  with  that  of  the  flexor 
longus  digitorum.  The  assistant  first  relaxes  and  then  extends  the 
tendon,  as  advised  above. 

If  the  artery  be  cut,  as  shown  by  the  jetting  haemorrhage  and  the 
blanching  of  the  foot,  firm  pressure  must  be  apphed,  the  foot  being  first 
bandaged.  The  writer  generally  prefers  to  expose  the  tendon  through  a 
short  vertical  incision.  This  avoids  injury  of  the  flexor  longus  digitorum 
and  post-tibial  vessels ;  moreover,  some  of  the  tibiahs  posticus  tendon  may 
be  excised  if  desirable  to  prevent  reunion. 

Plantar  Fascia.  This  may  be  divided  just  below  its  origin  from  the 
OS  calcis,  or  in  advanced  cases  of  tahpes  close  to  the  transverse  crease, 
which  is  here  found  in  the  sole.  With  regard  to  this  fascia,  the  surgeon 
should  not  tie  himself  down  to  any  fixed  spot,  but  divide  resisting  bands 
whenever  they  are  felt.  The  writer  prefers  to  excise  two  inches  of  the 
plantar  fascia  in  order  to  prevent  recurrence  of  contracture,  which  is 
very  common  and  difiicult  to  prevent  even  with  a  good  instrument  and 
careful  after-treatment.  A  longitudinal  incision  one  and  half  inches  long 
is  made  on  the  inner  side  of  the  sole,  and  the  posterior  two  inches  of  the 
fascia,  when  the  latter  is  narrow  and  thick,  is  excised. 

Syndesmotomy.  This  term  was  introduced  by  Mr.  R.  W.  Parker  ^  who  believes 
that  in  many  cases,  e.g.  severe  ones,  cases  not  treated  in  early  life,  and  in  some 
relapsed  cases,  the  foot  cannot  be  rectified  even  by  multiple  tenotomy.  He  attributes 
this,  not  to  adhesions,  but  to  the  faulty  shortness,  and  unyielding  nature  of  the 
ligaments.  Chief  amongst  these,  in  equino-varus,  are  the  ligaments  about  the 
astragalo-scaphoid  joint.  "  In  these  cases  there  is  a  capsule  made  up  above  and 
internally  by  a  blending  together  of  the  superior  astragalo-scaphoid  ligament  with 
fibres  from  the  anterior  ligament,  and  the  anterior  portion  of  the  deltoid  ligament 
below  with  fibres  from  the  inferior  calcaneo-scaphoid  ligament.  To  these  are 
miited  fibrous  expansions  of  the  tendons  of  the  anterior  and  posterior  tibial  muscles  ; 
together  they  form  an  imyielding  capsule  of  great  strength,  which  is  attached  to  the 
several  bones,  not  in  the  usual  maimer,  but  in  adaptation  to  their  altered  relative 
positions.  This  I  would  name  the  '  astragalo-scaphoid  capsule.'  "  Mr.  Parker  gives 
directions  for  dividing  this  structure  which  can  be  made  to  combine  division  of  the 
tibial  tendons.  While  I  consider  this  method  superior  to  that  just  given,  I  much 
prefer  that  by  a  flap,  by  which  the  needful  tendons,  fascia  and  ligaments  can  all  be 
divided  together.  In  syndesmotomy  it  is  more  difficult  to  make  sure  of  dividing 
the  tibialis  posticus. 

The  site  chosen  for  this  combined  division  of  tendons  and  ligaments  is  a  little 
below  and  anterior  to  the  tip  of  the  internal  malleolus.^  Other  guides  are  the  site 
of  the  astragalo-scaphoid  joint,  and  in  older  cases  the  transverse  crease  which, 
running  dowTi  on  to  the  sole,  denotes  the  continued  inversion  of  the  foot.     Two 

^  Congenital  Cliihfoot,  p,  62  et  passim. 

*  Mr.  Parker  {loc.  supra  cit.,  p.  78)  shows  that  Velpeau  and  Syme  pointed  out  the 
possibility  of  dividing  the  tendon  of  the  tibialis  posticus  here. 


TENOTOMY  OF  TENDONS  ABOUT  FOOT     963 

tf  notonies  are  required,  one  of  ordinary  pattern,  and  one  curved,  somewhat  sicklc- 
shajxxl,  and  witli  a  cutting  l>lade  about  half  an  inch  in  length. 

The  surgeon  notes  the  i)osition  of  the  arteries,  and  the  lines  along  which  the  tibial 
tendons  are  curving  towards  the  internal  cuneiform.  Having  marked,  at  the  spot 
above  given,  the  jx).sition  of  these  tendons,  he  enters  a  sharp-pointed  tenotome,  the 
parts  being  relaxed,  just  al>ove  the  posterior  tibial  artery,  and  pushes  it  outwards 
on  to  the  dorsum  to  a  sjwt  jiLst  short  of  the  dorsalis  jx-dis  artery,  the  knife  travelling 
just  beneath  the  skin  to  make  a  path  for  the  next  instrument,  which  does  the  work. 
The  curved  tenotome  is  then  inserted  under  the  skin,  and  pushed  on,  fiat-wise, 
till  its  tip  can  be  felt  over  the  tibialis  anticas;  it  is  then  turned  blade  downwards, 
the  til)ialis  anticus  is  felt  to  give  way,  and,  as  the  knife  cuts  on  the  subjacent  bones 
and  cartilages,  the  ligaments  are  felt  to  yield  to  it,  while,  as  it  is  withdrawn,  its 
edge  divides  the  tibialis  posticus. 

Tendo  Achillis.  This  should  be  divided  half  an  inch  above  its  insertion 
in  an  infant,  and  an  inch  and  a  half  in  an  adult. 

The  foot  and  leg  being  turned  well  over  on  to  the  outer  side,  and  the 
tendon  being  relaxed  by  the  assistant  bending  the  foot  downwards,  the 
margins  of  the  tendon  are  accurately  defined.  The  knife  is  then  intro- 
duced Vertically  close  to  the  inner  side  of  the  tendon  till  it  reaches  a 
sufficient  depth  to  ensure  being  beneath  it ;  ^  it  is  then  pushed  horizontally 
across  under  the  tendon  till  it  is  felt  under  the  skin  by  the  left  index 
finger,  which  accurately  marks  out  the  outer  hmit  of  the  tendon  ;  the  blade 
is  then  turned  towards  the  tendon,  which  being  at  the  same  time  put  on 
the  stretch  by  bending  up  the  foot,  is  divided  by  a  series  of  levering  move- 
ments of  the  handle.  Creaking  movements,  followed  by  a  sudden  snap 
or  thud,  denote  complete  di\'ision,  when  the  tendon  is  to  be  at  once 
relaxed  and  the  knife  brought  out  horizontally.  The  writer  prefers  to 
hold  the  foot  himself,  always  standing  on  the  outer  side  of  the  affected 
Kmb  and  holding  the  tenotome  in  the  left  hand  for  the  right  Hmb  and  vice 
versa.  When  the  shortening  of  the  tendo  Achillis  is  over  one  and  a  half 
inches  the  writer  divides  the  two  lateral  halves  of  the  tendon  at  different 
levels,  subcutaneously,  and  splits  the  tendon  between.  This  gives  quicker 
and  stronger  union,  and  avoids  the  risk  of  non-union. 

The  Peronei.  The  peroneus  longus  and  brevis  occasionally  require 
division.  They  may  be  di\nded  simultaneously  by  entering  a  tenotome 
between  them  and  the  bone  about  two  inches  above  the  external  mal- 
leolus. Immediately  above  this  process  they  are  more  under  cover  of 
the  bone.     If  divided  below  it,  their  syno\4al  sheath  would  be  opened. 

Date  of  rectification.  In  the  case  of  the  smaller  tendons,  and  in  the 
more  common  cases  of  tenotomy,  e.g.  for  congenital  equino-varus,  this 
should  be  immediate.  Where  the  tendo  Achillis  has  been  divided,  and  in 
many  cases  of  tenotomy  for  infantile  paralysis,  correction  must  be  made 
more  gradually.  Whatever  operation  is  performed,  over-correction  must 
be  ensured  during  the  first  fortnight,  owing  to  the  certain  tendency  to 
relapse.  For  retaining  appliances  I  prefer  felt  or  poroplastic  in  children, 
or  a  notched  spHnt,  like  a  Dupuytren's  (p.  961).  If  a  plaster  of  Paris 
bandage  is  employed  it  should  be  removed  as  soon  as  possible,  to  allow  of 
the  needful  daily  movements  of  the  joints,  and  rubbing.  Thus,  after  about 
ten  or  fourteen  days,  the  foot  should  be  daily  manipulated  by  the  surgeon 
for  a  while  and  active  exercises  performed  by  the  patient ;  and,  later  on, 
several  times  daily  by  the  mother  or  nurse,  the  surgeon  seeing  the  case 
every  few  days.     If  such  manipulations  are  daily  persevered  with,  and  the 

^  Young  operators  often  do  not  insert  the  knife  sufficiently  deep  ;  they  thus,  when  it 
is  pushed  across,  get  into  the  tendon  instead  of  beneath  it,  and  so  divide  it  incompletely. 


964       OPERATIONS  ON  THE  LOWER  EXTREMITY 

case  kept  under  the  surgeon's  eye,  recurrence  in  deformity  is  unlikely, 
especially  if  suitable  day  and  night  instruments  are  used.  To  allow  of 
these  manipulations  being  begun  early  over-correction  is  essential. 
Finally,  if  only  justice  were  done  to  the  methods  of  tenotomy  and  division 
of  ligaments  and  to  ensuring  early  over- correction  by  suitable  boots  and 
instruments,  we  should  hear  little  of  severer  methods. 

TENOTOMY  OF  THE  HAMSTRINGS 

Semi-tendinosus  and  Semi-membranosus.  These  tendons  can  be 
divided  subcutaneously.  A  contracted  knee  can  generally  be  straightened 
after  division  of  the  biceps  and  semi-tendinosus.  If  it  is  needful  to  insert 
the  knife  more  deeply  so  as  to  divide  the  semi-membranosus,  it  would  be 
well  to  use  a  blunt-pointed  tenotome,  or  to  operate  through  an  open 
incision.  The  writer  generally  divides  the  inner  hamstrings  as  follows. 
After  dividing  the  biceps  through  an  open  wound  over  it,  he  inserts  a  finger 
to  feel  and  protect  the  popliteal  vessels,  while  a  tenotome  is  introduced  in 
front  of  the  inner  hamstrings  from  the  inner  side,  guided  by  the  finger 
behind  the  large  blood-vessels. 

TENOTOMY  OF  THE  STERNO-MASTOID 

The  open  method,  in  which  the  muscle  is  divided  through  a  curved 
incision  across  the  lower  end  of  the  sterno-mastoid,  is  the  best  here,  as  it 
allows  of  every  step  being  seen,  of  avoiding  abnormal  vessels,  and  securing 
not  only  complete  division  of  the  muscle,  but  also  of  any  fascial  bands. 
It  is  often  necessary  to  divide  or  lengthen  these  tendons  for  straightening 
the  knee  contracted  as  a  result  of  arthritis,  spastic  paraplegia,  or  infantile 
paralysis,  imperfectly  healed  by  apparatus. 

Biceps.  The  proximity  of  the  external  popLteal  nerve  makes  an 
open  incision  far  safer.  An  incision  two  inches  long  is  made  parallel  to  and 
just  in  front  of  the  biceps  tendon,  and  the  latter  carefully  separated  from 
the  nerve,  which  lies  just  behind  and  internal  to  it.  The  tendon  is  either 
divided  or  split  and  lengthened  as  required.  If  necessary  for  the  correc- 
tion of  associated  genu  valgum  the  ilio-tibial  band  and  the  external 
lateral  ligaments  of  the  knee  can  be  divided  at  the  same  time,  after 
lengthening  the  incision  as  required. 

If  punctures  are  employed  the  two  heads  are  best  divided  separately 
just  above  the  clavicle.  The  muscle  being  made  prominent,  by  one 
assis'ant  manipulating  the  head  and  another  depressing  the  shoulder, 
the  surgeon,  standing  facing  the  patient  on  the  side  to  be  operated 
upon,  defines  ths  limits  of  the  inner  border  of  the  sl^ernal  tendon, 
opens  the  fasciae  sufficiently  freely  here,  and  then,  taking  a  blunt-pointed 
tenotome,  insinuates  it  horizontally  behind  and  close  to  the  tendon  till  it 
is  felt  just  beneath  his  left  index  finger,  which  is  placed  at  the  outer 
margin  ;  the  edge  is  then  turned  towards  the  tendon,  and  divides  it. 
It  is  withdrawn  with  the  usual  precautions.  The  clavicular  tendon  is 
divided  in  a  similar  way  through  another  puncture. 

Care  must  be  taken  to  avoid  the  anterior  jugular,  which  runs  outwards 
under  the  muscle  a  little  above  the  clavicle,  and  the  external  jugular, 
which  lies  at  a  varying  level  close  to  the  outer  border  of  the  clavicular 
head.  If  a  sharp  tenotome  were  dipped  too  deeply,  the  internal  jugular 
might  also  be  wounded. 


OPERATIVE  TREATMENT  OF  TALIPES  965 

If  any  smart  venous  haemorrhage  occur,  a  pad  of  dry  gauze  should  be 
firndy  bandaged  on. 

Lengthening  the  Sterno-Mastoid.  For  moch'ratc,  and  especially  severe 
shortening  of  the  stenio-niastoid,  and  except  in  infants  when  subcutaneous 
tenotomy  is  satisfactory,  lengthening  the  muscle  is  by  far  the  most 
satisfactory  operation.  This  operation,  which  was  introduced  by  the 
writer  some  ten  years  ago,  has  proved  most  satisfactory,  the  after- 
treatment  being  rendered  simple  and  of  short  duration,  and  the  functional 
results  and  a})pearance  being  almost  perfect.  A  curved  incision  similar 
to  Kocher's  incision  for  goitre  but  much  shorter  and  only  on  one  side,  is 
made,  and  the  sternal  tendon  is  detached  from  the  bone,  and  the  clavicular 
fibres  are  divided  obliquely  upwards  and  backwards  about  an  inch  and  a 
half  or  two  inches  up.  The  sternal  head  is  joined  to  the  clavicular  fibres 
at  this  point  by  a  catgut  suture.  A  massive  dressing  is  applied  to  maintain 
the  over-corrected  position. 

Causes  of  Failure  after  Tenotomy.  (1)  Incomplete  division  of  the 
tendon.  (2)  Division  of  important  structures,  ejj.  the  tibial  arteries,  the 
external  popliteal  nerve,  the  anterior  or  internal  jugular  veins.  (3)  Non- 
union of  the  tendon.  (4)  Mal-union  of  the  tendon,  e.(j.  adhesions  formed 
by  it  to  adjacent  structures,  its  sheath  or  a  bone.  These  are  both 
extremely  rare,  and  are  due  to  neglect  of  early  movements,  both  active 
and  passive.  (5)  Breaking  off  the  point  of  the  tenotome,  usually  against 
a  bone. 

THE  OPERATIVE  TREATMENT  OF  TALIPES 

Space  does  not  allow  a  full  discussion  of  the  treatment  of  the  various 
forms  of  talipes  here.  Only  a  few  suggestive  methods  for  some  of  the 
common  deformities  will  be  described.  Talipes  equino-varus,  either 
congenital  or  acquired  and  paralytic,  is  by  far  the  commonest  and  will  be 
most  fully  discussed.  Calcaneo  valgus  and  equino  valgus,  pure  equinus 
and  pes  cavus  are  far  less  frequent  and  will  be  more  briefly  discussed. 
Flat  foot,  the  commonest  form  of  talipes  valgus,  does  not  often  require 
operative  treatment,  but  this  and  the  grave  variety  following  fracture 
dislocation  of  the  ankle  will  be  briefly  coiLsidered. 

SOME  POINTS  IN  THE  TREATMENT  OF  SEVERE  TALIPES 

Befors  proceeding  to  describe  the  operations  a  few  remarks  may  be 
made  upon  the  prophylaxis  of  paralytic  talipes  and  the  early  treatment  of 
congenital  talipes,  for  the  old  proverb  that  "  prevention  is  better  than 
cure  '"  is  very  true  of  deformities.  Most  deformities  are  either  preventable 
or  curable  in  their  early  stages  by  safe  and  simple  means.  If  these  facts 
were  more  widely  and  thoroughly  appreciated,  there  would  be  fewer 
hopeless  cripples  and  far  less  misery  and  poverty.  Many  cripples,  now 
hopelessly  handicapped  in  the  struggle  for  existence,  would  be  useful 
members  of  society.  The  ignorance  that  prevails  concerning  the  proper 
treatment  of  congenital  tahpes  is  appalling.  The  parents  are  commonly 
told  that  it  is  of  no  use  commencing  treatment  until  the  child  is  several 
months  old.  The  most  hopeful  time  for  treatment  is  thus  allowed  to  pass, 
and  deformities,  which  are  curable  by  manipulations  and  simple  splints  in 
the  first  few  weeks  of  life,  are  allowed  to  become  serious  and  more  or  less 
intractable.     Paralytic  tahpes  develops  so  insidiously  that  it  may  appear 


966       OPERATIONS  ON  THE  LOWER  EXTREMITY 

to  be  inevitable,  whereas  it  is  mostly  preventable  by  simple  means.  The 
value  and  importance  of  suitable  instruments  designed  to  prevent  over- 
stretching of  the  paralysed  muscles  and  fibrous  retraction  of  their  antago- 
nists are  not  sufficiently  reahsed.  The  surest  way  of  completing  the 
paralysis  of  a  weak  muscle  is  to  overstretch  it,  and  one  of  the  most  im- 
portant conditions  of  its  recovery  is  the  avoidance  of  excessive  tension; 

There  is  a  current  belief  that  instruments  of  all  kinds  do  not  aid  but 
hinder  the  restoration  of  function  of  the  paralysed  limb.  This  is  by  no 
means  true  of  suitable  instruments,  provided  that  their  use  be  combined 
with  well-planned  exercises  designed  to  develop  the  weak  muscles,  and 
manipulations  for  stretching  muscles  that  tend  to  retract.  Too  much 
faith  is  placed  in  massage  and  electricity.  They  certainly  tend  to  maintain 
the  nutrition  of  the  weak  muscles  in  the  early  stages  of  paralysis,  but 
their  good  effect  is  often  more  than  neutraUsed  by  the  neglect  of  the  other 
and  better  means  which  have  been  already  mentioned. 

After  the  tahpes  has  been  more  or  less  corrected  by  simple  operation, 
recurrence  and  increase  of  the  deformity  is  exceedingly  common  because 
of  the  want  of  care  in  the  after-treatment.  Without  this  care  operations 
and  instruments  are  more  or  less  wasted.  The  after-treatment  of  hospital 
patients  is  pecuharly  difficult  because  of  the  trouble  and  expense  of 
getting  suitable  instruments.  The  patients  often  fail  to  attend  regularly 
for  various  reasons  ;  they  may  not  take  a  sufficient  interest  in  their  con- 
dition ;  circumstances  may  make  it  impossible  for  them  to  keep  their 
instruments  in  repair,  and  frequently  they  reappear  only  when  their  de- 
formity is  obviously  getting  worse. 

Operations.  Tenotomy  and  division  of  hgaments ;  tendon  lengthening ; 
transplantation  of  tendons  ;  resection  of  bone  ;  nerve  anastomosis. 

Tenotomy  and  tendon  lengthening  have  been  considered.  It  is  rarely 
necessary  to  do  any  other  operation  for  correction  of  congenital  tahpes  in 
infants,  or  for  earhj  acquired  tahpes  in  young  children.  Careful  after- 
treatment  along  the  lines  already  mentioned  serves  to  complete  the  cure. 

For  later  cases  hgaments  sometimes  require  division;  for  instance, 
the  plantar  ligaments  are  divided  when  there  is  much  elevation  of  the  arch 
of  the  foot,  and  the  plantar  fascia  is  divided,  or  better,  a  portion  of  it  is 
excised. 

Transplantation  of  tendons.  The  whole  or  a  portion  of  a  tendon  is 
shifted  to  a  new  insertion.  The  best  example  is  the  transference  of  the 
tibiahs  anticus  insertion  from  the  inner  to  the  outer  side  of  the  foot,  thus 
changing  its  adductor  function  into  abduction,  while  maintaining  its 
power  of  dorsi-flexion  of  the  ankle.  Similarly  other  tendons  are  trans- 
ferred. Experience  has  shown  that  certain  rules  must  be  observed  in  order 
to  secure  good  results  from  this  operation. 

(1)  It  is  better  to  sew  the  tendon  to  the  periosteum  or  ligaments  than 
to  another  tendon,  for  the  latter  is  apt  to  spht,  making  the  insertion  less 
secure. 

(2)  It  is  better  to  transfer  the  whole  tendon  than  to  use  only  half  of  it,  for 
the  new  function  desired  is  rarely  obtained  when  some  of  the  old  insertion 
is  preserved.  It  is  clearly  unreasonable  to  expect  a  portion  of  the  tendo 
Achillis  transferred  to  the  front  of  the  foot  to  act  as  a  dorsi-flexor  of  the 
ankle. 

(3)  The  adaptation  of  the  nervous  system  to  the  new  result  of  any 
voluntary  effort  is  easier  when  the  new  movement  is  simple  and  not 
entirely  antagonistic  to  the  old  one. 


OPERATIVE  TREATMENT  OF  TALIPES  9G7 

(4)  Relaxation  of  the  transplanted  tendon  is  essential  for  some  months 
after  the  operation,  for  over-stretching  paralyses  the  muscle.  It  is 
evident  that  in  many  cases  transplantation  of  a  tendon  is  far  more  per- 
manently efHcient  than  mere  division  of  it,  which,  as  a  rule,  is  followed  by 
a  return  of  some  of  the  original  power,  the  amount  varying  with  the  care 
bestowed  u})on  the  after-treatment.  After  transplantation  of  the  whole 
tendon  the  old  function  is  permanently  lost,  and  moreover  a  new  one  is 
accjuired.  As  a  nde,  however,  transplantation  of  tendons  is  most  efficient 
when  combined  with  other  methods  such  as  resection  of  bone. 

Nerve  amistomosis.  In  certain  cases  nerve  suture  or  nerve  anastomosis 
is  of  value ;  for  instance,  after  division  of  the  external  popliteal  nerve 
secondary  nerve  suture  should  be  performed,  but  the  secondary  talipes 
equino-varus  must  be  corrected  at  the  same  time  in  order  to  ensure  the 
return  of  power  in  the  stretched  and  paralysed  muscles.  And  the  nutrition 
of  the  paralysed  nuiscles  must  be  maintained  by  massage  and  electricity 
until  the  nerve  recovers  its  function.  In  other  cases,  especially  of  infantile 
paralysis  affecting  one  of  the  popliteal  nerves,  a  portion  of  the  central  end 
of  the  healthy  nerve  is  joined  to  the  peripheral  end  of  the  paralysed  one. 
Up  to  a  third  of  the  healthy  nerve  can  be  used  in  this  way  without  per- 
manently damaging  its  function.  Here  again  correction  of  the  talipes 
by  direct  means  is  necessary  to  secure  the  best  results. 

As  a  rule  operations  on  the  soft  parts  with  instrumental  after-treat- 
ment are  sufficient  for  children  up  to  three  or  four  years  of  age.  It  is 
rarely  necessary  to  resect  any  bone  under  this  age,  for  the  bones  are  soft 
and  capable  of  moulding  by  constant  endeavour-with  instruments. 

After  this  age  too  much  is  expected  from  tenotomies  and  similar 
tinkering  measures,  and  too  much  is  left  to  the  after-treatment,  especially 
with  hospital  patients.  It  should  be  our  endeavour  to  anticipate  the 
well-known  tendency  to  recurrence,  and  to  design  our  operations  accord- 
ingly, making  the  patient  as  independent  as  possible  of  prolonged  after- 
treatment  by  instruments.  Such  operations  need  not  be  mutilating  in  any 
sense  of  the  term.  On  the  contrary,  they  should  restore  both  the  shape 
and  function  of  the  foot  as  far  as  possible.  The  false  conservatism  that 
prevails  may  be  a  survival  of  pre-aseptic  days  when  it  was  dangerous  to 
perform  extensive  operations  for  tahpes. 

Operation  for  severe  Talipes  Equino-varus.  The  operation  which  I 
am  about  to  describe  is  suitable  for  neglected  cases.  It  is  even  apphcable 
to  severe  deformities,  which  are  often  regarded  as  unsuitable  for  operation 
other  than  amputation.  For  these  late  cases  it  is  particularly  important 
to  secure  a  free  range  of  movement,  especially  of  the  ankle-joint.  This 
is  essential  for  the  development  of  the  muscles  which  have  degenerated  as 
a  result  of  over-stretching  and  inaction.  It  is  astonishing  to  notice  the 
recovery  of  function  that  may  follow  the  provision  of  a  free  range  of 
movement,  and  the  relaxation  and  exercise  of  the  over-stretched  muscle. 
With  time  I  have  gradually  learnt  to  combine  a  variety  of  methods  in  order 
to  be  more  certain  of  getting  good  results,  which  depend  upon  the  cumu- 
lative effect  of  the  various  procedures.  Some  of  the  steps  and  precautions 
may  appear  trivial  in  themselves,  but  the  best  results  are  obtained  only  by 
making  use  of  every  available  means.  The  operation  recommended  for 
severe  talipes  equino-varus  may  be  described  first,  and  the  various  proce- 
dures and  modifications  of  them  may  then  be  discussed. 

Operation.  The  leg  and  foot  are  cleansed  with  the  most  scrupulous 
care.     A  general  anaesthetic  is  given.     The  leg  and  foot  are  elevated  for  a 


068       OPiERATlONS  ON  THE  LOWER  EXTREMITY 

few  minutes,  then  a  tourniquet  is  applied  round  the  lower  third  of  the 
thigh,  the  skin  being  protected  with  lint.  The  tense  plantar  fascia  is 
divided  subcutaneously.  The  ligaments  below  the  medio-tarsal  joint  are 
similarly  divided  through  a  puncture  placed  below  the  inner  side  of  the 
joint ;  meanwhile  the  fore  part  of  the  foot  is  forced  upwards  and  outwards. 
An  incision  about  three  or  four  inches  long  is  made  in  the  groove  internal 
to  and  in  front  of  the  lower  part  of  the  tendo  Achillis.  This  tendon  is  trans- 
fixed in  the  antero-posterior  direction  and  cleft  for  several  inches,  the  extent 
being  determined  by  the  amount  of  equinus  (see  Fig.  397).    The  inner  half  of 


Fig.  397.     Lengthening  the  heel  tendon.     The  tendon  is  slit  longitudinally  and 

the  fibres  are  divided  obliquely,  and  the  ends  are  joined  with  catgut.     The 

incision  is  placed  in  the  groove  in  front  of  this  tendon  on  the  inner  side.     Dorsi 

flexion  beyond  the  right-angle  must  be  easy  after  the  lengthening. 


it  is  cut  off  the  os  calcis  and  the  outer  half  is  severed  obliquely  upwards  and 
outwards  from  the  upper  end  of  the  cleft.  If  necessary  the  tibialis  posticus 
is  divided  from  the  wound.  The  ankle  is  forcibly  flexed  as  far  as  possible. 
If  the  deformity  be  incompletely  corrected  an  elliptical  incision  is  made 
over  the  front  and  outer  side  of  the  foot,  commencing  a  little  below  and 
internal  to  the  middle  of  the  anterior  surface  of  the  ankte  and  extending 
downwards,  forwards,  and  outwards  nearly  to  the  outer  border  of  the  foot 
opposite  the  medio-tarsal  joint,  or  about  one  inch  behind  the  prominence 
of  the  fifth  metatarsi:!  bone.  The  width  of  the  piece  of  skin  to  be  removed 
varies  in  different  cases,  but  it  must  be  just  enough  to  leave  no  slack  when 
the  wound  is  closed  after  the  bone  is  removed.  The  upper  and  lower 
edges  of  the  wound  are  mobilised  a  little,  care  being  taken  not  to  cut  the 
musculo- cutaneous  nerve.  The  skin  is  excluded  from  the  field  of  the 
operation  by  means  of  gauze  pads  carefully  fixed  to  the  edges.  A  longi- 
tudinal incision  is  then  made  through  all  the  soft  parts  covering  the  promi- 
nence of  the  head  of  the  astragalus.  No  tendon  need  be  divided.  The 
capsule  of  the  astragalo-navicular  joint  is  then  opened  and  separated  from 
the  head  and  neck  of  theastragalusby  means  of  a  suitable  knife  carefully 
used  from  within  the  joint  and  kept  close  to  the  bone.  When  the  head  and 
neck  of  this  bone  have  been  fully  exposed  they  are  removed  by  means  of  a 
Macewen  osteotome.  The  section  is  made  more  or  less  obliquely  in  two 
senses,  both  from  above  downwards  and  forwards  and  from  without 
inwards  and  forwards.  In  this  way  both  the  equinus  and  varus 
are  diminished.  A  similar  longitudinal  incision  is  made  through  the 
soft  parts  covering  the  fore  part  of  the  outer  side  of  the  os  calcis.  The 
calcaneo-cuboid  joint  is  opened  and  a  wedge-shaped  piece  of  the  anterior 
and  outer  part  of  the  os  calcis  is  removed.  The  tibialis  anticus  tendon  is 
exposed  in  its  sheath  and  divided  close  to  its  insertion  into  the  navicular 


OPERATTVK  TREATMENT  OF  TALIPF>S 


9G9 


aiul  internal  cuneiform.  An  attempt  is  made  to  correct  the  deformity, 
and  if  this  be  impossible,  some  more  bone  may  have  to  be  removed  and 
some  ligamentous  iibres  lyinji;  below  the  medio-tarsal  joint  may  need 
carefurdivision  from  within  the  joint.  When  the  deformity  is  over- 
corrected  and  the  foot  is  held  in  this  position  the  tendon  of  the  tibialis 
anticus  is  carefully  sewn  to  the  periosteum  and  ligaments  on  the  dorsal 
aspect  of  the  cuboid  and  to  the  tendon  of  the  peroneus  tertius.  The 
sutures  are  not  tied  until  the  foot  is  brought  into  the  over-corrected 
position,  and  with  the  foot  still  held  in  this 
attitude  the  overlapping  ends  of  the  heel 
tendon  are  sewn  together  with  fine  catgut. 
The  dorsal  ligaments  attached  to  the 
scaphoid  and  astragulus  may  be  shortened 
by  means  of  catgut  sutures.  The  wounds 
are  accurately  closed,  and  the  foot  is 
covered  with  antiseptic  dressings  and  firmly 
bandaged.  The  tourniquet  is  then  re- 
moved, and  the  leg  and  foot  are  fixed  in  a 
comfortable  back  splint  and  footpiece,  and 
well  elevated. 

Comments  upon  the 
Various  Steps  of  the  Oper- 
ation. In  commenting 
upon  the  various  steps  of  this  operation  I 
wish  again  to  lay  stress  upon  the  great  im- 
portance of  perfect  cleanliness.  There  is 
no  doubt  that  it  is  a  very  difficult  thing 
to  clean  the  deformed  foot  satisfactorily. 
It  needs  a  great  deaf  of  scrubbing  with 
soap  and  water  and  the  use  of  ether  soap 
or  turpentine.  This  is  followed  by  painting 
with  tincture  of  iodine.  The  toes  are  care- 
fully covered  before  the  operation  is  com- 
menced. The  tourniquet  is  very  valuable 
for  these  cases,  for  it  not  only  saves  blood 
but  also  time,  and  it  enables  the  surgeon 
to '[do  far  more  accurate  and  clean  work. 
There  is  no  need  to  take  the  tourniquet  off 
for  the  purpose  of  catching  up  the  vessels 
before  closing  the  wound.   These  peripheral 

vessels  are  easily  controlled  by  means  of  firm  bandaging  over  plenty  of 
elastic  dressings,  provided  that  the  pressure  be  apphed  before  the  tourniquet 
is  removed  and  the  foot  be  kept  elevated  after  the  operation.  This  also 
lessens  the  pain.  There  are  great  advantages  in  taking  the  steps  of  the 
operation  in  the  order  recommended.  It  is  sometimes  almost  impossible  to 
tell  beforehand  how  much  may  be  necessary  for  the  over-correction  of  the 
deformity,  but  by  adopting  the  order  suggested  it  is  quite  easy  to  decide  this 
point  and  to  leave  off  at  any  stage  when  the  required  result  has  been  ob- 
tained. For  instance,  in  some  fairly  severe  cases,  resection  of  bone  for  the 
correction  of  the  equinus  or  varus  may  prove  to  be  unnecessary  after  the 
soft  partshave  been  divided  in  the  orderdescribed.  It  must  be  remembered, 
however,  that  it  is  necessary  to  over-correct  the  deformity,  and  that  a 
comparison  with  the  passive  mobility  of  the  opposite  foot  is  often  valuable. 


Fig.  398.  Operation  for  severe 
talipes  equine- varus.  The  fore- 
parts of  the  astragalus  and  os 
calcis  have  been  removed,  and 
the  tibialis  anticus  tendon  trans- 
planted to  the  dorsal  ligaments 
of  the  cuboid,  thus  converting  it 
into  an  abductor  of  the  foot. 


970       OPERATIONS  ON  THE  LOWER  EXTREMITY 

Nothing  less  than  the  normal  range  of  mobility  is  sufficient.     It  is  easier 
to  divide  the  planter  fascia  and  the  plantar  ligaments  efficiently  while  the 


Fig.  399.     J.  L.     The  extreme  talipes  equinus  is  well  shown  with  the  prominence 

of  the  head  of  the  astragalus  in  front,  the  scaphoid  articulating  with  its  inferior 

surface  only.     The  head  and  neck  of  the  bone  were  removed,  the  section  passing 

almost  vertically.     Note  the  malposition  and  atrophy  of  the  heel-bone. 


OS  calcis  is  fixed  by  the  tendo  Achillis.  It  is  difficult  to  divide  the  plantar 
ligaments  until  the  arch  of  the  foot  is  opened  out  by  first  dividing  the 
plantar  fascia  and  then  forcibly  pushing  the  fore  part  of  the  foot  upwards 


OPERATIVE  TREATMENT  OF  TALIPES  971 

and  outwards.  In  bad  cases  tendon  lengthening  is  more  satisfactory  than 
tenotomy,  for  non-union  with  flail  ankle  may  follow  the  latter  when  the 
ends  have  to  be  separated  more  than  about  2  in.  Further,  the  tendency  to 
retraction  after  it  is  much  greater  than  after  tendon  lengthening,  so  that 
it  is  a  matter  of  common  experience  that  tenotomy  may  have  to  be 
repeated,  whereas  tendon  lengthening,  if  properly  done,  is  final.     After 


i 


Fig.  400.  J.  L.  The  same  foot  as  shown  in  Fig.  399,  but  the  radiogram  has 
been  taken  from  the  outer  side,  whereas  Fig.  399  was  taken  from  the  inner  side. 
Note  the  improvement  in  the  shape  of  the  whole  foot,  in  the  position  of  the 
heel- bone,  the  absence  of  the  head  and  neck  of  the  astragalus,  and  the  approxima- 
tion of  the  scaphoid  to  the  front  of  the  body  of  the  astragalus. 

repeated  tenotomies  the  lower  part  of  the  tendon  is  often  found  to  be 
replaced  by  broad  and  thick  sheets  of  adherent  and  contracted  fibrous 
tissue.  The  simple  method  of  cleaving  the  tendon  into  two  lateral 
halves  is  quite  satisfactory.  For  varus  the  outer  half  of  the  tendon  is  left 
attached  to  the  os  calcis.  and  for  valgus  the  inner  half.  Other  tendons  are 
often  transplanted  ■with  advantage.  For  instance,  a  part  of  the  tendo 
AchilHs  may  be  diverted  into  the  peroneus  tertius  or  peroneus  bre^ns. 
The  removal  of  the  head  and  neck  of  the  astragalus  and  the  fore  part  of  the 
OS  calcis  is  better  than  the  resection  of  a  wedge  on  the  outer  border  of  the 
foot,  because  it  is  more  efficient  and  interferes  less  with  the  insertion  of 
tendons,  and  therefore  with  the  natural  functions  of  the  foot.  The  tarsec- 
tomy  is  usually  done  too  far  forward,  whereas  the  head  and  neck  of  the 
astragalus  forms  the  keystone  of  the  arch,  so  that  a  hmited  and  obhque 
resection  produces  a  very  striking  degree  of  correction  of  the  deformity. 


972       OPERATIONS  ON  THE  LOWER  EXTREMITY 

The  mobility  of  the  medio-tarsal  joint  need  not  be  seriously  interfered 
with  if  care  be  taken  to  preserve  the  articular  cartilage  of  the  navicular 
and  cuboid,  and  to  adopt  massage  and  movements  in  tlie  after-treatment. 
Complete  astragalectomy  is  not  nearly  so  efficient  in  correcting  the  de- 
formity, and  it  has  the  serious  disadvantage  of  shortening  the  hmb.  This 
is  especially  to  be  avoided  when  congenital  talipes  is  unilateral,  and  in  all 
paralytic  talipes  in  which  the  paralysed  limb  is  already  a  good  deal  shorter 
than  its  fellow.  In  my  experience,  the  removal  of  the  head  and  neck  of 
the  astragalus  and  the  fore  parts  of  the  os  calcis  is  far  more  efficient  in 
correcting  the  varus  than  taking  a  wedge  from  the  side  of  the  body  of  the 
astragalus  within  the  ankle-joint.  Moreover,  the  method  which  I  have 
described  does  not  interfere  in  the  least  degree  with  the  mobility  of  the 
ankle-joint,  which  is  the  most  important  joint  to  preserve  in  the  foot. 
It  may  be  said  that  the  foot  is  shortened  by  the  operation  which  I  have 
described,  but  this  is  not  true,  as  is  shown  by  the  actual  measurements 
taken  before  and  after  operation.  The  removal  of  bone  from  the  con- 
vexity of  the  arch,  and  the  division  of  the  plantar  fascia  and  plantar  liga- 
ments, allows  the  arch  to  open  out  so  much  that  the  foot  is  lengthened. 
Malleotomy  is  apt  to  disturb  the  stability  of  the  ankle-joint. 

Modifications.  When  the  deformity  is  the  extreme  equmo-valgus  so 
often  seen  in  infantile  hemiplegia,  the  incision  is  a  longitudinal  one  over  the 
prominence  of  the  head  of  the  astragalus,  and  only  the  head  and  neck  of 
the  astragalus  need  be  removed.  The  section  of  the  bone  is  oblique,  so 
that  the  base  of  the  wedge  removed  is  above  and  internal,  instead  of  above 
and  external  as  for  the  correction  of  equino-varus.  It  is  not  wise  to 
remove  any  of  the  os  calcis,  for  this  would  exaggerate  the  valgus  deformity. 
In  certain  paralytic  cases  an  attempt  may  be  made  to  get  bony  union  be- 
tween the  astragalus  and  navicular,  the  os  calcis  and  the  cuboid.  In  these 
cases,  therefore,  it  is  an  advantage  to  remove  the  articular  cartilages  of  the 
navicular  and  cuboid  and  to  take  particular  care  to  get  and  to  maintain 
accurate  bony  apposition.  When  the  tibialis  anticus  is  completely  parra- 
lysed  it  is  hardly  worth  while  to  transplant  it,  and  in  certain  patients 
who  have  been  already  submitted  to  multiple  tenotomies  for  congenital 
talipes,  the  tendon  may  not  be  long  enough  for  transplantation  into  the 
cuboid,  but  the  gap  may  be  bridged  by  means  of  silk  threads. 

For  the  accompanying  illustrations  of  two  of  my  cases  I  am  much 
indebted  to  the  photogi-apher  at  Guy's  Hospital. 

Operations  for  severe  Talipes  Calcaneo  Valgus.  Congenital  talipes 
calcaneo  valgus  is  very  easily  cured  during  the  first  few  months  of  life 
by  manipulations  and  instruments,  and  it  rarely  calls  for  operation.  On 
the  other  hand,  the  paralytic  variety  in  older  children  and  adults  is  very 
difficult  to  cure.  The  following  is  the  operation  which  I  have  designed  and 
found  most  efficient. 

The  preliminary  preparations  are  the  same  as  already  described,  the 
strictest  asepsis  being  maintained,  and  a  tourniquet  used.  A  sand  pillow 
is  placed  behind  the  leg  so  that  the  foot  is  raised  from  the  table  and  turned 
well  out.  A  curved  incision  with  its  convexity  dowuM^ards  is  made  from 
just  below  the  tip  of  the  internal  malleolus  to  the  inner  border  of  the  tendo 
Achillis.  The  tendons  of  the  tibialis  posticus,  flexor  longus  digitorum, 
and  flexor  longus  hallucis  are  identified  and  drawn  aside.  The  posterior 
tibial  vessels  and  nerve  all  together  are  separated  from  the  ankle-joint 
and  gently  drawn  outwards.  The  posterior  ligament  of  the  ankle  is 
divided,  and  with  an  osteotome,  wedge-shaped  pieces  of  bone  and  cartilage 


OrKUATn'K  TREATMENT  OF  TALIPES  073 

arc  reiuoved  from  the  posterior  two-thirds  of  the  articular  surfaces  of  the 
tibia  and  astragalus.  The  bases  of  the  wedges  are  posterior,  and  their 
thickness  varies  with  the  degree  of  deformity.  This  corrects  the  calcaneus. 
Now  a  wedge  with  its  base  directed  inwards  is  removed  from  the  upper 
and  inner  surfaces  of  the  astragalus,  and  the  foot  is  vigorously  adducted 
and  inverted.  More  bone  is  removed  if  necessary  until  a  satisfactory 
position  is  obtained,  some  being  taken  from  the  lower  surface  of  the  tibia 
just  external  to  the  internal  malleolus.  The  malleoh  are  carefully 
preserved,  but  their  articular  cartilage  is  removed.  If  necessary  to  get 
the  heel  well  back  and  up,  the  os  calcis  is  divided  with  the  osteotome  at  its 
narrow  part.  This  lengthens  the  heel  and  confers  a  great  mechanical  ad- 
vantage. In  young  children  the  flexor  longus  digitorum  is  divided  and 
its  central  end  is  joined  to  the  tibialis  posticus  to  serve  as  an  additional 
adductor  of  the  foot.  The  peripheral  end  is  joined  to  the  flexor  longus 
hallucis,  which  is  thus  made  a  flexor  of  five  toes  instead  of  one.  The 
tendo  Achillis  is  divided  obliquely,  and  the  superfluous  length  of  it  is 
excised  ;  the  remaining  oblique  surfaces  are  sutured  with  catgut.  The 
tendons,  vessels  and  nerves  are  replaced,  the  wound  closed  and  a  firm 
dressing  apphed  before  the  tourniquet  is  removed.  A  suitable  tin  splint 
is  applied  to  retain  the  foot  at  rest  in  the  corrected  position.  Standing 
and  walking  are  not  attempted  for  two  months  and  then  only  with  the 
aid  of  a  surgical  instrument,  which  prevents  dorsi-flexion  of  the  ankh 
beyond  the  right  angle.  After  this  operation  a  well-shaped  and  stable 
foot  is  obtained  and  yet  some  movement  is  preserved  at  the  ankle-joint. 
This  and  the  mobihty  of  the  mid-tarsal  joint  are  sufficient. 

Operations  for  Congenital  Spastic  Paraplegia.  For  mild  degrees  of  this 
condition  tenotomy  of  the  tendo  Achillis  is  enough,  but  when  the  knees  are 
flexed  the  hamstrings  may  need  division  in  the  manner  already  described 
(p.  9():3).  When  the  thighs  are  adducted  the  shortened  adductors  may  be 
divided  a  little  below  the  spine  of  the  pubis,  and  the  abducted  position 
maintained  by  an  instrument.  For  severe  cases,  some  of  the  correspond- 
ing posterior  nerve  roots  have  been  di^nded  with  success  ;  but  it  must  be 
remembered  that  loss  of  voluntary  movement  of  the  legs  or  paralysis  of 
the  sphincters  may  follow  it  miless  great  care  is  taken  in  the  selection  of 
the  posterior  nerve  roots  to  be  divided.  In  59  recorded  cases  ^  there 
were  8  deaths  and  46  excellent  results,  i.e.  in  all  of  which  the  mental 
condition  was  good  and  careful  after-treatment  adopted  for  a  year.  The 
details  of  this  operation  are  discussed  under  Laminectomy. 

Operations  for  severe  Contractures  of  the  Legs.  In  these  cases  all  the 
muscles  of  the  lower  limbs  may  be  paralysed,  and  in  some  the  hip-joints 
may  be  insecure.  When  the  hip- joints  are  firm  and  there  is  a  little 
power  of  voluntary  flexion  of  one  or  both  hip-joints,  severe  deformities 
may  be  corrected  and  the  patient  enabled  to  walk  about.  With  the 
aid  of  operation  and  instruments  many  patients  who  could  only  crawl 
about  or  go  on  crutches  before  have  been  enabled  to  walk  about  and 
enjoy  life.  For  instance,  a  young  sohcitor  24  years  of  age,  whose  legs, 
knees  and  ankles  were  so  severely  contracted,  as  a  result  of  infantile 
paralysis,  that  he  could  only  get  about  on  crutches  with  great  difficulty, 
could  walk  thirteen  miles  with  the  aid  of  only  one  stick  and  his  concealed 
instrument  a  year  after  his  operation.  A  feather  merchant,  aged  27, 
who  had  one  lower  limb  completely  paralysed  and  the  other  partly,  so  that 
he  cou'd  only  hobble  about  with  a  crutch,  was  enabled  to  v  alk  naturally 
1  Hev  Groves,  Med.  Ann.,  1913,  p.  4:3 


974       OPERATIONS  ON  THE  LOWER  EXTREMITY 

and  even  go  up  and  down  stairs,  and  return  to  his  work  three  months 
after  operation.  Generally  the  hips  are  contracted  and  somewhat 
abducted,  the  knees  flexed,  the  legs  everted  and  abducted,  and  the  feet  are 
in  severe  talipes  equino- varus. 

Operation  at  one  sitting,  (a)  To  straighten  the  hip.  The  patient  is 
lying  on  his  back  and  the  surgeon  finds  the  pulsating  femoral  artery  in  the 
groin,  and  then  judges  the  position  of  the  anterior  crural  nerve  to  be  half 
an  inch  external  to  this.     He  places  his  left  index  finger  over  the  nerve 

to  serve  as  a  guide,  and 
then  inserts  a  long  shghtly 
curved  tenotome  on  the 
outer  side  of  the  hip,  and 
passes  it  in  front  of  the  con- 
tracted tissues  until  its  point 
is  a  little  outside  the  left  in- 
dex finger.  Now  an  assist- 
ant standing  on  the  other 
side,  presses  the  knee  well 
back  and  flexes  the  opposite 
hip  fully  while  the  surgeon 
cuts  directly  backwards 
towards  the  hip- joint  until 
the  whole  length  of  the 
thigh  can  be  easily  pressed 
back  to  the  table.  Then  the 
tenotome  is  partly  with- 
drawn and  its  point  directed 
backwards  between  the  skin 
and  shortened  fascia  on  the 
outer  side  of  the  hip.  This 
is  divided  as  the  assistant 
draws  the  knee  well  inwards. 
The  opposite  hip  is  simi- 
larly treated  if  necessary, 
and  a  sealed  dressing  is  ap- 
plied over  each  puncture. 

(6)  For  straightening  the 
knees.  A  longitudinal  in- 
cision three  inches  long  is 
made  just  in  front  of  the 
lower  part  of  the  biceps 
tendon.  This  tendon  is 
divided,  great  care  being  taken  of  the  external  popliteal  nerve  lying 
behind  and  internal  to  it.  Then  the  left  index  finger  is  inserted  to  feel 
for  and  protect  the  popliteal  vessels  and  nerve,  while  a  tenotome  is 
inserted  from  the  inner  side  in  front  of  the  inner  hamstrings,  which  are 
divided  backwards,  while  the  knee  is  pushed  backwards  to  keep  them  on 
the  stretch.  Sometimes  a  great  deal  of  force  is  required  to  straighten  the 
knee  even  after  all  the  tendons  have  been  divided,  and  the  posterior 
ligament  may  give  way  with  a  loud  report.  All  force  should  be  gradually 
increased  without  any  violent  or  jerky  movements.  In  a  few  cases  it  is 
necessary  to  prolong  the. wound  down  over  the  external  lateral  hgaments, 
which  are  divided  to  correct  the  genu  valgum,  and  in  some  the  crucial 


EiG.  401.     Showing  the  mode  of  progression  and 
the  talipes  valgus  in  a  case  of  paraplegia  from  ex- 
tensive infantile  paralysis. 


OPERATIVE  CONTRACTURES  OF  THE  LEG 


975 


ligaments  have  to  be  divided  from  this  opening  into  the  joint.  In  very- 
severe  cases  the  knee  cannot  be  straightened  with  excision,  but,  as  a  rule, 
it  is  wise  to  preserve  the  knee-joint  and  to  be  satisfied  with  gradual  com- 


FiG.  402.     Showing  the  patient  wearing  the  apparatus  after  operation. 


pletion  of  the  extension  of  the  knee  with  the  aid  of  the  instrument  mentioned 
later  on.  When  both  knees  have  been  straightened,  the  talipes  equino- varus 
is  easily  corrected  by  subcutaneous  division  of  the  tibialis  anticus  and  the 
inferior  calcaneo- navicular  ligament,  the  tendo  AchilHs,  and,  if  necessary, 
the  tibiahs  posticus  {see  Fig.  402).  Manipulation  completes  the  cor- 
rection. The  wounds  are  dressed  and  the  knees  are  put  slightly  flexed  in 
a  massive  dressing.  An  attempt  to  keep  them  straight  at  this  stage  may 
lead  to  gangrene  from  over- stretching  of  the  popliteal  vessels.  A  few  days 
later  the  knees  are  gradually  straightened  by  instruments  made  before 


/ 


976       OPERATIONS  ON  THE  LOWER  EXTREMITY 

the  operation.  With  the  aid  of  side  steel  supports  provided  with  joints, 
racks  and  screws,  there  is  httle  difficulty  in  getting  complete  correction 
without  much  pain.  The  deformities  of  the  feet  and  hips  are  treated  by- 
daily  manipulations  and  suitable  instruments.  At  the  end  of  a  month  the 
patient  can  begin  to  stand  with  the  aid  of  special  supports,  and  he  learns 
the  art  of  walking  perhaps  for  the  first  time.  At  first  he  needs  crutches, 
but  he  gradually  dispenses  first  with  one  and  then  both.  Soon  he' goes 
about  with  two  sticks  and  ultimately  with  one. 

Operations  for  Talipes  Valgus  and  Flat  Foot.     Flat  foot.     Operations 
should  be  rarely  required  for  ordinary  weak  or  flat  foot,  for  in  its  early 

stages  the  condition  is  amenable  to 
treatment  by  correction  of  bad 
habits  of  standing  and  walking, 
perseverance  with  exercises  de- 
signed to  strengthen  the  supports 
of  the  arches  of  the  foot,  and  the 
use  of  suitable  supports.  But  when 
the  foot  becomes  rigid  and  painful 
as  well  as  deformed,  and  does  not 
.  >s.    /rw I  f  I   \mw        react  to  massage  and   manipula- 

/       i  il  I  I  I   I    •  iIot        tions,  and  instruments  fail  to  bring 

relief,  an  operation  is  required. 
Under  general  ansesthesia,  with 
the  muscle  relaxed,  an  attempt  is 
made  to  correct  the  deformities  by 
manipulation.  The  shortened 
peronei  often  need  subcutaneous 
division,  and  so  do  the  hgaments 
above  and  external  to  the  mid- 
tarsal  joint.  Occasionally  a  con- 
tracted heel  tendon  needs  division. 
Forcible  adduction  ;and  inversion 
of  the  foot  usually  completes  the 
correction.  The  removal  of  a 
wedge  of  bone  from  the  depressed 
inner  border  of  the  foot  is  rarely  satisfactory,  for  this  removes  the  key- 
stone of  the  arch.  The  foot  is  fixed  in  the  over- corrected  position  by 
means  of  plaster  of  Paris  bandages  extending  from  the  toes  to  the 
middle  of  the  leg.  The  bandages  are  applied  over  a  layer  of  cotton  wool, 
and  should  not  be  tight.  The  feet  are  elevated  and  the  plaster  splint  is 
left  on  for  nine  days,  when  massage,  movements  and  exercises  are  begun, 
and  a  suitable  instrument  is  provided  to  maintain  the  correction  during 
standing  and  walking. 

The  talipes  valgus  and  flat  foot  which  is  far  too  common  after  fracture 
dislocations  of  the  ankle  can  be  corrected  as  follows  : 

A  general  ansesthetic  is  used  and  the  ankle  is  moved  as  freely  as 
possible.  If  necessary  the  peronei  are  divided  and  in  many  cases  the 
tendo  AchilUs  also.  The  ankle  is  again  freely  moved  in  all  directions. 
The  ankle  is  laid  on  its  outer  side  on  a  sand  pillow,  and  an  incision  half  an 
inch  long  is  made  over  the  inner  surface  of  the  tibia,  one  inch  above  the 
internal  malleolus,  and  the  tibia  is  divided  transversely  with  a  narrow 
osteotome.  If  necessary  to  ensure  correction  the  osteotome  is  driven  on 
into  the  fibula.    The  foot  is  strongly  adducted  and  inverted  so  as  to  over- 


'^^ 


/ 


Fig.    403.      Operation    for   correction   of 

hallux  valgus.     The  prominent  inner  half 

of  the  metatarsal  head  is  removed,  and  the 

extensor  brevis  hallucis  is  divided. 


OPERATIVE  HALLUX  VALGUS         077 

correct  tlie  delonnity.  The  wounds  are  closed  with  catgut  and  a  dressing 
is  applied.  The  foot  is  secured  in  the  slightly  over- corrected  position 
in  plaster  of  Paris  for  fifteen  days,  and  then  treated  by  daily  massage, 
movements  and  exercises,  and  at  the  end  of  eight  weeks  the  patient  is 
allowed  to  walk  with  the  aid  of  side  irons,  a  T-valgus  strap  and  a  boot 
raised  a  (juarter  of  an  inch  on  its  iimer  border. 

OperatiDn  for  Hallux  Valgus.  The  best  operation,  as  a  rule,  is  the 
one  illustrated  in  Fig.  41  3.  The  prominent  inner  half  of  the  head  of 
the  first  metatarsal  is  removed,  and  sometimes  the  prom'nent  inner 
basal  angle  of  the  first  phalanx.  The  extensor  brevis  liallucis  is  divided 
and  sometimes  the  extensor  longus  hallucis  is  lengthened.  Movement 
is  good  after  the  operation,  and  walking  is  easy  and  comfortable. 
For  hallux  flexus  the  dorsal  prominence  on  the  head  of  the  metatarsal 
is  removed  with  similar  relief. 


SURGERY    I  52 


CHAPTER  XLVIII 

OPERATIONS  ON  NERVES 

NERVE  SUTURE.     NERVE  GRAFTING.     NERVE   ANASTOMOSIS 

NERVE  SUTURE 

This  may  be  required  as  a  primary  or  secondary  operation.  The 
latter  is  accompanied  with  much  more  difficulty,  owing  to  the  greater 
retraction  of  the  nerve  ends,  their  bulbous  or  filiform  extremities,  their 
being  often  buried  in  scar  tissue  or  matted  by  it  to  neighbouring  parts, 
e.g.  tendons  and  fasciae  ;  to  which  must  be  added  other  unfavourable 
points,  e.g.  the  atrophy  and  fatty  change  in  the  muscles  and  the  stiffness 
of  the  joints. 

Primary  Suture.^  As  the  mode  of  uniting  nerves  will  be  fully  de- 
scribed under  the  head  of  secondary  nerve  suture,  the  more  difficult 
proceeding,  it  need  not  be  repeated  here.  It  only  remains  to  emphasise 
the  importance  of  always  resorting  to  it,  and  not  trusting  to  spontaneous 
cure.  Howell  and  Huber  -  have  collected  84  cases  of  primary  nerve 
suture  ;  42  per  cent,  of  these  were  successful,  40  per  cent,  were  improved, 
and  in  the  remaining  18  per  cent,  the  operation  failed.  Sherren,^  speaking 
after  careful  observation  of  over  50  cases,  says  that  in  every  case  of 
primary  suture  which  he  watched,  "  motor  power  was  regained  and  the 
second  stage  of  recovery  of  sensibihty  completed.  All  cases  uncomph- 
cated  by  suppuration  which  he  was  able  to  keep  under  observation  for  a 
sufficiently  long  period  regained  perfect  sensation."  The  results  of  second- 
ary suture  can  never  be  so  good  as  these. 

The  chief  cause  of  failure  here  is  infection  of  the  wound  As  in  all 
accidental  wounds  sterilisation  may  be  incomplete.  Irrigation  with 
some  dilute  antiseptic  should  be  employed  ;  the  wound  should  not  be 
closely  sutured  at  first,  sufficient  drainage  should  be  employed,  and  a 
boracic  acid  fomentation  frequently  applied  for  the  first  few  days,  when 
the  remaining  sutures  can  be  drawn  together,  and  the  usual  dressings 
employed. 

Secondary  Suture.  The  operation  on  the  median  or  ulnar  will 
be  considered,  as  these  are  so  commonly  injured.  The  following  steps 
must  be  remembered  :  (1)  Finding  the  nerve  ends.  (2)  Freeing  and 
resecting  them.  (3)  Passing  the  sutures,  and  bringing  the  ends  into  appo- 
sition.    (4)  Dressing  the  wound,  and  the  after-treatment. 

(1)  Finding  the  Nerve  Ends.  With  accurate  anatomical  knowledge 
this  is  easy.     An  Esmarch  bandage  does  not  appear  to   be  necessary, 

^  Much  information  on  the  subject  of  primary  and  secondary  suture  will  be  found 
in  the  section  on  Suture  of  Tendons.  2  Journ.  of  Physiol.,  vol.  xiii. 

3  Injuries  of  Nerves  and  their  Treatment,  p.  110. 

978 


NERVE  SUTURE  979 

as  the  incision  is  made  parallel  with  the  vessels,  and  the  use  of  one 
leads  to  oozing  afterwards.  Sir  Anthony  Bowlby  ^  thinks  that  the  parts 
should  be  rendered  bloodless.  If  this  course  is  adopted  care  must  be 
taken  to  provide  any  needful  drainage,  and  the  bandage  must,  if  possible, 
be  applieci  sulliciently  far  from  the  wound  not  to  interfere  with  pressing 
down  the  parts  when  the  nerve  ends  are  approximated.  If  this  bandage 
is  employed,  the  parts  should  be  made  absolutely  evascular ;  careless 
application  will  only  cause  most  annoying  oozing.  An  incision,  three  or 
four  inches  long,  being  made  over  and  parallel  to  the  nerve  ends,  the  deep 
fascia  and  any  scar  tissue  are  carefully  divided  and  the  nerve  found  well 
above  and  below  the  injury,  where  it  is  easily  recognised.  It  is  then 
traced  towards  the  injury  without  fear  of  doing  damage  especially  to  the 
smaller  peripheral  end.  The  upper  end  is  bulbous  and  the  lower  fila- 
mentous usually,  and  not  always  in  a  hne  with  each  other,  so  that  the 
distal  end  may  be  very  difficult  to  find  owing  to  its  filiform  shape  and  its 
being  embedded  in  scar  tissue.  The  ends  are  next  freed  from  the  adjacent 
parts,  and  cleared  of  cicatricial  tissue. 

(2)  Resection  of  the  Nerve  Ends.  This  is  best  effected  by  a  sharp 
knife,  with  one  stroke,  and  without  any  bruising.  If  the  nerve  is  held 
with  forceps,  these  must  hold  the  sheath  only.  In  case  of  primary  suture, 
jagged  or  frayed  ends  need  only  be  pared  sufficiently.  In  later  cases 
there  is  much  more  difficulty.  Supposing  the  upper  bulbous  end  to 
be  taken  first,  before  this  is  pared  the  nerve  should  be  carefully  stretched, 
so  that  dissecting-forceps  or  any  other  means  of  holding  the  nerve  may 
inffict  any  necessary  damage  on  parts  that  will  be  cut  away.  It  is 
necessary  to  cut  away  the  whole  of  the  bulb.  With  regard  to  the 
lower  end,  Sir  Anthony  Bowlby  says  all  that  is  needed  is  "to  cut 
away  the  extreme  end,  which,  being  matted  with  fibrous  tissue  and 
compressed  by  the  surrounding  scar,  is  very  fikely  to  contain  no 
nerve  tubules.  It  is  seldom  necessary  to  remove  as  much  as  a  quarter 
of  an  inch,  and,  however  unhealthy  the  section  may  look,  no  good 
is  ever  to  be  gained  by  a  further  sacrifice."  '^ 

(3)  Passing  the  Sutures  and  bringing  the  Nerve  Ends  into  A'pposition. 
The  sutures  should  be  of  properly  prepared  catgut.  Silk  is  not  so  satis- 
factory, for  in  some  cases  it  may  lead  in  the  course  of  time  to  a  gradual 
interstitial  inflammation,  or  even  to  the  formation  of  an  abscess,  especially 
after  primary  nerve  suture  in  accidental  cases.  Under  these  circum- 
stances paralysis  returns.  There  has  been  much  dispute  as  to  whether  the 
stitches  should  be  passed  through  the  substance  of  the  nerve  itself  or  only 
through  the  sheath.  Experience  has  shown  that  the  former  practice  is 
not  only  harmless  to  the  nerve,  but  is  the  method  most  generally  appficable. 
One  fine  catgut  suture  is  generally  sufficient  to  secure  accurate  apposition. 
It  should  be  passed  at  a  sufficient  distance  from  the  ends,  viz.  at  least 
a  cjuarter  of  an  inch,  otherwise  it  may  cut  out  when  they  are  tightened.  If 
necessary  a  few  additional  ones  in  the  sheath  will  remove  some  of  the 
tension.  Where  there  is  much  separation,  several  sutures  should  be 
passed  through  part  of  the  depth  of  the  nerve,  one  suture  thus  taking 
ofi  some  of  the  tension  from  its  fellows.  Another  method  is  to  pass  one 
suture  completely  through  the  nerve  trunk  at  least  a  quarter  of  an  inch 

^  Loc.  infra  cit.,  and  Hunt.  Lect.,  Lancet,  July  16,  1S87. 

^  As  the  whole  length  of  the  lower  end  is  in  the  same  condition  of  degeneration 
throughout,  manifestly  no  good  can  be  done  by  cutting  off  successive  sections  in  the  hope 
that  the  cut  surface  may  look  more  healthy  than  that  which  is  seen  in  the  first  section 
(Bowlby). 


980       OPERATIONS  ON  THE  LOWER  EXTREMITY 

from  each  cut  end.  When  the  sutures  in  the  nerve  itself  have  been 
tied,  two  or  three  more  very  fine  ones  may  be  placed  in  the  sheath,  where 
the  nerve  is  large  enough. 

In  cases  of  much  separation,  before  any  sutures  are  passed,  and  again 
before  they  are  tied,  the  parts  should  be  as  much  relaxed  as  possible,  and 
the  upper  end  brought  down  by  pressing  down  the  soft  parts.  Stretching 
the  nerve  has  been  already  advised.  The  sutured  part  of  the  nerve  is  sur- 
rounded with  Cargile  membrane,  which  is  supplied  already  sterilised 
and  is  not  absorbed  for  about  six  weeks.  It  prevents  adhesion  to  the 
surrounding  tissues  and  lessens  the  invasion  of  the  nerve  by  inflammatory 
cells  from  these  tissues. 

All  haemorrhage  being  scrupulously  arrested,  and  drainage  provided 
according  to  the  amomit  of  the  disturbance  of  the  parts,  &c.,  the  usual 
dressings  are  apphed,  and  the  hmb  placed  on  a  well-padded  splint  in  a 
position  which  will  best  retain  the  nerve  ends  in  apposition  wdth  the 
least  discomfort  to  the  patient. 

Amowit  of  Nerve  Tissue  ivTiich  may  he  successfully  removed.  From 
half  an  inch  to  three-quarters  of  an  inch  is  probably  an  average  amount. 

Causes  of  Failure.  (1)  Infection  of  the  wound.  (2)  Wide  separation 
of  ends  and  subsequent  tension.  (3)  Atrophy,  bulbous  enlargement  and 
sclerosis  of  nerve  ends,  so  marked  as  to  require  much  trimming,  and 
thus  tending  to  w^ide  separation.  (4)  Unnecessarily  rough  handhng 
of  the  nerve  ends. 

Aids  in  Difficult  Cases.  (1)  Previous  stretching  of  the  ends.  (2)  Ap- 
proximation of  the  ends  by  position  of  the  limb.  (3)  Using  several 
sutures,  w^hich  distribute  the  tension  evenly.  (4)  The  use  of  "  stitches 
of  support."  (5)  In  some  cases  it  is  impossible  to  bring  the  pared 
ends  together,  then  a  piece  of  nerve  of  suitable  size  may  be  grafted 
between  the  ends.  Preferably  this  should  be  taken  from  the  patient 
himself ;  for  instance,  the  upper  part  of  the  radial  nerve  may  be  shifted 
(without  loss  of  sensation)  to  fill  a  gap  in  the  lower  part  of  the  musculo- 
spiral  nerve;  failing  this,  a  healthy  nerve  from  a  newly  amputated  limb 
should  be  used,  or  a  nerve  may  be  grafted  from  a  sheep.  (6)  Autoplastic 
operation  wath  nerve-flaps  is  not  so  good.  M.  Letievant  advises  to  make 
a  slit  through  the  nerve  with  a  narrow  bistoury  about  one-fifth  of  an 
inch  from  the  end ;  the  knife  being  then  carried  upwards  for  an 
inch  or  an  inch  and  a  half  is  made  to  cut  to  one  side  so  as  to  make  a 
flap.  The  same  is  then  done  with  the  lower  end,  and  the  two  flaps, 
being  turned  towards  each  other,  are  united  by  their  raw  surfaces. 
Dr.  C.  A.  Powers,  of  Denver,^  from  a  collection  of  cases  in  w^hich  this 
method  was  used,  concludes  that  of  six  (all  doubtful  ones  being  excluded) 
two  were  failures,  and  four  partial  or  complete  successes.  (7)  Gluck  and 
Vanlair  advise  that  the  nerve  ends,  whether  united  or  only  placed  as 
closely  as  possible  in  apposition,  should  be  passed  through  and  left  in  a 
decalcified  bone-tube,  so  as  to  keep  the  uniting  material  and  granulations 
in  a  straight  fine.  (8)  The  substitution  of  threads  of  catgut  may  be  tried  ; 
and  this  may  be  combined  with  the  last  mentioned  plan. 

(9)  Nerve  Anastomosis.  Implanting  one  nerve  trunk  upon  another, 
or  joining  a  part  of  a  healthy  nerve  to  the  peripheral  end  of  the  divided 
nerve.  Dr.  Powers  ^  gives  abstracts  of  ten  cases  in  which  implantation 
or  anastomosis  was  employed ;  in  five  or  six  the  results  are  encouraging. 

^  Ann.  of  Surg.,  November  1904,  p.  641, 
*  Loc.  supra  cii. 


NERVE  SUTURE  981 

'this  method  is  indicated  wliere  nerve  trunks  run  parallel,  e.r/.  in  the  fore- 
arm ;  in  the  case  of  the  popliteals  it  has  been  much  less  satisfactory.  Two 
noteworthy  cases  are  quoted  from  Dumstrey.^ 

In  one  of  extensive  destruction  of  the  ulnar,  Dumstrcy  implanted  the  peripheral 
portion  of  this  nerve  into  a  button-hole  in  the  median  and  placed  substitution  threads 
of  catgut  between  the  same  point  in  the  median  and  the  proximal  portion  of  the  ulnar. 
In  three  mouths  there  was  a  marked  return  of  sensation,  to  a  less  degree  of  motion, 
and  a  diminution  of  the  contraction.  In  a  case  quoted  by  Dumstrey,  Sick  and 
Senger  thus  dealt  with  a  ease  of  extensive  destruction  of  the  radial.  The  peripheral 
portion  of  the  radial  and  the  median  nerves  having  been  exposed  by  one  incision, 
a  Hap  was  split  from  the  median  and  carried  mider  the  muscles  to  the  peripheral 
portion  of  the  radial.  For  several  months  there  was  no  improvement,  but,  in  a  year 
and  a  half,  the  paralysis  had  almost  entirely  disappeared.  In  other  cases  the  central 
end  of  the  injured  nerve  has  been  sutured  into  a  parallel  one,  at  one  point,  and  a 
little  lower  down,  the  peripheral  end  is  implanted  in  like  manner.  Nerve  anastomosis 
has  been  fairly  successful  in  the  treatment  of  infantile  and  other  forms  of  paralysis.  Up 
to  one-third  of  the  trunk  of  an  ordinary  mixed  nerve  may  be  divided,  and  the  central 
end  of  the  divided  part  raised  as  a  flap  and  formed  to  the  peripheral  part  of  the 
paralysed  nerve. 

(10)  Making  use  of  nerve-grafts.  Gluck  has  resected  an  inch  and  a 
half  of  the  great  sciatic  in  chickens,  and  replaced  it  by  a  bit  of  a  rabbit's 
sciatic  sutured  in.  The  birds  walked  afterwards  as  well  as  those  treated 
by  direct  suture.  In  man  the  results  have  been  more  satisfactory  in 
recent  years. 

]VIr.  Mayo  Robson  ^  after  the  removal  of  a  growth  from  the  median  nerve,  leaving  a 
gap  of  two  inches  and  a  half  between  the  ends,  successfully  made  use  of  a  correspond- 
ing bit  of  the  posterior  tibial  nerve  from  a  limb  which  was  amputated  in  the  ad- 
joining theatre.  The  following  conditions  are  rightly  given  as  essential :  First, 
the  entire  absence  of  tension  ;  two  inches  and  a  half  of  nerve  being  employed  to 
fill  an  interval  of  two  inches  and  a  quarter.  Secondly,  great  care  was  observed 
in  handling  the  nerve  to  be  transplanted.  Thirdly,  the  transplanted  posterior 
tibial  nerve  was  transferred  immediately  as  living  tissue  into  its  new  bed.  Fourthly, 
only  one  fine  catgut  suture  was  employed  at  each  end  to  fix  the  nerve.  The  same 
surgeon  successfully  used  the  spinal  cord  of  a  rabbit  as  a  graft  in  the  median  nerve 
of  a  man.* 

Mr.  Damer  Harrison,  of  Liverpool,*  gives  nine  other  cases  of  nerve -grafting. 
The  nerves  used  were  the  sciatic  of  recently  killed  rabbits  or  kittens,  and  the  median 
from  a  human  arm.  Of  the  ten  cases,  three  are  stated  to  have  been  perfectly  success- 
ful, six  partially  successful,  and  only  one  a  failure. 

Mr.  C.  Heath  made  use  of  nerve-grafting,  replacing  a  gap  in  the  ulnar,  due  to 
removal  of  a  sarcoma,  by  two  and  a  half  inches  of  the  posterior  tibial  nerve  from 
a  limb  just  amputated.*  A  fibro-sarcoma  had  been  removed  from  the  ulnar  nerve. 
The  graft  was  retained  in  position  by  two  fine  silk  sutures  at  either  end.  About 
twenty  minutes  elapsed  from  the  time  at  which  the  limb  from  which  the  nerve 
was  taken  was  severed  from  the  body  and  the  time  when  the  jimction  of  the  piece 
of  nerve  with  the  ulnar  nerve  was  completed.  The  wound  healed  by  first  intention, 
but  fom"teen  months  later  there  was  no  restoration  of  function  in  the  nerve. 

Nerve  Crossing.  In  this  a  healthy  nerve  of  less  value  is  divided  and  its 
central  end  is  joined  to  the  peripheral  end  of  a  valuable  nerve.  It  is 
chiefly  applicable  to  the  facial  nerve. 

Period  required  for  Repair.  The  following  appears  to  be  a  fact  not 
sufficiently  recognised.  The  period  required  for  union  after  secondary 
nerve  suture  is  very  much  longer  than  is  usually  supposed  to  be  neces- 
sary, owing  to  the  peripheral  end  being  degenerated,  the  muscles  atrophied, 
and  the  joints  fixed.     Complete  restoration  of  function  will  often  require 

1  Deut.  Zeitsch.f.  Chir.,  Bd.  Ixii,  1901-1902,  s.  370. 

^  Clin.  Soc.  Trans.,  vol.  xxii,  p.  120. 

3  Brit.  Med.  Journ.,  October  31,  1896,  p.  1312. 

*  Clin.  Soc.  Trans.,  vol.  xxv,  166.  ^  Lancet,  1893,  vol.  i,  p.  1195. 


982       OPERATIONS  ON  THE  LO^^'ER  EXTREMITY 

from  one  to  three  years.  A  patient  who  leaves  his  surgeon  apparently  but 
little  better  for  the  operation  may  return  at  the  end  of  the  above  time 
with  great  improvement  in  the  function  of  the  limb.  But  it  is  seldom 
possible  to  restore  the  function  of  the  part  absolutely.^ 

It  is  the  condition  of  the  muscles  and  joints  which  alcne  puts  any- 
thing like  a  limit  on  the  period  at  which  secondary  suture  can  be  success- 
fully practised. 

The  longer  the  interval  ^  between  the  injury  and  the  suture,  the  more 
persevering  must  friction,  electricity,  passive,  and  active  movement, 
and  massage  be  made  use  of,  and  the  more  will  patience  be  required  by 
both  patient  and  surgeon. 

Modern  Gunshot  Injuries  of  Nerves.  Mr.  G.  H.  Makins,^  C.B.  gives 
the  following  advice  as  to  operative  treatment.  ''  Early  interference  was 
only  warranted  by  positive  knowledge  that  some  source  of  irritation  or 
pressure  could  be  removed  ;  thus  a  bone  sphnter,  or  a  bullet,  or  part  of  one, 
particularly  portions  of  mantles. 

'■'  In  case  of  contusion,  the  expiration  of  three  months  is  the  earliest 
date  at  which  operation  should  be  taken  into  consideration.  The 
two  strongest  indications  for  operations  are  (1)  signs  pointing  to  the 
secondary  implication  of  the  nerve  in  a  cicatrix,  especially  when  these 
are  of  such  a  nature  as  to  indicate  local  tension,  fixation  or  pressure  ; 
(2)  the  possibihty  of  the  irritation  being  the  result  of  the  presence  of 
some  foreign  body  ;  in  such  cases  the  X-rays  will  often  give  useful  help. 

"  With  regard  to  the  early  exploration  of  cases  of  traumatic  neuralgia, 
it  may  be  pointed  out  that  when  this  was  undertaken  the  results  were, 
as  a  rule,  very  temporary.  In  many  cases,  either  no  macroscopic 
e^^dence  of  injury  to  the  nerve  was  discovered,  or  a  bulbous  thickening 
was  met  with  of  such  extent  as  to  make  excision  inadvisable. 

'■'  Even  when  complete  section  of  the  nerve  was  assured  by  the  absence 
of  any  power  of  reaction  to  stimulation  by  electricity  from  above  on 
the  part  of  the  muscles,  operation  was  better  not  undertaken  until 
cicatrisation  had  reached  a  certain  stage.  If  done  earlier  than  the 
end  of  three  weeks,  the  sutured  spot  became  implicated  in  a  hard  cicatrix, 
and  anv  advantage  to  be  obtained  by  early  interference  was  lost.  When 
partial  division  of  a  trunk  was  determined,  the  same  date  was  the  most 
favourable  one  for  exploration,  the  gap  in  the  nerve  being  freshened  and 
closed  by  suture.  There  is  little  doubt,  however,  that  in  some  cases 
such  injuries  were  recovered  from  spontaneously." 

The  same  authority  thus  advises  in  cases  where  the  lesion  to  the 
nerve  was  of  doubtful  nature.^  "  As  favourable  prognostic  elements 
we  may  bear  in  mind  low  velocity  on  the  part  of  the  bullet,  and  with  this  a 
lesser  degree  of  continguity  of  the  track  to  the  nerve.  The  early  return 
of  sensation  is  a  favourable  sign,  and  in  this  relation  the  development  of 
hypersesthesia,  whether  preceded  by  anaesthesia  or  not,  points  to  the 
maintenance  of  continuity  of,  and  a  moderate  decrree  of  damage  to  the 
nerve.  The  earlv  return  of  sensation,  even  if  modified  in  acuteness,  was 
alwavs  a  verv  hopeful  sign  ;  also  the  production  of  formication  in  the  area 
of  distribution  of  the  nerve  on  manipulation  of  the  injured  spot." 

1  Bowlby.  Lajicd.  July  26.  1902. 

2  The  longest  of  these  with  which  I  am  acquainted  is  a  case  of  M.  Tillaux's  in  which 
fourteen  years  had  elapsed  between  the  injurv  to  the  median  and  its  suture. 

3  Surgical  Experiences  in  South  Africa.  1899-1900.  p.  .372. 
*  Ibid.,  p.  370. 


VWIT  V 

()i^i:i{ATK)Ns  ()\  Tin:  vkktebkal 

COLUMN 

CHAPTEE  XLIX 

SPINA  BIFIDA.  LAMINECTOMY  OR  PARTIAL  RESECTION  OF 
THE  VERTEBRiE.  TAPPING  THE  SPINAL  THECA.  SPINAL 
ANAESTHESIA.    ANOCI-ASSOCIATION 

SPINA  BIFIDA 

Indications.  All  operative  treatment  should,  if  possible,  be  postponed 
until  the  child  is  two  years  of  age  or  older.  The  operation  is  then  borne 
far  better,  as  is  shown  by  pubhshed  results.  Where,  in  younger  children, 
rapid  increase  in  the  size  of  the  swelling  is,  however,  taking  place,  and 
leakage  is  threatening  or  has  actually  occurred,  the  methods  of  injection 
or  tapping  may  be  resorted  to  as  palliative  measures,  although  the 
results,  with  few  exceptions,  will  be  disappointing.  Briefly,  the  smaller 
the  sweUing,  the  less  the  evidence  of  involvement  of  the  spinal  cord  or 
nerves  ;  ^  the  more  the  overlying  skin  approaches  to  normal,  the  less 
the  swelling  shows  signs  of  increase  in  size  ;  and  the  older  the  child — 
the  greater  are  the  chances  of  cure.  The  greatest  possible  importance, 
therefore,  attaches  to  the  c^uestion  of  careful  selection  of  cases  to  be 
submitted  to  operative  interference. 

Operations.  Simple  tapping  being  merely  palliative  and  any  form 
of  drainage,  e.g.  with  sterihsed  horsehair,  being  very  liable  to  be  followed 
by  infective  meningitis,  especially  if  the  coverings  of  the  sac  are  thin 
and  unhealthy,  the  only  methods  before  us  are  :  (1)  Injection  with 
Morton's  Fluid.  (2)  Excision.  (3)  Drainage  of  the  Cerebro  -  spinal 
Fluid  into  the  Connective  Tissues  or  into  the  Peritoneum. 

(1)  Injection  with  Mortons  Fluid.  The  Clinical  Society's  Committee  ^ 
collected  71  cases  treated  by  this  method.  Of  these,  35  recovered, 
27  died,  4  were  relieved,  and  5  unreheved.  In  a  letter  to  the  Committee 
(dated  May  11,  1885),  Dr.  Morton  was  able  to  refer  to  50  cases  thus 
treated.  Of  these,  41  appear  to  have  been  successful,  and  9  unsuccessful. 
But  it  is  obvious  that  these  statistics  are  largely  unreliable.  It  is  not 
unfair  to  say  that  nearly  every  successful  case  has  been  at  once  reported, 
while  scores  of  unsuccessful  ones  have  never  been  heard  of.     Owing  to 

^  Points  which  make  it  probable  that  nerve  trunks  or  the  cord,  or  both,  are  present  in 
the  sac,  are  paralysis  of  the  sphincters  or  lower  extremities,  a  large  sessile  tumour  with  a 
broad  base,  and  the  appearance  of  cord-like  bands  when  the  sac  is  thin  enough  to  transmit 
Ught.  -  Trans.,  vol.  xviii. 

983 


984      OPERATIONS  ON  THE  VERTEBRAL  COLUMN 

the  large  number  of  successes  which  attended  the  use  of  this  method, 
it  is  the  only  one  which  was  recommended  by  the  Committee  of  the  Clinical 
Society.  In  four  of  the  cases  in  which  I  have  employed  this  method 
while  complete  shrinking  of  the  sac  was  secured  in  each,  hydrocephalus 
eventually  supervened.  And  where  this  is  not  the  case,  the  later  effects 
of  pressure  of  the  cicatricial  tissue  upon  any  nerves  present  must  be 
remembered. 

The  parts  ha\ang  been  sterilised,  a  syringe  which  will  hold  about  two 
drachms  of  the  iodo-glycerine  solution  ^  is  chosen,  and  a  fine  trocar. 
The  calibre  of  this  must  not  be  too  fine  for  the  thick  fluid  which  has  to 
pass  through  it.  The  puncture  into  the  swelling  should  be  made  well 
at  one  side,  obliquely  through  healthy  skin,  and  not  through  the  mem- 
branous sac-wall,  the  objects  being  to  avoid  wounding  the  cord  or  nerves, 
and  also  to  diminish  the  risk  of  leakage  of  cerebro-spinal  fluid.  Unless 
the  sac  is  very  large  it  is  probably  better  not  to  draw  of!  much,  if  any, 
of  the  fluid  from  the  sac  on  the  first  occasion.  The  position  of  the  child 
during  the  injection  has  been  a  good  deal  dwelt  upon,  most  recommending 
that  it  should  be  upon  its  back.  The  Clinical  Society's  Committee  advise 
that  the  child  should  be  upon  its  side.  About  a  drachm  of  the  fluid 
should  be  injected.  Every  care  must  be  taken  to  prevent  any  continued 
escape  of  the  cerebro-spinal  fluid,  now  and  later,  it  being  clearly  under- 
stood that  any  such  leakage,  which  is  most  difficult  to  prevent,  will  lead 
to  infective  meningitis  and  death.  When  the  needle  is  withdrawn  the 
puncture  should  be  pressed  around  it,  and  immediately  painted  with 
collodion  and  iodoform,  a  dressing  of  dry  gauze  being  also  secured  with 
collodion.  I  prefer  to  give  a  little  chloroform  to  prevent  any  crying 
and  straining  at  the  time.     The  child  should  be  kept  as  quiet  as  possible 

.  afterwards,  on  its  side,  and  an  assistant  should  make  sure,  for  the  first 
hour  at  least,  that  no  leaking  is  going  on.  Shrinking  of  the  cyst,  continu- 
ing steadily,  shows  that  all  is  well.  If  the  injection  fail  altogether,  or 
only  cause  partial  obliteration  of  the  sac,  it  should  be  repeated  at  intervals 
of  a  week  or  ten  days. 

(2)  Excision  of  the  Sac.  ^  This  is  the  method  which,  in  spite  of 
certain  grave  dangers,  promotes,  on  the  whole,  the  best  results  in  carefully 
selected  cases.  The  dangers  are,  of  course,  the  suddenness  with  which 
the  fluid  may  escape,  with  grave  resulting  changes  in  the  hydrostatic 
pressure  and  circulation  in  the  cerebro-spinal  system,  shock  from  inter- 
ference with  important  nerve  filaments,  and  meningitis  set  up  at  the 
time  or  as  the  result  of  subsequent  leakage. 

A  wise  selection  of  cases  is  most  difficult.  It  is  only  possible  to 
advise  in   general  terms.     A   condition   of  the   overlying   parts   which 

renders  it  doubtful  if  asepsis  can  be  secured  to  begin  with,  should  forbid 
operation.     Weak  antiseptics  are  likely  to  be  useless,  and  strong  ones 

harmful ;  they  may  even  inflict  further  damage  on  the  closely  adjacent 
nerve  tissues.  An  advanced  degree  of  paralysis  present  should  contra- 
indicate  interference  ;  it  will,  probably,  be  impossible  to  separate  and 
return  the  nerves  present  in  the  walls  of  the  sac,  and  what  is  the  real 

value  of  the  fife  which  it  is  attempted  to  preserve  ?     It  will  be  remem- 

^  The  fluid  is  iodine,  gr.  x  ;  iodide  of  potassium,  3J  ;   glycerine,  jj. 

^  The  Clinical  Society's  Committee  collected  twenty-three  cases  treated  by  excision 
of  the  sac.  Of  these,  sixteen  recovered,  seven  died.  They  point  out  that  no  mention 
of  the  contents  of  the  sac  is  made  in  six  cases  ;  that  nerves  were  certainly  absent  in  sixteen 
cases  ;  and  that  in  one,  which  was  fatal,  they  were  certainly  present  (Trans.,  vol.  xviii, 
p.  380).  ^  y  i'  \  ' 


SPINA  BIFIDA  985 

bered  that  this  coiKlition  and  the  preceding  one  often  coexist.  Other 
severe  malformations  are  also  contra-indications.  As  I  stated  above, 
any  operation  should,  when  possible,  be  deferred  till  about  the  age  of 
two  years.  The  ejects  of  the  interference  are  better  met,  the  parts  are 
more  easy  to  handle,  and  one  source  of  infection,  that  from  the  usually 
closely  adjacent  anus,  is  diminished.  In  the  rare  variety  of  meningocele 
such  delay  is  especially  indicated. 

Operation.  If  needful,  the  too  rapid  escape  of  fluid  can  be  prevented 
by  a  preliminary  tapping  and  attention  to  the  position  of  the  patient. 
Every  precaution  against  shock  must  be  taken  before,  during  and  after 
the  operation,  and  this  nuist  be  completed  as  quickly  as  is  consistent 
with  safety.  The  parts  having  been  sterilised  and  arrangements  made 
for  keeping  the  head  low  prior  to  and  during  the  opening  of  the  sac, 
elliptical  incisions  are  made  through  the  skin  on  either  side  of  and  suffi- 
ciently far  from  the  base  to  ensure  if  possible  (a)  sound  skin  and 
(p)  sufficient  skin  to  meet  in  the  middle  line  after  partial  excision  of 
the  sac  and  removal  of  the  fluid.  Such  incisions  are  always  to  be  employed 
when  the  central  skin  is  unsound  and  undermining  will  be  required. 
In  other  cases  a  flap  may  be  preferable.  The  skin  is  then  dissected 
back  on  each  side  with  great  care  so  as  to  avoid,  if  possible,  punctures 
of  the  membranes,  until  the  laminae  are  reached.  It  may  now  be  found 
that  the  tumour  is  clearly  a  meningocele  being  attached  by  a  pedicle, 
which  may  be  quite  slender.  In  such  a  case  the  interior  of  the  pedicle 
is  inspected,  and  if  it  contain  no  structures  of  importance,  it  should  be 
surrounded  with  a  purse-string  ligature  of  fine  kangaroo-tendon,  and 
the  sac  beyond  cut  away. 

If  there  is  no  pedicle  the  sac  is  now  carefully  opened,  at  first  with  a 
trocar  so  that  the  fluid  is  slowly  withdrawn,  and  the  effects  on  the  cerebral 
centres  noted.  The  opening  is  then  enlarged,  and  the  interior  carefully 
examined.  If  no  nerve  structures  are  present,  the  redundant  sac  is  then 
cut  away  with  blunt-pointed  scissors,  and  the  edges  brought  together 
with  a  continuous  catgut  suture.  The  connective  tissues  are  similarly 
sutured  over  the  stump,  and  sometimes  a  flap  of  the  lumbar  aponeurosis 
is  sewn  over  it.  So  far  the  operation  has  been  simple  and  straight- 
forward. We  must  now  consider  more  difficult  cases.  Where  the  cover- 
ings are  in  great  part  thin  and  translucent,  even  when  this  condition 
extends  to  the  margin  of  the  swelhng,  if  the  coverings  can  be  rendered 
aseptic  they  may  be  partly  utilised  to  form  the  meningeal  flaps,  the 
adjoining  skin  being  undermined  and  made  to  slide  over  the  new 
meninges. 

When  on  opening  the  sac  nerve  structures  are  seen  within,  that  part 
of  their  course  which  lies  in  the  sac  must  be  carefully  detached  with 
blunt-pointed  instruments,  until  they  can  be  gently  pushed  through  the 
opening  that  communicates  with  the  spinal  canal.  In  more  difficult 
cases,  incisions  must  be  made  with  blunt-pointed  scissors  between  portions 
of  nervous  structures,  in  order  to  set  them  free,  or  they  must  be  returned 
with  a  part  of  the  sac  en  masse.  In  cases  where  the  presence  of  nerve 
structures  difficult  to  detach  is  marked,  the  safest  plan  will  be  the  last. 
Having  opened  and  examined  the  sac,  the  surgeon  cuts  away  any  super- 
fluous part  that  is  safe,  then  detaches  the  remainder  and  returns  it  with 
the  nerves  which  run  in  it,  through  the  opening,  into  the  canal.  It  is 
greatly  to  be  desired  that  surgeons  should  specify  what  nervous  structures 
were  present,  and  how  they  were  dealt  with.     As  a  rule  this  has  been 


986      OPERATIONS  ON  THE  VERTEBRAL  COLUMN 

most  imperfectly  done.  Where  it  is  plain  that  the  sac  and  its  contained 
nerves  cannot  be  returned  ^^dthout  sacrificing  some  of  the  latter  the 
surgeon  should  hold  his  hand  and  close  the  wound.  However  small  the 
nerves  may  be,  it  is  impossible  to  determine  their  importance.  Their 
removal  runs  a  decided  risk  of  causing  permanent  paralysis,  or  of  increas- 
ing that  already  present. 

The  nerve  structures  having  been  returned,  the  flaps  of  meninges  and 
skin  are  sutured  separately  and  not  in  one  fine.  A  precaution  of  Mr. 
Robson's  1  should  be  followed  here.  The  skin  and  meningeal  flaps  should 
be  so  cut  that  their  Hues  of  union,  when  sutures  are  apphed,  are  not 
opposite.  Thus,  the  flaps  should  be  cut  of  unecjual  width,  so  as  to  bring, 
e.g.  the  wider  skin  flap  on  the  left  side,  and  the  wider  meningeal  one 
on  the  right.  Another  means  of  obtaining  the  same  end  is  to  suture 
the  membranes  transversely,  and  the  •  skin  longitudinally.  In  some 
cases  periosteal  grafts  -  or  bones  from  freshly  kiUed  animals  have  been 
introduced  with  varying  success,  and  are  to  be  preferred  to  attempts 
to  close  the  gap  by  fragments  chiselled  off  from  the  laminae  or  sacrum. 
Considering  the  tender  age  and  feeble  powers  of  these  patients — infants, 
as  a  rule — it  is  certainly  not  worth  while  to  prolong  an  operation,  anaes- 
thetic, kc,  for  this  purpose.  If,  however,  the  patient  is  not  an  infant 
and  the  condition  is  good,  and  moreover  if  the  gap  in  the  spine  is  a  large 
one,  an  attempt  should  be  made  to  protect  this  by  means  of  flaps  of 
aponeurosis  and  muscle  derived  from  the  erector  spinae.  Either  one 
large  flap  may  be  raised  and  swung  across  so  that  the  line  of  sutures  is 
at  the  side,  or  two  flaps  may  be  used  and  united  in  such  a  manner  that 
the  fine  of  sutures  is  not  immediately  beneath  the  skin  sutures.  The 
very  lowest  part  of  the  meningeal  and  skin  flaps  may  be  left  unsutured, 
but  no  drainage  will  be  needed,  and  leakage  is  greatly  to  be  deprecated. 
Sterilised  pads  ha^nng  been  placed  on  the  wound,  a  sufficient  thickness 
of  sahcyhc  wool  is  then  applied,  and  bandaged  with  firm  and  even  pressure. 
For  the  first  few  days  the  head  should  be  kept  low  and  the  spine  raised 
so  as  to  prevent  the  tendency  to  leakage  of  cerebro-spinal  fluid,  and  to 
take  the  tension  of  the  sutures.  Prof.  A.  Henle  ^  advises  strapping  the 
child  to  a  plaster  of  Paris  cast  of  the  anterior  surface  of  the  body,  reaching 
from  the  neck  to  the  feet.  The  hips  and  knees  are  partially  flexed  and 
the  legs  somewhat  separated.  Soihng  of  the  dressings  is  thus  prevented. 
The  patient  is  raised  for  the  purpose  of  feeding.  A  shield  of  silver, 
vulcanite,  or  thin  sheet-lead  should  be  worn  later  until  the  parts  have 
thoroughly  consolidated. 

(3)  Drainage  into  the  Tissues.  Heile  ^  has  recorded  a  successful 
case  of  drainage  of  the  fluid  into  the  peritoneum  by  means  of  six  silk 
threads  connecting  the  two  ca\-ities.  The  patient  was  only  two  days 
old,  had  a  tense  meningomyelocele  in  the  lumbar  region.  An  attempt 
at  excision  was  made  but  proved  impossible,  and  silk  threads  were  passed 
forward  into  the  peritoneum,  just  external  to  the  spinal  membrane. 

^  Clin.  Soc.  Trans.,  vol.  xviii,  p.  211. 

-  Dr.  R.  T.  Hayes,  of  Rochester  (N.Y.)  introduced  twenty  grafts  of  periosteum  from 
a  freshly  killed  rabbit.  Three  months  later  the  case  was  reported  to  be  satisfactory,  with 
a  firm,  hard,  resistant  covering.  {3Ied.  Record,  June  16.  1883.)  Messrs.  Watson  Cheyne, 
C.B..  and  Burghard  [Man.  of  Surg.  Treat.,  Part  iv,  p.  301)  advise  the  use  of  the  scapula  or 
skull  bones  of  rabbits.  "  The  scapula,  divested  of  its  muscles,  forms  a  very  satisfactory 
plate,  and  has  succeeded  in  more  than  one  instance." 

3  V.»Bergmann's  iS2/s^  of  Pract.  Surff.  (Amer.  Trans.),  vol.  ii,  p.  662. 

«  Berlin  Klin.   Woch.,   1910,  2298. 


LAMINECTOMY  087 

The  child  was  well  ten  months  later.  It  is  probable  that  drainage  into 
the  subcutaneous  tissue  of  the  back  will  prove  as  effective. 

Causes  of  Failure  after  the  Radical  Cure  of  Spina  Bifida.  (1)  Leakage 
and  inlVctive  meningitis.  {2)  ( 'onvulsions  and  lapid  d^at  li.  ]\Ir.  Clutton, 
who  brought  a  succes.sful  case  of  Dr.  Mortons  treatment  before  the 
Clinical  Society/  mentioned  another  in  which  this  treatment  was  imme- 
diately followed  by  fatal  convulsions.  The  same  proved  fatal  in  about 
ten  hours  in  a  case  under  my  care.  Sir  W.  Bennett,  during  the  same 
di.scussion,  mentioned  a  case  in  which,  owing  to  the  child  being  indisposed 
at  the  time,  lie  declined  to  operate.  On  its  way  home  the  child  died 
of  convulsions.  He  remarked  that  if  he  had  used  the  injection,  this 
would  have  been  credited  with  the  convulsions.  (3)  Paraplegia.  This 
setting  in  after  injection  or  operation  may  be  temporary  or  permanent, 

(4)  Hydrocephalus.  This  also  may  make  its  appearance  after  the 
injection  with  iodo-glycerine  or  excision,  as  happened  in  a  case  of  my 
own  three  weeks  after  the  latter  operation.  The  nerves  here  were  few 
and  small  and  easily  detached  with  the  adjacent  sac  into  the  canal. 

(5)  After  tapping  or  injection  the  swelhng  may  progress  unaltered. 

LAMINECTOMY,  OR  PARTIAL  RESECTION  OF  THE  VERTEBRA 

This  operation  may  be  referred  to  here  under  the  following  indications  : 
A.  Cases  of  injury,  i.e.  hcBmatorracliis  or  hleeding  into  tJie  spinal  theca ; 
Jraciures  and  dislocation.  B.  Penetrating  ivound  of  the  canal.  C.  Gunshot 
injuries.  D.  Cases  of  inflammatory  disease,  e.g.  Pott's  curvature  ;  chronic 
spinal  meningitis.  E.  Cases  of  new  groicth.  F.  For  resection  of  posterior 
nerve  roots  or  section  of  lateral  columns  of  the  cord. 

A.  Cases  of  Injury.  Here  the  operation  has  been  suggested  by  the 
analogous  one  performed  on  the  skull,  and  the  large  amount  of  success 
which  has  followed  it.  But  the  analog}^  is,  for  several  reasons,  a  decep- 
tive one.  ThiLs,  owing  to  the  small  size  of  the  cord,  an  injury  which 
would  only  damage  the  brain  slightly,  almost  ine^atably  destroys  the 
structure  of  the  cord  throughout  its  thickness.  Again,  it  must  be  remem- 
bered that  a  fragment  of  bone  often  inflicts  injury  upon  the  cord  instanta- 
neously, and  that,  in  a  moment,  irremediable  damage  may  be  done, 
though  all  deformity  may  be  absent.  Further,  the  cord  may  be  most 
severely  damaged,  though  its  theca  shows  no  sign  of  injury. 

Again,  when  the  surgeon  trephines  the  skull,  he  not  only  hopes 
that  the  damage  is  slight  and  of  a  removable  nature,  but  he  also  believes 
that  the  only  damage  to  the  bones  is  that  which  lies  close  to  his  trephine 
and  finger.  But  in  the  case  of  the  spine  we  are  faced  by  this  dilemma  : 
If  the  fracture  has  been  from  direct  \4olence,  and  the  spinous  processes 
and  laminae  have  been  driven  in,  it  is  only  too  probable  that  when  these 
are  elevated  the  spinal  cord,  so  limited  in  size,  will  be  found  too  much 
damaged  to  profit  by  the  operation.  On  the  other  hand,  if  the  fracture 
has  been  caused  by  indirect  \nolence,  it  is  almost  certain  that  the  bodies 
of  one  or  more  vertebrae  will  have  been  crushed  down,  and  a  portion 
shot  back  into  the  canal.  Usually  the  cord  is  nipped  between  the  postero- 
superior  edge  of  the  body  below  and  the  lamina  of  the  vertebra  above 
the  fracture-dislocation.  In  this  case  the  part  which  has  inflicted  the 
injury,  and  which  is  keeping  up  the  mischief,  will  be  in  front  of  the  cord 
and  difficult  to  reach.     With  a  good  exposure  and  perseverance  the 

^  Trans.,  vol.  xvi,  p.  .34. 


988      OPERATIONS  ON  THE  VERTEBRAL  COLUMN 

surgeon  may  be  able  to  remove  the  projecting  bone  in  front  of  the  cord, 
after  drawing  the  theca  first  to  one  and  then  to  the  other  side  and  using 
gouge-forceps. 

But  it  must  be  remembered  that  permanent  compression  of  the  cord — 
compression  that  can  be  removed,  as  can  fragments  of  the  skull — is  a 
very  rare  event.^  Even  where  permanent  compression  is  present  lami- 
nectomy will  do  but  httle.  The  surgeon  may  find  it  possible  to  restore 
the  lumen  of  the  vertebral  canal,  but  the  cord  has  usually  been  crushed 
as  well  as  compressed.  Mischief,  usually  hopeless  mischief,  has  been 
done,  for  it  has  been  proved  by  experiments  and  otherwise  that  a  crushed 
cord  is  incapable  of  regeneration. 

It  remains  to  be  shown  that  trephining  the  spine  is  not  only  likely 
to  be  void  of  any  good  results,  but  that  it  also  involves  serious  risks  and 
entails  additional  dangers  of  its  own.  Thus,  the  conversion  of  a  simple 
into  a  compound  fracture,  the  formation  of  a  large,  deep,  and  more  or 
less  ragged  wound,  the  risk  of  subsequent  suppuration  with  free  access 
to  the  sheath  of  the  cord,  the  opening  up  of  cancellous  tissue  with  its 
various  channels  and  exposure  of  these  to  possible  suppuration — -all 
these  have,  I  admit,  been  lessened  by  the  use  of  modern  precautions. 
But  the  risk,  though  diminished,  remains  ;  the  large  amount  of  venous 
oozing  tending  to  soak  quickly  through  in  this  region  can  only  be  met 
by  frequent  dressing.  And  though  it  has  been  shown  that  in  some  of 
these  cases  the  wound  has  healed  quickly,  and  though  no  improvement 
has  followed,  the  spinal  column  has  not  been  fatally  weakened  by  the 
removal  of  the  laminae  and  spines,  yet  the  weakening  for  a  time  must 
be  considerable  ;  and  it  must  be  remembered  that  by  the  removal  of 
these  structures  the  mobility  of  the  fractured  parts  will  be  much  increased, 
and  when  any  attempt  is  made  to  vary  the  position  of  the  patient  in 
bed,  there  will  be,  for  some  time,  a  risk  of  disturbing  the  fragments  and, 
thus,  of  inflicting  further  injury  on  the  cord. 

It  will  be  seen  from  the  above  that  my  own  opinion  is  averse  to  any 
surgical  interference  in  cases  of  fractured  spine,  owing  to  the  amount 
of  damage  to  the  cord  being  usually,  from  the  first,  irreparable.  To 
quote  other  writers  :  Mr.  Thorburn  ^  comes  to  the  same  conclusion,  but 
draws  an  important  distinction  between  the  cord  and  its  nerves.  This 
writer  thus  sums  up  the  question  of  operative  interference  in  fractures 
and  dislocations  of  the  spinal  column  :  ^  "In  compound  fractures, 
operate.  In  fractures  of  the  spinous  processes  and  laminae,  with  injury 
to  the  cord,  we  also  operate.  In  simple  fractures  and  dislocations  of 
the  bodies  of  the  vertebrae,  if  there  is  a  reasonable  probability  that  the 
injury  is  due  to  haemorrhage,*  operation  is  advisable,  but  in  all  other 
cases  of  this  nature  we  cannot  hope  to  do  good  save  where  the  injury 
is  below  the  level  of  the  first  lumbar  vertebrae.  In  such  cases  laminec- 
tomy  is   an   eminently   valuable   surgical   procedure."     Mr.    Thorburn 

^  J.  Hutchinson,  Lond.  Hnsp.  Rep.  ;  Thorburn,  loc.  infra  cit.  It.  will  be  noticed  that 
permanent  compression  is  a  very  different  thing  from  irreparable  injury.  The  latter  is 
present,  only  too  frequently. 

2  Surgery  of  the  Spinal  Cord.  1889,  p.  160 ;  Brit.  Med.  Journ.,  1894,  vol.  i, 
p.  1348. 

^  Loc.  supra  cit. 

*  Mr.  Thorburn  thinks  that  the  following  would  be  the  most  advisable  steps  in  these 
very  rare  cases:  A  laminectomy  at  the  scat  of  injury,  and  an  endeavour  to  arrest  the 
hsemorrhage  and  to  give  exit  to  the  blood  ;  this  procedure  being  combined  in  the  first 
instance  with  paracentesis  of  the  meninges  in  the  lumbar  region  after  Quincke's  method 
{vide  infra),  and  this  failing,  a  secondary  laminectomy  at  the  lower  part  of  the  spine. 


LAMINECTOMY  989 

advocates  surgical  interference  here  on  the  following  grounds  :  (1)  "  We 
may  here  expect  a  regeneration  of  the  nerve  roots,  the  physiological 
evidetice  ])eiiig  strongly  in  favour  of  such  regeneration,  and  not  against 
it,  as  in  the  case  of  tiie  cord.  (2)  The  absence  of  spontaneous  recovery 
in  such  cases  in  itself  indicates  the  presence  of  a  mechanical  obstacle, 
such  as  permanent  compression  by  bone,  blood-clot,  or  cicatrix,  other- 
wise we  should  expect  the  roots  of  the  cauda  equina  to  recover,  as  other 
peripheral  nerves  after  severe  injuries."  For  my  own  part  I  should  only 
be  inclined  to  interfere  where  the  following  conditions  are  present :  A 
history  of  a  direct  injury  ;  mobility  and  displacement,  laterally  or  down- 
wards, of  the  spinous  process ;  great  local  tenderness ;  the  usual 
symptoms  of  swelling,  &c.  ;  and  paraplegia  less  marked  than  usual. 

Those,  on  the  other  hand,  who  advocate  surgical  interference  do 
so  on  the  following  ground  :  Dr.  J.  "VV.  White  ^  believes  that  fracture 
of  the  lamina3  and  spinous  processes,  and  therefore  lelievable  pressure 
on  the  spinal  cord,  will  not  be  found  so  rare  as  has  been  usually  believed. 
I  fear  that  the  weight  of  pathological  evidence  is  all  the  other  way.  Dr. 
Weeks  ^  considers  that  ''  the  surgeon  should  perform  laminectomy  in 
every  case,  if  the  condition  of  the  patient  is  such  as  to  justify  any  opera- 
tion, regarding  the  operation  in  the  first  instance  as  an  exploratory  one. 
The  hope  of  restoration  of  function  in  those  cases  in  which  the  cord  is 
not  irretrievably  injured  depends  on  the  promptitude  with  which  the 
cause  of  compression  is  removed  ;  and,  however  small  the  number  of 
cases  in  which  benefit  is  to  be  looked  for,  I  hold  that  even  those  few 
justify  one  in  immediate  operation.  Laminectomy  is  not  a  difficult 
operation,  since  the  soft  parts  are  always  found  torn  and  quite  detached 
from  the  bone,  and  the  introduction  of  cutting  instruments  under  the 
laminae  is  very  easy  from  the  displacement  present." 

One  case  only  is  given,  a  very  interesting  one  as  far  as  it  goes,  as  it  occvured  in  a 
patient  of  70,  and  the  laminectomy  exposed  a  fracture  of  the  laminae  of  the  third 
and  fourth  cer%ical  vertebrae.  Very  few  details  are  given  of  the  patient's  condition 
— the  left  upper  and  lower  extremities  appear  to  have  been  chiefly  affected — or  of  the 
operation.  Two  and  a  half  months  later  there  was  some  improvement  in  the  motion 
of  the  left  arm  and  hand,  the  patient  could  walk  short  distances  by  being  supported 
on  either  side,  and  the  action  of  the  bladder  had  become  normal. 

Dr.  Mixter  and  Dr.  Chase,  of  Boston,^  also  advocate  operative  inter- 
ference. Two  cases  are  given  suggesting  a  total  transverse  lesion  of  the 
lower  cer\acal  cord.  One  patient  died  in  about  twelve  months  from 
cystitis  and  pyelo-nephritis.  The  other  recovered  sufficiently  to  engage 
in  business  again.  The  authors  follow  Dr.  Walton  ^  in  advocating 
laminectomy  because  there  are  no  t}^ical  infallible  symptoms  from  which 
it  can  be  asserted  that  the  cord  is  crushed  beyond  a  certain  degree  of 
repair.  While  e^^idence  of  degeneration  may  persist  after  a  laminectomy, 
the  improvement  which  followed  in  the  second  case  suggests  that  an 
"  increased  transmission  of  impulses  takes  place  along  the  remaining 
scattered  fibres  ;  the  analogue  of  which  is  found  in  the  increase  of  functions 
occmring  in  the  kidney  after  unilateral  nephrectomy,  showing  the  power 
of  nature  to  accommodate  herself  to  adverse  conditions." 

I  remain  of  opinion  that  where  a  large  number  of  cases  of  laminectomy, 
carefully  reported,  are  placed  before  the  profession,  the  balance  of  patho- 

1  Ann,  of  Surg.,  July  1889.  2  Trans.  Amer.  Surg.  Assoc.,  1901,  p.  319. 

3  Ann.  of  Surg.,  1904. 

*  Journ.  of  Ment.  and  Nerv.  Dis.,  vol.  xxix,  1902. 


990      OPERATIONS  ON  THE  VERTEBRAL  COLUMN 

logical  evidence  will  be  against  operation.  A  few  isolated  cases  in  which 
a  varying  degree  of  recovery  has  followed  may  show  that  where  the 
condition  of  the  patient  and  the  surroundings  are  favourable,  interference 
in  skilled  hands  with  the  object  of  exploration  is  justifiable.  Beyond 
this  we  cannot  go.  Few  will  accept  the  statement  of  Dr.  Weeks  that 
in  these  cases  ''  laminectomy  is  not  a  difficult  operation."  Even  if  the 
tearing  of  the  soft  parts  facihtates,  as  he  claims  is  always  the  case,  the 
prehminary  steps  of  the  operation,  such  injury  facihtates  the  introduction 
of  infection,  and,  a  httle  later,  the  difficulties  in  restoring  irregularities 
of  the  vertebrae — I  refer  especially  to  their  bodies — may  be  enormous. 
If  operation  be  undertaken,  it  is  clear  that  this  should  be  as  soon  as  the 
patient  has  recovered  from  the  primary  shock  :  if  possible  within  the 
second  twenty-four  hours.  While  the  Rontgen-rays,  if  available,  should 
always  be  employed,  their  use  is,  often,  unsatisfactory. 

B.  Penetrating  Wounds  of  the  Spinal  Cord.  Mr.  Thorburn  ^  shows 
that  while  the  percentage  of  recovery  is  good  as  to  hfe,  complete  recovery 
of  function  is  uncommon,  owing  to  the  httle  power  of  recovery  of  function 
after  a  destructive  lesion  of  the  spinal  cord  in  man,  especially  in  adults. 
He  would  also  regard  as  useless  the  operation  of  suture  of  the  pia  mater 
as  proposed  by  Chipault,  and  points  out  that  it  may  be  harmful  not  only 
by  necessitating  manipulation  of  the  injured  cord,  but  also  by  confining 
effused  blood  and  serum,  and  thus  increasing  the  pressure  upon  those 
parts  which  have  escaped  section.  With  the  nerve  roots,  on  the  other 
hand,  which  are  capable  of  repair,  operation  and  suture  would  be  quite 
justifiable. 

C.  Operative  Interference  in  Injuries  of  the  Column  and  Cord  from 
Gunshot  Injuries.  G.  H.  Makins,  C.B.,  our  most  recent  authority ,2  is 
very  emphatic  here.  '"In  no  form  of  spinal  injury  is  this  less  often 
indicated,  or  less  hkely  to  be  useful.  It  is  useless  in  the  cases  of  severe 
concussion,  contusion,  or  medullary  haemorrhage  which  form  such  a 
very  large  proportion  of  those  exhibiting  total  transverse  lesion,  and 
equally  unsuited  to  cases  of  partial  lesion  of  the  same  character.  Extra- 
medullary  haemorrhage  can  rarely  be  extensive  enough  to  produce  signs 
calhng  for  the  mechanical  rehef  of  pressure  ;  the  section  of  the  cord 
cannot  be  remedied.  In  one  case  with  signs  of  total  transverse  lesion, 
in  which  a  laminectomy  was  performed,  no  apparent  lesion  was  discovered, 
and  this  would  frequently  be  the  case,  since  the  damage  is  parenchy- 
matous." 

Only  three  indications  for  operation  exist.  "  (1)  Excessive  pain 
in  the  area  above  the  paralysed  segment ;  operation  is  here  of  doubtful 
practical  use,  except  in  so  far  as  it  reheves  the  immediate  suffering  of 
the  patient.  (2)  An  incomplete  or  recovering  lesion,  when  such  is 
accompanied  by  evidence  furnished  by  the  position  of  the  wounds,  pain 
and  signs  of  irritation,  of  pressure  from  without,  or  possibly  palpable 
displacement  of  parts  of  the  vertebrae,  that  the  spinal  cord  is  encroached 
upon  by  fragments  of  bone.  (3)  Retention  of  the  bullet,  accompanied 
by  similar  signs  to  those  detailed  mider  (2). 

"  In  both  the  latter  cases  the  aid  of  the  X-rays  should  be  invoked 
before  resorting  to  exploration. 

"  Operation,  if  decided  upon,  in  either  of  the  two  latter  circumstances, 
may  be  performed  at  any  date  up  to  six  weeks  ;   but  if  pressure  be  the 

^  Lcc.  mipni  cif. 

2  Surgical  Experiences  in  South  Africa,  1899-1900,  p.  340. 


LAMINECTOMY  991 

actual  source  ol"  trouble,  it  is  obvious  that  the  more  promptly  the  operation 
is   uudertakeii  the  better." 

D.  Caacs  of  Injlammatonj  Disease^  e.<j.  FulCs  Curvature.^  Interfer- 
ence here  will  be  but  very  rarely  called  for,  as  we  have  abundant  evidence 
that  paralysis,  even  when  of  long  duration,  has  a  marked  tendency  to 
recovery,  if  the  treatment  by  absolute  rest  in  the  recumbent  position 
is  vigorously  enforced.^  Where  a  sufficient  trial  of  this  has  really  failed, 
operative  interference  is  justifiable  if  there  be  no  evidence  of  tuberculous 
disease  elsewhere  or  infected  sinuses.  Dr.  De  Forest  Willard  ("'  Tubercular 
Conditions  of  the  Spine  requiring  Surgical  and  Mechanical  Relief  ")  ^ 
thus  sums  up  on  this  point :  "  Laminectomy  for  paraplegia  is  advisable 
only  after  long  continued  and  patient  treatment  from  one  to  two  years, 
since  the  prognosis,  especially  in  children,  is  favourable  and  good  powers 
of  locomotion  may  be  confidently  expected.  The  operation  is  justifiable 
in  selected  cases  where  loss  of  motion  and  sensation  are  progressively 
worse  and  the  symptoms  threaten  hfe."  The  anatomical  difficulties  and 
risks  of  laminectomy  are  w^ell  given  in  this  candid  and  practical  paper. 

Mr.  Thorburn  ■*  gives  the  following  indications  and  contra-indications 
for  operation.  Indications  :  (1)  "  Assuming  the  prognosis  to  be  thus 
favourable,  we  are  never  called  upon  to  perform  laminectomy  save  under 
certain  sj)ecial  conditions.  It  will  not  be  argued  that  the  recovery  after 
laminectomy  is  more  complete  than  that  produced  by  Nature,  and 
experience  shows  that  relapses  also  are  only  too  common  after  operation. 
The  indications  which  appear  to  me  to  point  to  the  necessity  for  operations 
are  then  as  follows  :  A  steady  increase  in  symptoms  in  spite  of  favourable 
conditions  and  treatment.  The  presence  of  symptoms  which  directly 
threaten  life.  Thus,  in  my  second  case,  the  secondary  chest  troubles 
were  very  grave. ^    Intractable  cystitis  would  fall  into  this  category, 

^  Reference  should  be  made,  in  addition  to  the  writings  quoted  above,  to  the  follow- 
ing :  (1)  In  cases  of  injury,  Macewen,  Brit.  Med.  Journ.,  1888,  vol.  ii.  p.  308  ;  Keetley, 
■ibid.,  p.  421  ;  Duncan,  Edin.  Med.  Journ.,  1889,  p.  830  ;  E.  Hart,  a  case  of  M.  Pean's, 
Brit.  Med.  Journ..  1889,  vol.  i,  p.  672  ;  H.  W.  Allingham,  ibid.,  p.  838  ;  Chipault,  Oaz.  des 
Hop.  ;  Arch.  Gen.  de  Med.,  1890  ;  Bev.  de  Chir.,  1890,  1891,  and  1892  ;  these  papers  are 
now  embodied  in  Chipault's  work  on  the  Surgery  of  the  Nervous  System  ;  Schede  of 
Hamburg,  Ann.  of  Surg.,  1892,  vol.  ii,  p.  230  ;  AV'yeth,  ibid.,  August  1894  ;  Biddell,  Med. 
and  Surg.  Reporter,  March  30,  1895  ;  Lejare,  Gaz.  des.  Hop.,  June  2,  1884  ;  Arnison,  ibid.. 
May  1895.  (2)  In  cases  of  Pott's  curvatures,  Macewen  and  Duncan  {loc.  supra  cil.) ; 
Wright,  Lancet,  July  14,  1888 ;  W.  A.  Lane,  Brit.  Med.  Journ.,  April  20,  1889  ;  Lancet, 
July  5,  1890  ;  Abbe,  New  York  Med.  Journ.,  November  24,  1888  ;  Kraske,  Centr.f.  Chir., 
1890,  Heft  25;  Dr.  S.  Lloyd,  of  New  York,  ^wn.  o/ -Swrfir.,  1892,  vol.  ii,  p.  289  ;  Bullardand 
Burrell,  Trans.  Med.  Orlhop.  Assoc,  vol.  ii,  p.  241.  Several  of  the  above  cases  have  been 
reported  so  soon  after  the  operation  that  their  value  would  be  much  increased  by  the 
authors  giving  later  details.  (3)  In  cases  of  new  growths,  Dr.  Gower's  and  Sir  V.  Horsley'3 
paper  (loc.  supra  cit.)  and  the  appended  table.  See  also  Dr.  -J.  W.  White's  paper  (loc. 
supra  cit.),  and  histat)le  of  the  most  obvious  diagnostic  points,  p.  32  ;  Starr,  "  Tumour  of 
the  Spinal  Cord,"  Amer.  Journ.  Med.  Soc,  June  1895  ;  and  Patnam  and  CoUins  Warren 
{Amer.  Journ.  of  Med.  Sci.,  October  1899). 

2  "  Most  of  the '  cures  '  reported  as  results  of  laminectomy  are  merely  examples  of  post 
hoc,  ergo  propter  hoc  reasoning.  I  have  read  the  reports  of  many,  and  have  little  doubt 
about  it.  The  exceptions  include  the  cases  in  which  laminectomy  has  led  to  the  liberation 
of  pus  and  the  exposure  and  erasion  of  pre-vertebralf oci  "  (Keetley,  Orthop.  Surg.,  p.  476). 

^  A7in.  of  Surg.,  October  1905,  p.  514.  *  Loc.  supra  cit. 

^  Dr.  Parkin,  of  Hull,  in  a  valuable  paper  [Brit.  Med.  Journ.,  1894,  vol.  ii,  p.  700), 
illustrated  by  cases  of  laminectomy  for  spinal  caries,  mentions  a  case  aged  9,  admitted  for 
cervical  caries,  cyanosis  and  bronchitis.  As  the  condition  became  more  critical,  the  sixth 
cervical  spine  was  removed.  The  cord  was  found  compressed  and  bent  by  a  mass  of  bone 
and  fibrous  tissue,  the  remains  of  the  foui'th  and  fifth  vertebrae.  When  the  cord  was 
freed,  pulsation  retui-ned.  Very  great  benefit  followed  on  the  operation,  but  the  child 
died  nearly  three  months  after  of  tubercular  meningitis,  thought  to  be  due  to  a  caseating 
gland  found  at  the  necropsy.  No  evidence  of  caseation  or  recent  caries  was  found  in  the 
vertebrae. 


992      OPERATIONS  ON  THE  VERTEBRAL  COLUMN 

but  it  is  by  no  means  common,  and  we  can  hardly  agree  with  those  who 
hold  that  the  condition  is  in  itself  incapable  of  spontaneous  recovery. 

"  The  persistence  of  symptoms,  in  spite  of  complete  rest,^  is  the 
indication  which  has  been  most  commonly  adopted,  but,  as  we  have 
already  seen,  such  symptoms  may  persist  for  very  long  periods  and 
then  yield  to  absolute  rest.  It  is,  however,  not  improbable  that,  in  a 
few  cases,  cicatricial  pachymeningitis,  or  rather  peri-pachymeningitis, 
may  remain  after  the  original  pressure-lesion  has  ceased  to  act,  and 
may  thus  keep  up  paraplegia  until  the  constricting  tissue  is  removed. 

"  (4)  In  posterior  caries  (that  is,  in  caries  of  the  arches  of  the  vertebrae) 
operation  is  clearly  indicated,  as  here  we  can  readily  both  treat  the 
paraplegia  and  remove  the  whole  of  the  tuberculous  tissue.  Two  cases 
of  this  nature  are  recorded  by  Abbe  and  by  Chipault  respectively,  and 
both  proved  highly  successful. 

"  (5)  In  my  fifth  case,  the  existence  of  severe  pain,  which  was  rapidly 
exhausting  the  patient,  was  regarded  as  an  indication  for  surgical 
interference. 

"  (6)  Lastly,  children  as  a  rule  yield  better  results  than  do  adults, 
so  that,  other  things  being  equal,  childhood  may  also  be  regarded  as  an 
indication  for  operation. 

"  Contra-indications.  The  presence  of  active  tuberculous  changes 
in  other  organs.  Macewen  holds  that  we  should  not  operate  when  there 
is  pyrexia,  which  is  almost  tantamount  to  saying  that  we  should  not 
operate  in  presence  of  active  tuberculosis.  If,  however,  the  pyrexia 
were  clearly  due  to  cystitis,  then  we  might  regard  it  as  an  indication 
for,  rather  than  against,  interference.  Again,  general  meningitis  (although 
fortunately  very  rare)  will  at  times  obviously  be  present  and  will  probably 
prove  fatal  whether  we  operate  or  not."  i< 

For  chronic  spinal  meningitis  Sir  Victor  Horsley  ^  recommends 
laminectomy  with  irrigation  and  drainage  of  the  spinal  theca.  He  bases 
his  advice  on  the  records  of  twenty- one  operations  for  this  condition. 
As  many  of  these  cases  are  syphilitic  salvarsan  should  be  tried  first. 
Spiller  ^  recommends  operation  for  a  circumscribed  serous  spinal  menin- 
gitis, which  closely  simulates  growth  as  the  collections  of  fluid  in  the 
pia-arachnoid  compress  the  cord.  The  drainage  of  the  fluid  appears 
to  be  satisfactory. 

E.  Cases  of  New  Growth.  It  is  in  the  intra-dural  variety  of  these, 
when  the  level  of  the  growth  can  be  correctly  estimated,  that  laminectomy 
is  most  decisively  indicated.  Sir  V.  Horsley  ^  has  here,  as  in  so  many 
other  instances  connected  with  the  surgery  of  the  central  nervous  system, 
operated  with  brilUant  success. 

The  patient  was  one  of  Dr.  Gower's,  aged  42,  and  his  chief  symptoms  were  com- 
plete paralysis  of  the  lower  limbs  and  abdomen,  the  former  being  frequently  flexed 
in  clonic  spasms,  the  pain  accompanying  these  being  extremely  severe.  There 
was  loss  of  tactile  sensibility  as  high  as,  and  involving  the  distribution  of,  the  fifth 
dorsal  nerve.     The  bladder  and  rectum  were  completely  paralysed.     The  growth 

1  Eeaders  with  careful  and  well-balanced  minds  wiU  not  fail  to  note  on  reading  the 
accounts  of  many  of  these  cases,  pubUshed  as  successful  cases  of  laminectomy  for  spinal 
caries,  that  many  of  them  before  being  submitted  to  operation,  had  only  been  treated  by 
rest  for  a  few  days  or  weeks,  "  the  mother  having  full  directions  to  keep  the  child  in  the 
same  horizontal  posture."  In  other  cases,  after  a  brief  period  of  in-patient  treatment, 
the  children  have  been  sent  out  in  Sayre's  jackets  to  attend  as  out-patients, 

2  Brit.  Med.  Journ.,  February  29,  1909. 

3  Amer.  J  (mm.  Med.  Science,  January  1909. 
*  Med.  C'hir.  Soc,  vol.  Ixxi,  p.  383. 


LAMINECTOMY  99.3 

proved  to  bo  an  almond-shaped  fibro-niyxoina  resting  on  the  left  lateral  column, 
in  which  it  had  formed  a  deep  bed,  and  adherent  to  the  fourth  dorsal  nerve.  The 
patient  recovered  perfectly,  the  report  being  continued  up  to  a  year  after  the  opera- 
tion. 

Dr.  H.  Gushing*  records  a  case  of  "  intra-dural  growth  of  the  cervical 
meninges."  The  history  before  and  after  the  operation  is  most  fully 
detailed.  Summaries  of  ten  other  cases  of  intra-dural  growth  success- 
fully operated  upon  are  also  given.  Dr.  Harte,  of  Philadelphia,^  gives 
a  full  list  of  cases  in  which  laminectomy  was  performed  for  intra-spinal 
"  tumours."  These  are  briefly  but  instructively  analysed  as  to  the 
nature  of  the  condition  found  and  the  mortality.  This  he  finds  to  be 
nearly  47  per  cent.  He  holds  that  it  should  be  capable  of  reduction  to 
30  per  cent.  Since  then  it  has  been  reduced  below  20  per  cent,  in  the 
published  cases. 

An  interesting  case  of  extra- medullary  tumour  is  recorded  by  Clark.  ^ 
The  tumour  was  successfully  removed  by  Hey  Groves,  who  points  out 
that  the  site  of  such  a  tumour  "  is  indicated  by  pain,  parsesthesia,  paralysis 
and  wasting  of  muscles  occurring  in  this  order  at  the  segment  correspond- 
ing to  the  lesion  and  followed  by  spastic  paralysis  of  the  parts  below 
the  lesion  at  a  later  date." 

In  recent  years  operations  for  spinal  tumours  have  multiplied  with 
great  rapidity,  and  increasing  experience  shows  that  they  are  very 
successful  when  undertaken  at  an  early  stage  of  the  disease.  Potel  and 
Veaudeau  ^  have  added  to  our  knowledge.  For  growths  invading  the 
spine  or  growing  in  the  vertebrae,  nothing  radical  can  be  done  as  a  rule, 
but  a  palUative  laminectomy  may  reheve  pain  and  pressure  on  the  cord. 
When  the  pain  is  very  severe,  the  paths  of  conduction  in  the  antero- 
lateral columns  of  the  cord  may  be  divided  through  a  small  laminectomy 
some  distance  above  the  growth. 

For  intra-vertebral  growths  there  is  more  hope,  especially  for  the 
extra-medullary,  for  they  rarely  recur  after  complete  removal.  They 
are  mostly  fibromata  or  fibro-sarcomata  or  endothehomata  of  low  mahg- 
nancy.  They  are  nearly  always  well  defined,  small  and  solitary.  More 
than  half  of  them  are  found  in  the  dorsal  region.  They  are  about  equally 
common  inside  and  outside  the  spinal  theca. 

At  first  these  tumours,  as  a  rule,  give  rise  to  unilateral  pain  along 
the  course  of  the  spinal  nerve,  whose  root  is  afiected  or  compressed, 
and  this  serves  as  a  very  good  indication  of  the  site  of  the  growth.  Later 
pressure  upon  one  side  of  the  cord  causes  weakness  on  the  same  and  loss 
of  sensation  on  the  opposite  side  of  the  body  below  the  growth.  Later 
more  severe  compression  of  the  cord  causes  spastic  paralysis  of  the  parts 
below  on  both  sides,  with  exaggeration  of  the  reflexes,  and  later  still  the 
sphincters  become  paralysed,  and  sensation  is  partly  lost. 

Intra-medullary  tumours  are  far  less  common,  and  are  sohtary 
gliomata,  which  are  encapsuled  and  removable  in  over  half  of  the  cases. 
They  cause  swelHng  and  loss  of  pulsation  of  the  cord.  As  they  grow 
in  the  central  grey  matter,  they  cause  vague  symptoms  consisting  chiefly 
of  extending  atrophic  paralysis  and  loss  of  sensation  of  pain,  and  tempera- 
ture without  tactile  anaesthesia. 

It  is  difficult  and  very  important  to  determine  the  exact  level  of  the 

1  Ann.  of  Surg.,  June  1904.  »  Ihid.  October  1905,  p.  514. 

3  Brit.  Med.  Journ.,  1912,  vol.  i,  175. 

*  Rev.  de  Chir.,  1913,  vol.  i,  p.  713,  vol.  ii,  p.  477. 

SURGERY    I  63 


994      OPERATIONS  OX  THE  VERTEBRAL  COLUMN 

tumour,  for  if  the  latter  causes  no  root  symptoms,  the  signs  of  compression 
of  the  cord  may  mislead.  Then  a  growth  in  the  dorsal  cord  may  not 
cause  any  appreciable  local  irritation  but  only  weakness  and  pareesthesia 
of  the  legs.  Therefore  the  tumour  is  often  sought  too  low.  The  first 
pains  being  due  to  root  irritation  give  a  good  indication  of  the  site,  but 
it  must  be  remembered  that  the  nerves  issue  from  the  spine  at  a  variable 
distance  below  the  origin  of  their  roots  from  the  cord.  Thus  in  the 
cer\'ical  region  the  nerves  issue  one  vertebra  below  their  root  origins, 
in  the  dorsal  region  from  two  to  three  vertebrae  below,  and  the  lumbar 
and  sacral  nerves  all  have  their  origins  near  the  lower  end  of  the  cord, 
which  terminates  opposite  the  first  lumbar  vertebra. 

The  upper  border  of  disordered  sensation  is  a  very  valuable  guide, 
but  as  several  nerve-roots  supply  every  piece  of  skin,  the  level  of  the 
tmnour  is  sure  to  be  a  httle  above  the  exact  level  of  the  segment  indicated 
by  the  altered  sensation.  Atrophy  of  muscle  also  affords  a  valuable 
clue,  but  it  is  difficult  to  find  it  in  the  dorsal  region.  If  a  tumour  is  not 
found  at  the  exploration,  a  silver  probe  should  be  passed  up,  first  outside 
and  then  inside  the  theca,  and  this  may  discover  it. 

Operation  of  Laminectomy.  Asepsis  must  be  maintained  and  every 
precaution  must  be  taken  against  shock  before,  during,  and  after  the 
operation.  As  the  patient  must  be  placed,  as  far  as  is  safe,  in  the  prone 
position,  pressure  must  be  taken  off  the  chest  by  the  use  of  small  pillows, 
and  the  operator  must  be  prepared  for  the  need  of  rolling  the  patient  over 
from  time  to  time,  especially  in  those  cases  where  the  abdominal  muscles 
are  paralysed.  Far  better  and  safer  is  it  to  adopt  intratracheal  insuffla- 
tion of  ether  whenever  this  can  be  adopted.  A  longitudinal  ^  incision 
is  made  down  to  the  spinous  processes,  with  its  centre  opposite  to  the 
site  of  the  supposed  displacement  or  disease.  The  deep  fascia  having 
been  divided  a  little  to  either  side  of  the  spines  and  also  transversely  at 
the  upper  and  lower  angles  of  the  wound,  the  tendinous  attachments  of 
the  muscles  are  cut  from  the  spine,  and  the  muscles  completely  detached 
from  these  processes,  the  laminae,  and  from  the  transverse  processes  as 
far  as  is  necessary,  by  the  edge  of  a  short,  stout  scalpel  or  a  chisel,  the 
spinous  processes  being  used  as  a  fulcrum.  The  use  of  a  blunt  instrument 
is  more  likely  to  lead  to  some  sloughing,  especially  where  the  structures 
separated  are  largely  tendinous.  To  prevent  haemorrhage  forceps  are 
quickly  apphed  to  the  chief  points,  and  sterihsed  pads  out  of  sterile  sahue 
solution  at  a  temperature  of  110''  are  tightly  packed  by  retractors  into 
the  incision  on  one  side  of  the  spine,  while  the  operation  is  proceeded 
with  on  the  other.  This  \nll  best  meet  the  chief  bleeding,  which  is  very 
free  for  a  time.  Sterihsed  adrenahn  (1 — 1000)  should  be  at  hand.  Effi- 
cient compression  will  usually  suffice.  Any  vessels  that  require  it  being 
tied,  and  the  muscles  held  back  with  retractors,  any  remaining  muscular 
tissue  is  scraped  away  and  the  periosteum  reflected  with  a  suitably  curved 
elevator.  In  cases  of  tuberculous  disease,  where  access  is  desired  to 
the  bodies  of  the  vertebrae  rather  than  to  their  posterior  processes  and 
the  spinal  cord,  the  operator  may  desire  to  make  his  attack  postero- 
laterally  through  the  transverse  processes  and  pedicles  rather  than 
through  the  spines  and  laminae.  In  these  cases  especially  it  will  be  well 
for  the  operator  to  refresh  his  memory  by  having  the  corresponding  part 

^  A  flap,  with  its  base  in  the  middle  line  or  to  one  side,  is  recommended  by  some,  but, 
not  admitting  of  ready  enlargement,  can  only  be  suitable  to  those  cases  where  the  nature 
and  site  of  the  lesion  are  exactly  known. 


LAMINECTOMY 


995 


of  the  column  in  a  dry  state,  kept  at  hand  by  an  assistant  (Keetley). 
In  the  one  ease  the  spinal  canal  is  skirted,  in  the  other  it  is  entered. 
But  to  obtain  free  access,  it  is  often  advisable  to  combine  the  two  routes 
in  tuberculous  cases.  Two  or  three  spinous  processes,  if  unfractured, 
are  then  cut  off  close  to  their  bases  with  powerful  bone-forceps  with 
jaws  at  different  angles.  The  lamintc 
may  be  next  removed  by  spinal  saws, 
aided  by  a  trephine,  or  the  opening 
made  by  this  instrument  may  be  en- 
larged, as  in  the  skull,  by  bone-forceps. 
Sir  V.  Horsley  has  devised  bone-forceps 
well  adapted  to  working  at  the  bottom 
of  a  deep,  steep  wound-cavity.^  Dr. 
W.  S.  Bickham,  in  a  very  instructive 
article  on  the  technique  of  operations  on 
the  vertebral  colunm,^  recommends 
strongly  Doyen's  saw  for  removal  of 
the  laminae  and  spinous  processes. 
This  is  a  strong  Hey's  saw  with 
an  adjustable  guard.  The  guard  of 
the  saw  is  set  at  10  mm.,  which 
will  give  a  sufficient  cutting  edge  to 
pass  completely  through  the  lanunse  at 
any  portion  of  the  spine,  provided 
the  section  be  made  well  within 
the  laminae  proper,  and  at  a  right 
angle  to  their  surface.  It  is  usually 
impossible  to  complete  the  section 
of  one  side  with  the  saw  in  one 
position,  as  the  proximal  end  of  the 
saw  will  not  travel  the  full  length  of 
the  wound  satisfactorily.  The  surgeon 
must  divide  the  upper  part  of  the 
laminae  on  both  sides,  sawing  from 
below  upwards,  and  then  walk  round 
the  table  and  complete  the  sections  by 

sawing  in  the  reverse  direction.  The  usual  flat  probe  tests  the  depth  of 
the  section.  Partial  division  of  the  laminae  above  and  below  those  to 
be  removed  is  unavoidable,  and  harmless  (Bickham).  A  chisel  and 
mallet  may  be  used  along  an  already  made  saw- line,  to  complete  the 
section ;  but  even  here  the  vibrations  may  be  hurtful.  Further, 
unless  a  groove  is  first  made  with  a  saw,  the  hue  of  the  chisel  is  hable 
to  be  irregular.  When  the  lumen  of  the  canal  is  narrowed,  this 
instrument  becomes  a  dangerous  one.  Where  the  arches  and  the 
dura  may  be  adherent,  the  bone  must  be  removed  mth  great  caution ; 
"  picked  away  piecemeal,"  Tubby.^  In  the  case  of  fracture,  any 
loose  bone  will,    of    course,   be  tested    and    removed    by  sequestrum- 

*  The  surgeon  should  take  the  trouble  to  be  provided  with  the  necessary  instruments. 
The  ordinary  saws  and  forceps  are  quite  unfitted  for  removing  the  laminse,  and.  in  the 
case  of  the  cervical  spine,  may,  by  prolonging  the  operation  and  pressing  on  the  cord, 
bring  about  a  fatal  result,  as  occurred  in  one  case  which  came  to  my  knowledge.  Haemor- 
rhage from  the  bones  should  be  arrested  by  packing  applied  as  above,  or  (Harte,  Zoc.  supra 
cit.)  by  Horsiey's  wax. 

^  Ann.  of  Surfj.,  March  1905.  *  Orthop.  Surg.,  p.  74. 


Fig.  404.  Laminectomy  for  fracture 
dislocation  of  tlie  spine.  Three  laminse 
have  been  removed,  the  cord  witliin  its 
membranes  displaced,  and  the  promi- 
nent anterior  superior  angle  of  the 
vertebra  below  the  dislocation  is  being 
chipped  off  with  forceps. 


996      OPERATIONS  ON  THE  VERTEBRAL  COLUMN 

forceps.  The  supra-  and  inter-spinous  ligaments  and  the  ligamenta 
subflava  are  next  divided  with  blunt-pointed  scissors  at  the  two  ends 
of  the  wound  and  the  isolated  segment  of  bone  and  ligaments  is  then 
partly  prised,  partly  dragged  out.  In  cases  of  fracture- dislocation, 
attempts  may  be  made  by  manipulation  of  the  parts  now  exposed  by 
the  wound,  combined  with  extension  and  rotation,  to  rectify  the  position. 
The  dura  mater,  covered  with  peculiar  vascular  fat,  is  next  exposed. 
At  this  stage,  if  the  opening  be  too  narrow,  it  must  be  enlarged  with 
rongeur-forceps  and  gouge.  If  the  operation  is  to  be  completed  in  one 
sitting  (p.  1001),  the  next  step  is  usually  to  expose  the  cord  and  membranes. 
The  latter  are  generally  found  covered  by  a  varying  amount  of  fatty 
tissue  containing  veins.  This  layer  should  be  quickly  divided,  exactly 
in  the  middle  line  with  sharp  scissors,  and  the  two  halves  packed  to  one 
side  with  pledgets  of  sterilised  gauze  to  meet  haemorrhage.  Irrigation 
with  hot,  sterile  saline  solution  may  also  be  tried.  The  dura  mater  is 
then  examined.  If  no  pulsation  be  present,  compression  or  increased 
tension  suggest  themselves.  Where  it  is  needful  to  open  the  membranes, 
in  the  case  of  a  growth,  or  the  presence  of  blood,  or  to  inspect  a  damaged 
cord,  this  step  is  best  effected  by  picking  up  the  dura  mater  with  two 
pairs  of  forceps  (one  of  these  is  held  by  an  assistant),  and  then  dividing 
the  dura- arachnoid  between  these  with  scissors.  Opening  the  sub-dural 
and  still  more  the  sub-arachnoid  space  will,  of  course,  increase  the  risk 
of  infection  from  the  escape  of  fluid,  and  is  therefore  not  a  step  to  be 
undertaken  hghtly.  Thus  the  dura  should  only  be  opened  when  fluid 
such  as  blood  is  present  within,  when  the  condition  of  the  cord  requires 
investigation,  when  sufficient  mischief  is  not  found  outside,  or  when 
an  intra-dural  growth  exists.  This  step  is  especially  to  be  avoided  in 
tuberculous  cases,  from  the  risk  of  meningitis  (Chipault).  Cerebro- 
spinal fluid  is  carefuUy  mopped  away,  and  if  the  spine  is  horizontal  and 
the  head  is  lowered,  the  flow  usually  soon  ceases.  If  needful,  the  flow 
must  be  arrested  by  a  small  pledget  of  gauze.  Where  the  anterior 
surface  of  the  cord  or  the  posterior  aspect  of  the  body  of  the  vertebrae 
needs  investigation,  it  is  possible  by  means  of  an  aneurysm-needle  to 
displace  the  cord  partially.  If  during  this  step  it  is  really  needful  to 
divide  one  or  two  nerve-roots,  these  should  be  subsequently  united  by 
suture.^ 

In  a  few  cases  the  cord  itself  has  been  sutured  like  a  divided  nerve, 
the  stitches  taking  up  the  membranes  and  the  cord  itself.  Such  cases 
are  recorded  by  Dr.  Harte  and  Dr.  Stewart,  and  Dr.  Estes,^  and  by  Dr. 
Fowler.^  In  this  case  the  careful  report  is  continued  up  to  two  years 
after  the  injury.  The  results  are  encouraging,  especially  in  two  of  the 
cases. 

In  cases  of  caries,  dense  scar  tissue,  granulation  tissue,  p\is,  or  a 
tuberculous  mass  may  present  themselves  when  the  dura  mater  is 
exposed.  In  some  it  will  be  sufficient  to  take  away  the  diseased 
material,  till  pulsation  of  the  cord  reappears  ;  in  others  the  tougher 
leathery  substance  must  be  snipped  away  with  scissors  till  the  cord  is 
exposed  with  a  surface  made  as  smooth  as  possible,  and  it  is  clear  that, 

^  Dr.  Fowler  stated  {loc.  infra  cit. )  that :  "  Spiller  and  Frazier  found  that  after  division 
of  a  posterior  root  in  the  dog,  followed  by  immediate  suture,  regeneration  occurs,  and  that 
regeneration  into  the  cord  does  not  occur." 

2  Trans.  Amer.  Surg.  Assoc.  1902,  pp.  28,  44. 

*  Ann.  of  Surg.,  October  1905,  p.  507. 


LAMINECTOMY 


997 


if  not  piilsatiiif;,  it  is  not  constricted.  Any  carious  bono  that  is  within 
reach  will,  of  course,  be  removed  by  the  sharp  spoon.  If,  as  is  not 
nnlikely,  the  mischief,  e.g.  tuberculous  caries,  abscess  and  granulation 
tissue,  lie  in  front,  this  must  be  got  at,  if  possible,  by  drawing  the  cord 
from  side  to  side  with  an  aneurysm-needle,  and  cautious  removal  of 
part  of  the  transverse  processes  and  adjacent  bones  (p.  995).  When 
all  diseased  bone,  granulation  tissue,  &c.,  have  been  removed  with  the 


Iff        ^^^  ™ 


Fig.  405.     Laminectomy  for  extradura 
tumour. 


Fig.  406.    Intramedullary  tumour.      The 

cord  has  been  incised  to  allow  the  growth 

to   be    extruded.     (After    Hey    Groves, 

Med.  Annual.) 


sharp  spoon,  a  small  flushing  gouge,  or  gauze  mops,  iodoform  emulsion 
may  be  applied,  and  the  greater  part  of  the  wound  closed  ;  drainage, 
preferably  by  means  of  gauze,  should,  however,  be  provided  for  twenty- 
four  or  forty-eight  hours,  as  oozing  may  be  considerable. 

In  the  case  of  groivths  the  intra- dural  ones  hitherto  operated  upon 
have  been  usually  met  with  on  the  postero-lateral  aspect  of  the  cord. 
A  capsule,  more  or  less  complete,  is  generally  present.  It  is  to  be  noted 
that  even  when  the  correct  level  has  been  exposed,  growths  of  the  cord 
are  sometimes  difficult  of  recognition. ^  Such  a  case  has  been  alluded 
to  at  p.  992.  This  fact  is  well  illustrated  by  the  case  which  forms  the 
basis   of  Dr.    H.    Cushing's   paper.^     "  Fluid   escaped   in   considerable 

^  If  no  growth  can  be  found  in  the  region  exposed,  the  surgeon  should  not  hesitate  to 
remove  the  spines  of  three,  four  or  five  of  the  vertebrae  higher  up.  The  chances  of  an 
error  in  diagnosis  are  much  less  than  those  of  failing  to  find  the  tumour  through  timidity 
in  exploration.  Of  course  the  extent  of  the  operation  must  be  governed  largely  by  the 
condition  of  the  patient ;  and,  in  case  of  collapse,  the  operation  should  be  concluded  after 
a  day  or  two,  if  possible,  when  reaction  has  occurred  (Harte,  Ann.  of  Surg.,  October  1905). 

*  Loc  supra  cit. 


998      OPERATIONS  ON  THE  VERTEBRAL  COLUMN 

amount  from  the  sub-dural  space.  The  dura  was  then  incised  the  full 
length  allowed  by  the  exposure,  and  on  holding  apart  the  edges  of  the 
membrane  the  thin  transparent  arachnoid  bulged  into  the  opening  like 
a  distended  bubble.^  This  was  pricked,  and  the  fluid  spurted  from  the 
opening  in  jets  corresponding  with  the  cardiac  and  respiratory  rhythm. 
Not  until  the  contents  of  the  sub-arachnoid  space  were  thus  evacuated, 
and  the  transparent  membrane  had  settled  closely  over  the  cord,  was 
it  apparent  that  there  was  some  underlying  abnormality.     The  arachnoid 


Fig.  407.     Hemilaminectomy  fui  division  oi  ])Osterior  nerve-roots.     (Hey 
Groves,  Med.  Annual.) 

was  then  incised,  and  lying  on  the  left  side  of  the  cord  was  seen  an  oval 
growth  of  dusky  purplish  colour."  This,  removed  by  "  gentle  manipula- 
tions "  and  "  shelling  out,"  proved  to  be  a  fibro-sarcoma.  The  patient 
made  an  excellent  recovery,  and,  three  months  later,  was  able  to  return 
to  his  work.  In  this  case  to  facilitate  removal  of  the  growth,  one  posterior 
nerve-root  was  divided.^  Where  such  a  root  is  infiltrated  it  must  be 
sacrificed.     Elsberg  ^  records  the  successful  removal   of  several  intra- 

^  Dr.  H.  Gushing  observes  that  it  has  several  times  been  noticed  in  these  cases  that 
the  meninges  below  the  growth  are  greatly  distended  with  fluid  (chiefly  sub-arachnoid) 
under  an  increased  tension,  the  growth,  as  it  were,  acting  as  a  cork  to  the  spinal  flask  in 
which  the  fluid  continuously  accumulates. 

^  This  was  believed  to  be  the  seventh  cervical.  The  loss  of  sensation  which  followed 
is  described  with  the  full  detail  which  abounds  in  this  excellent  paper. 

3  Ann.  of  Surg.,  1912,  vol.  i,  2l7. 


LAMINECTOMY  999 

nu'dullary  tumours.  lu  tho  first  stage  the  cord  is  incised  over  the  tumour 
witli  the  result  that  the  hitter  is  extruded  and  is  more  easily  removed 
a  week  later. 

For  Resection  of  Posterior  Nerve- Roots.  Mr.  Hey  Groves^  admirably 
describes  the  technique  of  posterior  root  resection  as  follows  : 

'"  Attempts  have  been  made  in  three  directions  to  minimise  the 
length  and  danger  of  the  operation.  Guleke  divides  the  nerves  outside 
the  dura.     This  may  be  suitable  for  the  cervical  and  dorsal  regions, 


Fig.  408.     Hemilaminectomy  for  division  of  post  nerve-roots.     (Hej^  Groves, 

Med.  Annual.) 

but  in  the  liimbar  and  sacral  regions  the  roots  pierce  the  dura  so  far 
from  their  origin,  that  it  would  involve  a  greater  difficulty  than  that 
which  it  seeks  to  overcome.  The  author  of  this  article  ^  and  Wilms 
and  Kolb  ^  have  recommended  a  procedure  by  which  the  lumbo-sacral 
nerves  are  attacked  at  their  origin  from  the  lower  end  of  the  cord,  instead 
of  at  their  exit  from  the  spinal  canal.  The  accompanying  Figs.  (407 
and  408)  illustrate  the  field  of  operation  for  both  the  cer^dcal  and  lumbo- 
sacral regions.  In  the  former  a  hemilaminectomy  of  the  fifth,  sixth,  and 
seventh  cervical,  and  first  dorsal  vertebrae  serves  to  expose  the  posterior 
roots  from  the  fifth  cer\4cal  to  the  second  dorsal  inclusive,  and  by  gentle 

1  Med.  Annual,  1913,  p.  454.  2  La7ice(,  1911,  vol.  ii. 

3  Munch.  Med.  Woch.,  1911,  1961. 


1000    OPERATIONS  ON  THE  VERTEBRAL  COLUMN 

traction  on  the  cord  the  same  roots  on  the  opposite  side  can  be  dealt 
with.  In  the  lumbo-sacral  region,  laminectomy  of  the  last  two  dorsal 
and  first  two  lumbar  vertebra  gives  access  to  all  the  lumbar  and  sacral 
roots  at  their  junction  \\ith.  the  cord.  The  determination  of  the  exact 
roots  can  be  made  by  counting  upwards,  it  being  borne  in  mind  that  the 
lowest  root  of  considerable  size  is  the  third  sacral.  Wilms  and  Kolb 
suggest  that  it  is  unnecessary  to  count  the  roots,  and  they  recommend 
division  of  rather  more  than  half  of  all  the  rootlets  composing  each 
root."     And  later  ^  he  writes  : 

"  In  operating  for  spastic  contractions  of  the  leg,  Foerster  now  holds 
that  five  roots  ought  to  be  cut :  the  usual  ones  are  the  second,  third, 
and  fifth  lumbar,  and  the  two  upper  sacral.  The 
fourth  lumbar  is  left,  because  it  guarantees  the 
extensor  reflex  of  the  knee  which  is  so  very 
necessary  for  standing  and  walking.  Unfortu- 
nately, there  is  some  variability  in  this  phenomenon, 
and  the  second  or  third  Imnbar  may  be  the  im- 
portant root  instead  of  the  fourth  ;  so  that  now 
Foerster  always  assures  himself  of  this  point  by 
electrical  stimulation  of  the  roots  at  the  time  of 
the  operation. 

'"  Foerster  himself  still  prefers  the  identification 
of  the  roots  at  their  exit  from  the  dura,  which 
involves  the  removal  of  aU  the  lumbar  laminae. 
But  it  has  been  urged  by  various  authors  that  this 
is  quite  unnecessary,  because  all  the  lumbar  and 
sacral  roots  can  be  exposed  by  a  laminectomy  of  the 
last  dorsal  and  first  two  lumbar  vertebrse.  The 
objection  to  this  is  that  the  filaments  of  the  pos- 
terior roots  he  so  near  together  that  they  cannot 
be  accurately  counted.  Elsberg  ^  has  made  a  valu- 
FiG.  409.  Forked  end  able  contribution  to  the  solution  of  this  problem, 
of  ligamentum  denticu-     jje  has  pointed  out  that  the  hgamentmn  denticu- 

latum  with  first  lumbar      i,  .  ■       .        r.  £     ^     j  t     •      ^  -j. 

nerve  just    below   it.     latum  termmates  by  a  forked  end  ]ust  opposite 
(After     Hey     Groves,     to  the  fijst  lumbar  nerve,  so  that  this  identifies  the 
Med.  Anmtal.)  highest  of  the  series  (Fig.  409).     Now  as  the  last 

nerve  of  any  considerable  size  to  be  given  off  from 
;he  conus  medullaris  is  the  third  sacral,  we  have  a  means  of  recognising  the 
last  of  the  series  also,  and  it  ought  therefore  to  be  easy,  if  all  the  posterior 
nerves,  from  the  first  lumbar  to  the  third  sacral,  are  lifted  up  on  a  director, 
to  enumerate  them  accurately." 

Treatment  of  the  Wound.  To  wash  away  clots  and  check  oozing, 
flushing  with  hot  sterilised  sahne  solution  may  be  employed,  or  a  solution 
of  adrenahn  made  use  of.  From  the  extent  and  depth  of  the  wound 
and  the  condition  of  the  muscles,  drainage  by  at  least  a  strip  of  sterihsed 
gauze  is  indicated.  When  the  theca  has  been  opened,  it  must  be  very 
accurately  closed  with  catgut  sutures  so  as  to  prevent  leakage  of  cerebro- 
spinal fluid.  The  muscles  are  brought  together  with  buried  sutures  of 
catgut.  In  a  few  cases  the  haemorrhage  has  been  so  severe  as  to  necessi- 
.tate  packing  the  wound.  Where  there  is  much  oozing  the  first  dressings 
will  require  changing  at  the  end  of  twelve  hours,  and  subsequently, 

1  3Ied.  Annual,  1914,  p.  525. 

^  Amer.  Journ.  Med.  Sci.,  1912,  vol.  ii.  p.  799. 


TAIMMNC;  TIIK  SPINAL  THKCA  1001 

peiliaps,  oiicc  in  two  days.  The  skin  should  on  these  occasious  be  care- 
fully rosteriiised.  p]fHcient  support  should  be  supplied  by  sand-bags. 
A  plaster  of  Paris  jacket  should  be  applied  as  soon  as  possible.  The 
application  of  this  at  the  first  considerably  prolongs  the  time  of  the 
patient  being  on  the  table,  and  where  much  oozing  takes  place,  may 
interfere  witii  this  being  efiiciently  dealt  with.  The  necessity  remains 
of  after-attejition  to  such  conditions  as  cystitis,  or  the  most  successful 
operation  will  be  brought  to  nought. 

Causes  of  Failure  and  Death  after  Laminectomy.  Many  of  these 
will  have  been  made  clear  by  the  above  given  details  :  (1)  8hock.  Here, 
as  in  the  case  of  the  brain,  the  question  of  completing  the  operation  in 
a  second  stage  will  sometimes  arise.  As  I  have  already  stated  (p.  995), 
the  failure  of  the  surgeon  to  supply  himself  with  proper  instruments 
may  lead  to  needless  prolongation  of  the  operation  and  pressure  on  the 
theca,  which,  especially  in  operations  on  the  cervical  region,  may  help 
to  bring  about  a  fatal  result.  (2)  Haemorrhage.  This  has  been  fully 
alluded  to  ;  the  extra-dural  plexus  appears  to  be  usually  obliterated 
in  cases  of  Pott's  curvature.  According  to  Chipault  haemorrhage  is 
nuich  more  serious  in  the  neck,  since  death  has  resulted  three  times  from 
a  lesion  of  the  vertebral  artery.  (3)  Respiratory  trouble,  partly  due 
to  the  prolonged  anaesthetic.  In  one  case  ^  the  respiration  became 
much  embarrassed  towards  the  end  of  the  operation ;  this,  continuing 
till  the  patient's  death  three  days  later,  was  attributed  to  injury  to 
the  phrenic  nerve  with  an  exploring  needle.  The  dura  mater,  thickened 
and  adherent  to  the  bones,  had  been  thus  explored  after  removal  of  the 
third  and  fourth  cervical  arches  W'hich  were  carious.  (4)  Infective 
complications.  (5)  Tuberculous  or  other  secondary  deposits  elsewhere, 
(G)  Temporary  improvement  followed  by  a  relapse. 


TAPPING  THE  SPINAL  THECA 

•  The  following  are  the  chief  indications  for  its  employment,  (i)  Pressure 
of  the  cerebro-spinal  fluid  on  the  nerve  centres  in  hydrocephalus  (Quincke), 
growths,  and  effused  blood.  In  the  case  of  growths  of  the  brain  temporary 
rehef  of  headache  has  followed,  but  death  has  taken  place  suddenly  in 
several  cases,  owing  to  the  withdrawal  of  the  fluid  having  allowed  the 
growth  to  make  pressure  upon  the  medulla.  In  tuberculous  meningitis 
it  has  been  used  as  a  means  of  diagnosis  (Quincke).  It  has  also  lessened 
the  headache  ;  in  the  epidemic  cerebro-spinal  form  puncture  has  occa- 
sionally withdrawn  pus.  (ii)  As  a  means  of  diagnosis  in  different  forms 
of  meningitis,  serous,  purulent  and  tuberculous  ^  (Quincke),  (iii)  In 
the  treatment  of  tetanus.  In  my  own  mind  this,  together  with  intra- 
neural injections,  is  the  most  scientific  and  promising  method  of  dealing 
with  this  terrible  disease.  American  surgeons  from  their  enormous 
experience  ^  have  shown  the  way  here.  The  treatment  must  be  early, 
and,  in  many  cases,  prophylactic.  "  It  has  been  well  said  that  a  patient 
who  is  having  tetanic  symptoms  is  not  beginning  to  have,  tetanus — he 

^  Deaver,  Inter.  Jotirn.  Med.  Sci.,  December  1888. 

2  Furbringor  found  tubercle  bacilli  in  27  out  of  37  cases  of  tubercular  meningitis,  one 
of  which  is  stated  to  have  ended  in  recovery  (Berlin  Clin.  Woch.,  November  13,  1893). 

3  Thus  a  leading  article  (Journ.  Amer.  Med.  A.ssoc,  August  29. 1903)  shows  that  out  of 
the  casualties  of  the  Fourth  of  July  celebration  of  that  year  alone.  466  ended  fatally. 
Four  hundred  and  fifteen  cases  of  tetanus  occurred,  and  it  is  believed  that  this  list 
is  incomplete. 


1002    OPERATIONS  ON  THE  VERTEBRAL  COLUMN 

is  beginning  to  die  from  it."  The  intraspinal  injection  has  been  success- 
ful when  accompanied  by  intraneural  ones  into  each  of  the  trunks  of 
the  brachial  plexus,  each  being  repeated,  the  intraneural  one  by  reopen- 
ing the  incision  made.  It  is  well  to  try  and  scratch  some  of  the  nerves 
in  the  cauda  equina. ^  Any  wound  present  should  be  thoroughly  dis- 
infected and  drained.  The  experimental  work  of  Marie,  Mever  and 
others  and  the  results  prove  this  method  to  be  more  logical  than  intra- 
cerebral injection,  simpler,  and  less  dangerous. 

Operation.  The  interval  between  the  second  and  third  lumbar 
vertebrae  may  be  found  in  thin  patients  by  counting  downwards  from 
the  twelfth  dorsal  vertebrae.  In  stout  or  muscular  patients  a  hue  drawn 
between  the  highest  points  of  the  ihac  crest  usually  traverses  the  upper 
edge  of  the  fourth  lumbar  spine  when  the  column  is  flexed.  It  is  better, 
even  in  children,  in  order  to  secure  the  needful  rigidity,  to  have  a  special 
needle  with  a  stylet.  Barker's  syringe  and  needles  are  figured  below, 
and  the  details  of  technic  are  described  under  Spinal  Analgesia. 

When  the  fluid  is  being  withdrawn  to  reUeve  tension,  the  operator 
must  be  guided  by  the  pulse,  any  tendency  to  syncope,  or  pain  in  the 
head. 

Albertin  ^  reported  a  most  interesting  case,  which  serves  to  illustrate 
the  usefulness  of  this  measure  in  relie\4ng  intraspinal  pressure  in  certain 
cases  : 

A  man  fell  from  a  window,  striking  his  knees  and  then  his  back.  Paraplegia 
was  the  immediate  result,  the  reflexes  were  absent,  and  there  were  large  areas  of 
cutaneou5  anaesthesia.  The  sphincters  were,  however,  unaffected.  Fourteen  days 
later  Albertin  inserted  a  trocar  into  the  spinal  canal  in  the  lumbar  region,  and 
drew  off  one  oimce  of  blood-stained  fluid.  Forty-eight  hours  later  the  reflexes  had 
returned,  and  from  this  time  slow  improvement  took  place,  so  that  two  weeks  later 
the  patient  could  walk  -n-ith  crutches.     The  final  result  is  not  given. 

SPINAL  ANALGESIA 

This  valuable  method  of  inducing  analgesia  by  the  direct  action  of 
drugs  upon  the  spinal  cord  and  nerve-roots  was  introduced  by  Coming 
of  New  York,  in  1885.  Since  then  it  has  been  gradually  improved  by 
many  enthusiastic  workers  in  America  and  on  the  Continent.  Its 
adoption  by  British  surgeons  was  somewhat  delayed  by  reports  of  bad 
residts  abroad,  but  Barker,  Chiene,  Leedham-Green,  McGavin,  Dean, 
and  others  have  shown  that  there  is  very  little  danger  attached  to  it 
when  used  with  care,  and  that  it  is  eminently  satisfactory  in  suitable 
cases.  To  Barker  especially  we  owe  a  debt  of  gratitude  for  perfecting 
the  technique  and  for  his  able  advocacy  based  on  his  pubhshed  results. 
At  the  present  time  the  method  is  widely  used  and  increasingly  appre- 
ciated all  over  the  world. 

Indications.  Briefly  it  may  be  said  that  spinal  anaesthesia  is  indicated 
for  operations  beJoic  the  unibilicus,  ichen  an  inhalation  ancBsthesia  is  con- 
sidered unusually  risky  and  a  local  analgesia  is  not  likely  to  be  sufficient. 
In  spite  of  Jonnesco's  teaching  that  safe  anaesthesia  can  be  obtained 
as  high  as  the  vertex  by  the  addition  of  a  little  strychnine  to  the  spinal 
analgesic,  few  surgeons  or  anaesthetists  believe  spinal  analgesia  by  itself 
to  be  satisfactory  for  operations  above  the  umbilicus.  In  some  opera- 
tions in  the  upper  abdomen  the  addition  of  a  very  little  general  anaesthetic 

^  Rogers,  Journ.  Amer.  Med.  Assoc.,  May  14.  1903. 
2  Lyon.  Med.,  October  8,  1899. 


SPTXAT.  ANALGESIA  1003 

is  sufficient,  and  licio  the  spinal  angesthesia  is  valuable  in  diminishing 
shock. 

Tims  spinal  anaesthesia  is  especially  valuable  for  operations  below 
the  umbilicus  when 

(1)  Any  respiratory  or  circulatory  disease  makes  a  general  anaesthetic 
more  dangerous  than  usual  either  at  the  time  or  later  from  bronchitis, 
&c.  Also  when  the  kidneys  are  diseased  or  the  small  arteries  athero- 
matous as  in  senile  and  diabetic  gangrene. 

(2)  When  great  shock  is  expected  as  after  severe  injuries  and  opera- 
tions for  such  injuries  to  the  lower  limbs.  The  prompt  injection  of 
stovaine  into  the  spinal  theca  undoubtedly  diminishes  or  prevents  shock 
in  these  cases.  The  same  is  true  for  severe  pelvic  operations,  especially 
excision  of  the  rectum. 

(3)  When  full  relaxation  of  muscle  is  valuable  as  for  prostatectomy, 
most  pelvic  operations,  and  those  for  hernia. 

(4)  Where  vomiting  during  or  after  the  operation  is  undesirable  and 
especially  dangerous,  as  in  strangulated  hernia  and  intestinal  obstruction. 


Fig.  410.     Barker's  Syringe  and  Needles.     (Down 


(5)  Where  consciousness  during  the  operation  is  desirable,  as  when 
the  patient  has  a  great  fear  of  a  general  anaesthetic,  or  the  surgeon  wishes 
to  consult  him  after  the  examination  or  exploration. 

(6)  When  an  anaesthetist  is  not  available  in  emergencies.  Then  the 
surgeon  can  work  single-handed  with  safety  and  without  anxiety. 

The  method  is  not  very  safe  when  the  Trendelenberg  position  has 
to  be  adopted.  There  are  some  enthusiasts  who  prefer  spinal  anaesthesia 
for  all  operations  below  the  navel,  but  the  writer  prefers  to  reserve  it 
for  selected  cases,  believing  that  a  general  anaesthetic  is,  as  a  rule,  more 
satisfactory.  It  is  probable  that  even  the  spinal  enthusiasts  would  hail 
general  anaesthesia  with  joy  if  it  could  be  brought  before  them  now  as 
a  new  and  daring  innovation. 

T}Trell  Grayi  has  shown  that  spinal  analgesia,  especially  stovaine 
and  dextrine,  is  very  valuable  and  safe  for  children,  in  whom  it  lessens 
shock  to  a  marked  degree. 

Preparation,  Solution,  and  Instruments.  It  is  necessary  to  empty 
the  bowels  satisfactorily,  for  the  sphincters  are  paralysed  by  the  analgesic. 
It  is  wise  for  the  patient  to  take  only  hght  food  "before  the  operation. 
Many  drugs  have  been  tried,  and  some  of  these  have  proved  to  be 
dangerous.  On  the  whole,  Barker's  solution  of  stovaine  is  the  most 
satisfactory.  This  consists  of  stovaine  and  glucose  each  -05  grm.  in  1  c.c. 
of  water.  Billon,  of  Paris,  supphes  the  sterihsed  solution  in  capsules 
of  2  c.c.  McGavin  recommends  a  dose  for  an  average  healthy  adult, 
1  Brii.  Med.  Journ.,  1909,  vol.  ii.  pp.  913,  991. 


1004    OPERATIONS  OX  THE  VERTEBRAL  COLUMN 

•05  grm.  for  feeble,  exhausted  patients,  and  -04  grm.  for  operations  below 
the  groin.  The  solution  is  a  little  heavier  than  cerebro- spinal  fluid  and 
is  nearly  isotonic  with  it.  The  Barker  s\Tinge  and  needles  are  the  best 
{see  Fig.  410).  The  needles  are  hollow  and  fitted  with  a  stylet  and  a 
cannula,  the  latter  a  httle  longer  than  the  needle.  These  are  well  boiled 
in  water  containing  no  soda  or  other  alkah. 

Position.  The  best  position  is  the  lateral  one,  the  patient  lying  on 
the  side  to  be  operated  upon,  with  the  thighs  and  back  well  flexed.  The 
back  is  carefully  cleaned  with  acetone,  ether,  or  ether  soap  and  methylated 
spirit.  The  anaesthetist's  hands  are  prepared  as  for  every  operation. 
The  pelvis  is  slightly  raised,  and  the  interval  between  the  second  and 
third  lumbar  spines  is  found,  and  ethylchloride  is  sprayed  on  this  spot 
for  a  few  seconds.  The  needle  containing  its  stylet  is  entered  in  the 
middle  line  between  the  spines,  and  thrust  directly  forwards  for  about 
two  inches,  when  it  is  withdrawn  and  the  needle  is  pushed  on  until  the 
cerebro-spinal  fluid  begins  to  issue.  When  about  5  c.c.  of  this  has 
escaped,  the  cannula  fitted  in  the  syringe  containing  the  solution  of 
stovaine  is  inserted,  and  the  latter  is  gently  injected.  The  needle  is 
then  withdrawn  and  the  patient's  head  is  raised  by  a  pillow.  After 
a  minute  or  two  the  patient  is  rolled  on  his  back.  The  head  is  always 
kept  well  above  the  level  of  the  dorsal  .spine.  Almo.st  immediately  the 
knee-jerks  vanish  and  aneesthesia  rapidly  spreads  up  so  that  it  reaches 
to  or  above  the  umbilicus  in  five  to  ten  minutes.  Then  the  pehds  is 
lowered  and  the  operation  commenced.  If  the  analgesia  is  imperfect 
a  second  injection  of  one-half  the  original  dose  may  be  given.  A  sterilised 
towel  on  a  frame  prevents  the  patient  seeing  the  operation,  and,  if  con- 
sidered necessary,  his  ears  may  be  plugged  with  cotton-wool.  As  a  rule, 
however,  it  is  well  for  an  assistant  to  engage  him  in  conversation,  and 
to  give  him  a  drink  of  water  if  he  complains  of  thirst  or  nausea.  Occa- 
sionally faintness,  pallor,  and  sweating  are  noticed,  and  sometimes  there 
is  a  Httle  vomiting.  The  analgesia  lasts  on  an  average  about  fifty  minutes, 
but  its  duration  varies  from  twenty  to  ninety  minutes  (McGavin).  A 
number  of  patients  have  a  headache  and  backache  after  the  operation, 
and  nearly  all  have  a  rise  of  temperature  up  to  101,  subsiding  on  the 
second  or  third  day. 

Precautions  after  the  Analgesic.  Xo  hot  bottles  must  be  placed 
near  the  patient's  legs  until  the  analgesia  has  completely  disappeared. 
A  perineal  pad  should  be  worn  until  the  power  of  the  sphincter  ani 
returns,  and  retention  of  urine  must  be  prevented. 

Advantages.  Very  little  preparation  or  star^'ation  is  required  before 
the  anesthetic,  and  vomiting,  shock,  and  other  sequelae  are  rare  after 
it.  The  patient  finds  it  very  pleasant  to  be  able  to  eat,  drink,  or  smoke 
immediately  afterwards. 


The  Disadvantages  of  Spinal  Analgesia 

(1)  Occasionally  it  fails  to  produce  a  sufficient  degree,  extent  or 
duration  of  analgesia.  An  average  of  fifty  minutes  is  hardly  long  enough 
for  some  extensive  and  difficult  operations  in  the  pehns.  A  failure  to 
secure  good  analgesia  is  often  due  to  errors  of  technique  preventing  some 
of  the  solution  reaching  the  spinal  theca.  In  other  cases  failure  is 
attributed  to  idiosyncrasy  to  the  drug  or  to  a  low  pressure  of  the  cerebro- 
spinal fluid.     With  increasing  experience  the  failures  become  fewer. 


DISADVANTAGES  OF  SPINAL  ANALCiESIA        1005 

(2)  According  to  Crile  the  blood -pressure  falls  sometimes  to  a  dangerous 
degree  owing  to  the  loss  of  the  vaso-motor  tone  in  the  anaesthetic  area, 
for  vaso-motor  impulses  are  blocked  by  the  analgesia  with  the  result 
that  the  vessels  of  the  abdomen  and  legs  dilate.  An  injection  of  pituitary 
extract  before  the  operation  is  sometimes  used  to  diminish  the  fall  of 
blood-pressure. 

(3)  It  does  not  prevent  mental  shock,  as  the  patient  is  conscious  and 
often  suffers  from  fear,  and  sometimes  is  depressed  by  excitation  of  the 
special  senses,  which  are  keener  than  ever.  This  makes  spinal  analgesia 
alone  someVhat  imsuitable  for  very  nervous  people,  especially  women 
about  to  undergo  gynaecological  operations.  The  special  senses  can  be 
blocked  to  some  extent  by  covering  the  eyes,  by  plugging  the  ears  with 
moist  cotton-wool,  and  by  conversation,  or  by  an  injection  of  morphine 
^  gr.  an  hour  before  the  operation. 

(4)  A  toxaemia  sometimes  develops  a  few  minutes  after  the  injection. 
This  is  sometimes  attributed  to  idiosyncrasy  to  the  analgesic,  and 
sometimes  to  the  addition  of  adrenalin  to  the  solution,  which  should 
be  avoided. 

(5)  The  mortality  is  still  a  Httle  higher  than  that  of  ether. 

(6)  In  a  few  cases  post- operative  comphcations,  mostly  due  to  errors 
of  technique,  have  ensued,  such  as  paresis  or  pains  in  the  legs  from  injury 
of  the  Cauda  equina,  or  haemorrhage  into  the  spinal  canal  or  theca. 
Gangrene  of  the  legs  has  also  been  mentioned.  Some  headache  and 
pyrexia  are  usual,  and  sometimes  these  are  troublesome. 

Asphyxia  may  occur  when  a  very  high  level  of  anaesthesia  is  attempted. 
When  symptoms  develop  artificial  respiration  must  be  carried  out, 
strychnine  injected,  and  an  ounce  of  cerebro-spinal  fluid  allowed  to 
escape  through  a  lumbar  puncture. 


ANOCI-ASSOCIATION 

As  a  result  of  his  brilhant  experimental  work,  Dr.  Crile  has  introduced 
anoci-association  into  surgery,  and  the  following  account  of  technique 
is  taken  from  his  book  on  this  subject.^ 

MORPHIN  AND  SCOPOLAMIN 

"  To  mitigate  the  pre-operative  dread  and  to  facihtate  the  induction 
of  anesthesia,  a  solacing  dose  of  morphin  and  scopolamin  (usually 
morphin,  J  gr.,  scopolamin,  yi^-  gr.)  is  given  an  hour  before  the 
operation  to  all  patients  excepting  the  aged,  the  very  young,  and 
those  whose  feeble  condition  contraindicates  the  use  of  these  narcotics. 
The  use  of  morphin  serves  the  double  purpose  of  diminishing  the  pre- 
operative psychic  strain  and  of  actually  preventing,  to  some  extent,  the 
damage  to  the  organs  of  the  kinetic  system  by  the  trauma  of  the  operation. 
Laboratory  experiments  have  shown  that  in  morphinised  animals  sub- 
jected to  trauma,  the  changes  in  the  cells  of  the  brain,  the  suprarenals, 
and  the  liver  are  less  than  in  traumatised  animals  without  this  protection. 

"  That  deep  morphinisation  will  almost  completely  prevent  shock  has 
been  abundantly  proved  in  both  the  laboratory  and  the  chnic. 

"  The  protective  effect  of  morphin  is  remarkably  exhibited  also  in  those 
^  Dr.  Crile  and  Dr.  Lower,  A nnd- Association,  pp.  113,  115-121. 


1036     OPERATIONS   ON  THE   VERTEBRAL  COLUMN 

cases  of  exophthalmic  goitre  in  which  some  exceptional  local  condition 
causes  a  break  in  the  complete  anoci-association  of  the  patient,  as  a 
consequence  of  which  the  pulse  and  respiration  increase  markedly  during 
or  after  the  operation.  In  these  cases,  if  morphin  be  given  in  repeated 
doses  until  the  respiration  and  pulse  are  held  stationary  or  fall,  the 
dangerous  exhaustion  of  the  patient  will  be  avoided.  The  morphin  may 
be  given  at  any  time  during  or  after  the  operation  when  it  is  seen  that  the 
patient's  energy  is  being  expended  at  too  rapid  a  rate. 

"  Morphin  is  especially  useful  also  in  those  cases  of  acute  infection  in 
which  emergency  operations  must  be  performed.  In  such  cases  morphin 
affords  a  double  protection — it  protects  the  brain  against  both  the 
infection  and  the  operative  trauma,  the  efiects  of  which  are  increased, 
because  during  the  activations  of  a  toxin  the  brain  thresholds  are  greatly 
lowered.  Here  also  morphin  should  not  be  given  in  one  dose,  but  in 
repeated  doses  until  the  physiological  effect  is  produced.  This  point  will 
be  indicated  by  the  reduction  of  the  respiration  to  the  normal  rate  or 
less. 

"  In  brief,  by  proper  use,  morphin  to  a  large  extent  controls  the  meta- 
bolic processes.  It  should  be  added  that  it  is  not  our  intention  to  suggest 
an  increase  in  the  use  of  morphin  in  average  cases,  but  to  emphasise  its 
usefulness  when  employed  in  physiologic  dosage  in  certain  exceptional 
cases.  .  .  ." 

NOVOCAIN 

"  Every  division  of  a  sensitive  tissue — that  is,  of  a  tissue  supplied  with 
nociceptors — -is  preceded  by  the  injection  of  novocain  in  1  :  400  solution. 
This  is  used  routinely  in  all  parts  of  the  body,  in  all  ages,  in  the  debilitated 
and  in  the  strong,  in  small  and  in  extensive  operations  under  all  sorts  of 
conditions.  There  are  certain  salient  points  to  be  observed  in  its  use  : 
the  tissue  to  be  divided  should  be  completely  infiltrated — no  nerve 
filament  should  be  omitted.  One  might  think  of  the  novocain  as  a 
stain  and  consider  that  only  the  stained  parts  are  ready  for  the  knife. 
The  infiltrated  parts  should  be  subjected  immediately  to  pressure,  as 
firm  pressure  with  the  hand  greatly  increases  the  efficiency  of  the  anesthetic 
and  the  extent  of  the  anesthetised  area. 

"  It  is  well  to  make  the  first  infiltration  between  the  superficial  and  deep 
layers  of  the  skin  in  such  a  manner  as  to  cause  a  pig-skin  appearance. 
This  is  facihated  by  putting  the  skin  on  tension,  and  then  while  making 
the  injection,  pushing  the  needle  along  in  the  skin  parallel  to  the  surface. 
"  Experience  in  operatingunder  local  anesthesia  alone  is  almost  essential 
for  learning  how  to  use  novocain  infiltration  effectively,  for  the  conscious 
patient  promptly  protests  if  the  infiltration  is  incomplete.  As  a  result 
of  an  abundant  experience  with  conscious  patients,  the  surgeon,  even 
when  operating  on  anesthetised  patients,  will  automatically  plan  the 
infiltration  and  handhng  of  the  viscera  in  the  manner  which  would  cause 
the  least  response  were  his  patient  conscious. 

"It  is  obvious  that  the  anaesthetic  solution  should  be  most  carefully 
prepared  and  sterilised.  In  our  clinic  this  is  done  as  follows  :  Normal 
sahne  solution  is  prepared  with  distilled  water  and  boiled  for  twenty 
minutes.  A  sufficient  number  of  novocain  crystals  are  added  to  make  a 
1 ;  400  solution  which  is  then  boiled  for  ten  minutes  on  two  successive 
days. 


ANOCI-ASSOCIATION  1007 

"  Novocain  when  properly  injected  anaesthetises  the  part  immediately  ; 
the  an;csth(>sia  lasts  i'or  approximately  an  hour  ;  and  it  presents  no 
interference  to  the  healing  of  tiie  wound." 

QUININ  AND   UREA  HYDROCHLORIDE 

"  To  minimise  post-operative  discomfort,  especially  in  abdominal 
operations,  quinin  and  urea  hydrochlorid  in  a  J.  to  |  per  cent,  solution  is 
injected  at  a  distance  from  the  wound.  The  effects  of  this  local  anaesthetic 
last  for  several  days,  so  that  by  its  use  the  patient  is  protected  from 
noci-impulses  from  the  operative  field  until  the  healing  process  has  well 
begun.  This  local  ausesthetic  can  be  safely  used  in  all  cases  in  which 
no  infection  is  present,  but  is  unsafe  in  the  presence  of  infection  because 
it  to  some  extent  diminishes  the  resistance  of  the  tissues.  Quinin  and 
urea  hydrochlorid  usually  cause  some  oedema  of  the  infiltrated  part 
which  may  last  for  weeks,  but  which  ultimately  disappears.  The  solution 
used  at  Lakeside  Hospital  is  prepared  by  boihng  distilled  water  for  twenty 
minutes  ;  adding  a  sufficient  number  of  sterile  quinine  and  urea  tablets 
to  make  a  solution  of  the  required  strength  and  boiling  again  for  ten 
minutes. 

"  Moynihan  has  devised  an  excellent  syringe  having  an  obtuse-angled 
needle  by  means  of  which  the  quinin  and  urea  hydrochlorid  may  be 
injected  at  a  distance  from  the  incision  so  that  the  entire  operative  field 
will  be  anaesthetised  for  two  days  or  more  after  the  operation,  while  the 
wound  itself  is  not  exposed  to  the  irritation  of  the  quinin  and  urea." 

GENTLE  MANIPULATIONS  :    SHARP  DISSECTION 

"  The  phylogenetic  facts  upon  which  the  kinetic  theory  of  shock  is 
founded  indicate  the  necessity  for  the  use  of  the  gentlest  manipulations 
throughout  the  operation.  In  this  respect  the  surgeon  should  at  all  times 
govern  his  movements  as  he  would  if  the  patient  were  to  be  conscious  of 
each  step  in  the  operation.  Pulling,  tearing,  and  crushing  manipulations 
awaken  phylogenetic  noci-associations  with  consequent  activation  for 
defence,  and  exhaust  the  organs  composing  the  kinetic  system,  especially 
the  brain.  In  addition  actual  coincident  trauma  is  produced  by  traction 
in  the  tissues  beyond  the  zone  which  is  protected  by  the  infiltration  of  the 
local  anaesthetic.  On  the  other  hand  the  division  of  the  tissues  with  a 
sharp  scalpel  is  a  form  of  injury  which  awakens  less  phylogenetic  associa- 
tion and,  in  addition,  produces  the  least  amount  of  damage  to  the  tissues. 
Gentle  manipulation  and  sharp  dissection  by  producing  the  least  amount 
of  tissue  injury  in  turn  necessitate  the  minimum  amount  of  healing. 
Clean-cut  wounds  give  the  least  ^post-operative  discofnfort.  It  should  he 
borne  in  mind  also  that  trauma,  by  diminishing  their  vitality,  predisposes 
the  tissues  to  infection.  For  every  reason,  therefore,  the  tissue  trauma 
should  be  as  slight  as  possible." 

Comment.  The  principles  underlying  anoci-association  are  sound 
and  excellent,  but  the  practice  and  much  of  the  technique  recommended 
by  Dr.  Crile  has  been  adopted  by  most  surgeons  for  a  long  time.  Morphin 
and  scopolamin  or  some  similar  sedatives  given  before  the  anaesthetic 
has  been  in  general  use  for  years,  and  the  adoption  of  nitrous  oxide  with 

^  The  ansesthetic  jjroperties  of  this  drug   were  discovered  by  Thibault,  of   Scott, 

Arkansas. 


1008     OPERATIONS  ON   THE   VERTEBRAL   COLUMN 

or  without  ether  instead  of  chloroform  has  been  attended  with  excellent 
results.  In  my  experience,  however,  shock  has  been  extremely  slight 
and  rare  after  abdominal  operations  in  recent  years.  Moreover  post- 
operative discomfort  has  been  very  trivial.  Gentle  manipulations, 
quick  operating,  skilled  anaesthesia,  good  preparation  before  the  opera- 
tion, and  careful  but  not  meddlesome  after-treatment  have  been  attended 
with  the  happiest  results  in  the  large  majority  of  cases.  Therefore  I  have 
not  thought  it  necessary  to  adopt  the  injection  of  novocain  with  quinin 
and  urea  hydrochlorid  as  a  routine  measure.  I  believe,  in  fact,  that  the 
delay  involved  in  the  process  and  the  unpleasant  oedema  of  the  tissues 
more  than  outweigh  the  advantages  of  the  method  in  the  majority  of 
cases.  For  very  extensive  and  somewhat  prolonged  operations  likely  to 
be  attended  with  considerable  shock,  the  method  has  very  much  to 
recommend  it. 


INDEX 


Abdomen,  t  lansplcunil  operation  on,  7>S1 
Abdominal   :u)r(a.   Maccwcn's   mothod   of 

(•om|)i('ssioii,  .S09 
Abnormalities  of  ft-inoral  artery,  843 
Abscess,  coiobral,  duo  to  injury,  trephining 
for,  2(39 
extradiu-al,    complicating   otitis   media, 
351,  350 
treatment  of,  35G 
in  cerebellum,  operation  for,  358 
in   temporo-sphenoidal   lobo,   operation 

for.  356 
mastoid,  337 
of  hip-joint,  815,  817 
Acetabulmu,  abscess  following  disease  of, 

817 
Acromion,  occasional  conditions  of  which 

call  for  ojieration,  242 
Actinomycosis  of  lung,  operation  for,  784 
Adams'   operation  for  contracted  palmar 
fascia,  82 
on  femur,  953 
saw,  958 
Adductor  tubercle,  exostoses  of,  removal, 

858 
Adenoids,  removal  of,  474 

anajsthetic  for,  474 
Adenomata  of  thyroid,  enucleation  of,  628 
Adrenalin,  administration  of,  in  shock,  29 

effect  on  blood-pressure,  36 
After-treatment,  general,  27 
of  acute  mastoid  abscess,  342 
of  cleft  palate  operations,  525 
of  enucleation  of  tonsils,  477 
of  ligature  of  sub-clavian,  704 
of  mastoid  abscess,  342,  349 
of  oesophagotomy,  651 
of  operation  on  nose,  458 
of  operation  on  wrist,  118 
of  operations  on  Gasserian  ganglion,  377 
of  operations  on  tongue,  547 
of  radical  mastoid  operation,  349 
of  rodent  ulcer,  395 
of  tendon  transplantation,  107,  109 
of  thyrotomy,  590 
of  tracheotomy,  570 
of  wounds  in  operation,  25 
Age  of  patient,  and  excision  of  elbow-joint, 
148 
and  operation  for  cleft  palate,  504 
and  removal  of  scapula,  232 
operations  and,  1 
Age,  old,  post-operative  shock  in,  2 
Agnew's  operation  for  webbed  fingers,  SO 
Air,  infection  by,  in  operations,  13 
Air-passages  in  neck,  operation  on,  559 
upper,  foreign  bodies  in,  removal  of,  602 


SURGERY  1 


Albmninm-ia,  10 

Alcohol  solut  ions  as  antiseptics,  16 
Alcoholism,  dangers  of  operations  in,  3 
Alimentary  system,  operations  and,  1 1 
Alveolar  process,  tapping  antrum  through. 

Amputation  at  hip-joint,  805 

by  difl'ercnt  flap  methods,  178,  812 
of  fingers,  57 
of  leg,  904 
of  thumb,  ()6 
of  toes,  950 

question  of,  in  compound  fractures,  916 
sub-astragaloid,  937,  939 
through  knee-joint,  862 
through  shoulder- joint,  177,  196,  208 
through  tarso-metatarsal  joints,  948 
through  thigh,  846 
through  wrist-joint,  120,  123 
Amputations,  Chopart's,  946 
circular  method,  144, 177 
conical  stump  in,  47 
Dubreuil's,  123 
flap  methods  in,  48,  178,  871 
general  points,  46 
immediately  above  knee-joint,  853 
interscapulo-thoracic,  234 
Lisfranc's,  948,  950 
methods  of,  47 

circular,  47,  177 

elliptical,  48 

flaps,  178,  180,  812 

modified  circular,  47 
multiple,  851 
Pirogoff's,  932,  935 
racket  incision  in,  48 
Roux's,  934 

Syme's  operation,  930,  933 
Anaemia,  traumatic,  acute,  infusion  in,  35 
Anaesthesia,  complications  following,  31 
Crile's  method,  1006,  1008 
intravenous  induction  of,  37 
morphine  in,  1006 
novocain  in,  1007 
quinin  in,  1007 
scopolamin  in,  1006 
spinal,  disadvantages  of,  1004 
urea  hydrochlorid  in,  1007 
Ansestbetics,  administration  of,  22 
effects  of,  4,  6 
in  adenoids,  474 

in  direct  vision  oesophagoscopy,  605 
in  empyema,  765 
in  operations  on  brain,  309 

on  tongue,  533,  537 
in   Whitehead's  operation   for  removal 

of  tongue,  533 

1009  64 


1010 


INDEX 


Anaesthetics,  precautions  after,  1004 

tracheotomy  and,  566 
Analgesia,  induction  of,  1002 
local.  Barker's  solution,  582 

tracheotomy  under,  581 
methods  for,  1004 
spinal,  disadvantages  of,  1004 
indications  for,  1002 
position  for,  1003 
preparations  for,  1003 
Anastomosis  of  blood-vessels,  end-to-end. 
52 
tendon, 97 
Aneurysm,  aortic,  surgical  interference  in, 
677,  720 
arterio-venous,  679 

of  axillary  artery,  190 
carotid,  690,  695 
.  growth  of,  arrested  bv  anastomosis,  682, 

690 
Matas's  operation  for,  894 
of  innominate,  ligature  of,  677,  721 

surgical  interference  in,  720 
orbital,  677 
palmar,  89 

peripheral,  of  larger  vessels,  53 
popliteal,  894 
spontaneous,  172 
thoracic,  581 

traumatic,  of  axillary  artery,  188,  189, 
195 
of  brachial  artery,  171 
varicose,  of  axillary  artery,  188,  190 
Aneurysmal  sac,  introduction  of  foreign 
bodies  into,  723 
varix,  190 
Angeio-sarcoma  of  clavicle,  241 
Ankle,  excision  and  erasion  of,  indications 
for,  939 
lateral  incisions,  941 
transverse  incision,  942 
Ankle-joint,  arthrodesis  of,  879 
Ankylosis,    excision    of    elbow-joint  and, 
160 
of  elbow-joint,  147 
of  hip-joint,  953 
of  knee-joint,  excision  for,  867 
of  shoulder-joint,  211 
Annular  ligament,  division  of,  92 
Anoci-association,  27.  29 
Crile's  technique,  1008 
gentle  manipulations  and,  1008 
morphine  and  scopolamin  in,  1006 
novocain  in,  1007 

quinin  and  urea  hj'drochlorid  in,  1007 
sharp  dissection  and,  1008 
Antiseptic  compresses,  16 
Antral  operation,  Kocher's,  368 
Antrectomy,  operations  of,  338 
Schwartze's,  338 
Stacke's,  338 
Antrum,  mastoid,  333 

of  Highmore,  suppuration  in,  opera- 
tions for,  431 
operations   for   through   alveolar 

process,  431 
puncture  of  antrum  and  drainage 

through  nose,  433 
radical  operation,  432 
Antyllus'  operation  for  ligature  of  axillary 
artery,  195 


Aorta,  abdominal,  Macewen's  method  of 

compression,  809 
aneurvsm   of,   surgical  interference   in, 
720" 
Aortic  and  innominate  aneurysm,  diagnosis 

between,  721 
Aphasia,  traumatic,  267,  293 
Arm,  amputation  of,  174 
by  circular  method,  177 
circular  division  of  muscles  in,  178 
combined  skin  flaps  in,  180 
indications  for,  174 
lateral  flaps  in,  180 
methods  for,  177 
skin  flaps  in,  178 
transfixion  flaps  in,  180 
gunshot  wounds  of,  176 
operations  on,  171 
ligature  of  brachial  artery  in,  171 
movements  after,  219 
paralj'sis  of,  tendon  transplantation  in, 

108 
removal  of,  234 
See  also  Forearm 
Arteries,  anastomosis  to  arrest  growth  of 
aneuiysm,  682 
iliac  and  femoral,  anastomotic  circulation 

of,  841 
in  buttock,  ligature  of,  835 
in  thigh,  ligature  of,  835 
of  head,  ligature  of,  670 
of  neck,  ligature  of,  670 
ligature  of,  46,  49,  670 
suture  of,  50,  51 

thyroid,  ligature  of,  610,  618,  630 
tibial,  898,  900,  902 
wounds  of,  52,  189 
Arteriorrhaphy,  50 

Dorrance  method  of,  51 
Matas'  operation  for,  53 
operation  of,  51 
Sucet  method  of,  52 
Artery,  anterior  tibial,  ligature  of,  902 
axillary,  anastomosing  branches  of,  175 
aneurj'smal  varix  of,  188,  190 
arterio-venous  aneurysm  of,  190 
bullet  wounds  of,  secondary  haemor- 
rhage in,  189 
false  traumatic  aneurysms  of,  189 
ligature  of,  indications  for,  187 
old  operation  for,  195 
anatomy  of  parts  in,  188 
ligature  of  first  part  of,  191,  193 

collateral  circulation  and,  191 
in  amputation  of  shoulder,  201 
operation  for,  191,  192 
ligature   of  third  part  of,    operation 

for,  194 
results  from  gunshot  wounds  of,  188 
rupture     of,      and     dislocations     of 

shoulder,  196 
traumatic  aneurj^sm  of,  188,  189 
varicose  aneur^'sm  of,  188,  190 
wounds  of,  187 

AVyeth  method  of  ligature,  201 
brachial,  abnormalities  of,  173 
anastomosing  branches  of,  175 
ligature  of,  at  bend  of  elbow,  168,  169 
collateral  circulation  and,  1 73 
indications,  168 
in  middle  of  arm,  171 


INDEX 


1011. 


Artery,  luachial,  li^iatmi^  iif,  ill  operations 
on  arm,  171 
operation  for,  Itil),  174 
carotid,  common,  lij^atiuo  of,  ()7."),  (JSO 

causo  of  failure  and  death  after, 

687 
difficulties,  687 
in     aneurysms     of     external     or 

internal  earotid,  ()7H 
in  artcrio-venous  aneurysms,  ((7!) 
in    hajmorrhago  after  removal  of 
tonsils,  681 
from  mouth,  681 
from  neek  or  jaw,  682 
from  throat,  680 
in  middle  meningeal  lucmorrhage, 

267 
in  orhital  aneurysm,  677 
in  wounds  of  jaw,  680 
through  mouth,  681 
operation,  68.3 

to   arrest   aneurysm    by    anasto- 
mosis, 682 
surgical  anatomy  of,  676 
external,  ligature  of,  688 

in  operations  on  tonsils,  5,j.j 
operation,  693 
surgical  anatomy  of,  694 
internal,  ligature  of,  695 
indications,  695 
operation  for,  697 
relations  of  in  neck,  696 
ligature  of,  in  aneurysm,  677 
temporary,  685 
facial,  ligature  of,  670 

relations  of,  in  neck,  671 
femoral,  abnormalities  of,  843 
ligature  of,  difficulties  and  mistakes 
in,  842 
in  Hunter's  canal,  843 
gluteal,  ligature  of,  835 

surgical  anatomy  of,  835 
innominate,  ligature  of,  710 
internal  mammary,  ligature,  710 
lingual,  guides  to  finding  the,  675 
ligature  of,  672 
operations,  673 
under  hyoglossus,  673 
meningeal,    middle,    haemorrhage    from, 

262,  267 
occipital,  ligature  of,  671 

relations  of,  672 
peroneal,  ligature  of,  904 
popliteal,  ligature  of,  894 
jiosterior  tibial,  ligature  of,  898 

relations  of,  900 
radial,   ligature    of,    at    back   of   wrist, 
123 
indications  for,  127 
in  forearm.  126 
in  lower  third  of  forearm,  127 
in  middle  third  of  forearm,  128 
in  upper  third  of  forearm,  128 
relations  of,  129 
sciatic,  ligature  of,  836 
subclavian,  anastomosing  branches  of, 
175 
first  part,  ligature  of,  707 
ligature  of,  after-treatment,  704 
difficulties,  &c.,  of,  706 
in  amputation  of  shoulder,  200 


Artery,  suIh  lavian,  s(!eond  and  third  part, 
ligature  of,  (i99 
third  or  second  portion,  ligature  of, 

702 
third  part,  ligature  of,  70;{ 
surgical  anatomy  of,  701 
temporal,  ligature  of,  67(J 
thyroid,  securing,  (i25 
ulnar,  ligature  of,  aids  to,  132 
difficulties  and  mistakes,  132 
in  forearm,  130 
just  above  wrist,  131 
lower  third  of  forearm,  130 
middle  third  of  forearm,  130 
vertel)ral,  jigatun;  of,  697 
indications,  697 
operations  for,  699 
ndations  of,  698 
Artery  clamp,  Crilc's,  51 
Arthrectomy,  824 
Arthritis  of  elbow- joint,  148 

of  iiip-joint.  824 
Arthrodesis,  877 
of  ankle  -joint,  879 
of  knee-joint,  879 
Arthrotomy  for  opening  elbow- joint,  146, 

166 
Arthrotomy  of  shoulder,  226 
Asepsis,  operations  and,  13 

operations  on  lung  and,  785 
Astragalus,  excision  of,  944 
in  sub-astragaloid  amputation,  937 
removal  in  excision  of  ankle,  939 
removal  of  fore-part,  969 
Auto-inoculation,  operations  and,  15 
Aveling's  transfusion  apparatus,  42 
Axilla,  contents  of,  removal  in  operation  for 
malignant  disease  of  breast,  742 
operations  on,  187 
Axillary  artery,  ligature  of,  187 


Ballenger's  swivel  knife,  458 
Bandages,  plaster  of  Paris,  155 
Barker's  solution  in  local  analgesia,  582 

of  stovaino,  1003 
Basedow's     disease.     See    Goitre,    exoph- 
thalmic 
Berry's  treatment  of  goitre,  629,  635 
Bezold's  mastoiditis,  338 
Biceps,  division  of,  964 
Bier's  osteoplastic  method  of  amputation 

of  leg,  906 
Blood,  transfusion  of,  34,  42 
Blood    pressure,    effect    of    adrenalin    on, 
36 
fall  of,  after  spinal  analgesia,  1004 
causes  of,  27 
Blood-vessels,  compression  of  in  amputa- 
tion of  shoulder,  200 
end-to-end  anastomosis  of,  52 
ligature  or  twisting  of  in  amput^-tion  of 

shoulder,  199 
surgery  of,  46 
See  also  Artery 
Boils  of  external  auditory  meatus,  330 
Bone,  cavities  of,  bone-grafting  for,  911, 
912 
decalcified,  use  of,  in  fracture  of  humerus, 

184 
incision  of,  956 


1012 


INDEX 


Bone,  instruments  for  removal  of,  339,  342 
necrosis  of,  908 

removal  of,  in  operations  on  wrist,  IIG 
resection  of,  for  tendon-suture,  103 

in  Volkmann's  contraction,  130 
sarcoma  of,  214,  228,  241,  240,  420 
section  of,  in  excision  of  shoulder,  220 
Bone-grafting,  450,  911 

in  fractures  of  humerus,  183 
in  ununited  fractures,  925 
Brachial  artery,   ligature   of,   at   bend   of 

elbow,  108,  171,  173 
Brachial  plexus,  operations  on,  068 
Brain,     abscess    in,    complicating    otitis 
media,  351 
trephining  for,  269 
bullet  wounds  of,  281 
compression  of,  symptoms  of,  262 
condition  of,  in  tre23hining  for  cjiiLlcpsy, 

275 
cortex     centres     of,     excision     of,     for 

epilepsy,  323 
cysts  of,  304 
decompression   of,    Cushing's   operation 

for,  318 
excision  of  parts  of  cortex,  277 
foreign  bodies  in,  localisation  of,  282 
operative  interference,  281,  284 
treatment  of,  283 
gliomata  of,  302,  321 
growths    of,    cerebral     localisation    in 
diagnosis,  and  removal  of,  293 
diagnosis,  294 
difficulty  in  detecting,  320 

isolating.  321 
nature  of,  296 
operation     for.     clinical     phenomena 

following,  295 
operative  procedures  for,  308 
osteoplastic  flap  in  operation  for,  313, 

315 
position  of  lesion  and  flap  in  opera- 
tion for,  308 
questions  arising  before  ojxjration  on, 

296 
removal    of    bone    and    exposui'c    of 

brain  for,  309 
tuberculous,  ."Ol 
gummata  of,  303 
hajniorrhage,  sub-dural,  208 
hernia  of,  324 
incision  of,  320 
inflammation  of,  cause  of  failure  after 

removal  of  upjjer  jaw,  430 
injuries  of,  sj^mptoms  of,  262,  269 
localisation  of,  practical  value  of,  292 

in  reference  to  operations,  289 
motor  area  of,  289 
operations  on,  anaesthetic  for,  309 
causes  of  difficulty  in,  324 
closure  of  wound  after,  323 
hsemorrhage  and,  320 
Stellwagen's  trephine  for,  316,  318 
treatment  after,  319 
pysemia  of,  260 
sarcomata  of,  302 
surgerv'  of,  276 
sutures  of,  position,  290 
syphilis  of,  299 

trephining  for  pus  between  bone  and,  259_ 
tumour  of,  cerebral  localisation  in,  289 


Brain,  ventricles  of,  drainage,  328 
Bramwell    (Byrom),    on    intracranial    tu- 
mours, 298 
Branchial  cysts,  64() 

fistula-,  646 
"Brawny  arm,"   lymph  -  angioplasty  for, 

55 
Breast,  excision  of,  indications  for,  758 
fibro-adenomata  of,  treatment,  758 
malignant  disease  of,  operation  for,  737 
after-treatment,  748 
clearing    out    axillary    contents, 

742 
division  of  muscles,  742 
drainage  and  closure  of  wound, 

745 
dressing  after,  747 
hasmostasis,  744 
incision,  739 
steps  of,  740 
radium  treatment,  757 
recurrence  after  removal,  730,  756 
results  of  operation,  728 
selection  of  cases  for  operation,  735 
value  of  palliative  operations  for, 

755 
X-ray  treatment,  757 
removal  of,  727 

Halstcad's  method,  750 
indications,  727 
mortality,  728 
results  and  dangers,  728 
tubercular  disease  of,  excision  of  breast 

for,  758 
tumours  of,  innocent,  Thomas's  method 
of  removal,  759 
Bright's  disease,  operation  risks  in,  7,  9 
Bronchi,  examination  of,  for  foreign  bodies, 

602,  606 
Bronchitis,  operation  risks  in,  8 
Bronchocele,  610 

Broncho-pneumonia  comijlicating  enuclea- 
tion of  tonsils,  477 
complicating  laryngectomy,  597 
Bronchoscopy,  direct  vision,  604 
Bronchus,   foreign  body  in,   evidence  of, 
602,  606 
Meyer's  suture  of,  788 
Brophy's  operation  for  cleft  palate,  523 
Brun's  method  of  cheiloplasty,  493 
Bullet  wounds.     Sec  Gunshot  wounds 
Bullets,  localisation  of,  284 
Bums,  35 
Buttock,  arteries  in.  ligature  of,  835 


Cancer  of  breast,  728 

of  larynx.  582 

of  parotid,  398 

removal  of  upper  jaw  for,  420 

surgical  treatment,  55 

of  tongue,  529 
Cannula,  Symonds'  frontal  sinus,  415 
Gardens  amputation  of  knee-joint,  853 
Cardiolysis,  803 
Caries,  excision  of  elbow- joint,  and,  160 

of  scapula,  removal  of  scapula  for,  233 

of  spine.  996 
Camochan's  operation,  modified  in  neurec- 
tomy of  second  division  of  fifth  nerve, 

365' 


INDEX 


1013 


Carotid  arteries,  ligature  of,  207,  075,  088, 

mr< 

Carpo-metacarpal  joint,  ainputation  at,  (»(), 

(i7 
Carpus,  tuberculous  disease  of,  119 
Catgut,  sterilisation  of,  15,  20 
Caustics  in  treatment  of  njevi,  401 
Cautery,  actual,  in  lupus,  .■}!)2 

in  ticatinent  of  najvi,  4(^4 
Cellulitis  followin<^  (>|)erations  on   thj'roid 

gland,  ()l{5 
Cerebellum,  abscess  in,  complicating  otitis 
media,  IJ52 
operation  for,  .358 

tumours  of,  o])erations  for,  322 
Cervical  nerves,  ui)per,  operations  on,  001 

resection  of  branches  of,  005 
Cervical  ribs,  removal  of,  047 
Cervical    sym])athetic,    resection    of,    for 

exophthalmic  goitre,  607 
Chauvel  S  operation  on  upper  lip,  by  verti- 
cal flaps,  500 
Cheek,  gap  in,  Israel's  method  of  closing, 
501 

splitting  of,  in  removal  of  tongue,  535 

defects  on,  restoration  of,  500 
Cheiloplasty,  Brun's  method  of,  493 

von  Langenbeck's  method  of,  493 
Chest,  gunshot  injuries  of,  770 

incision  of,  for  serous  effusions,  702 

injuries  of,  operative  interference  in,  770 

operations  on,  730,  778 

paracentesis  and  incision  of,  700 

penetrating   wounds    of,    involving   the 
diaphragm  and  abdomen,  770 
Chest  wall,  closure  of  opening  in,  789 
Cheyne  S  incision  for  removal  of   breast, 

739 
Child,  feeble  condition  of,  cause  of  failure 

of  operation  for  cleft  palate,  527 
Chopart's  operation,  940 
Circulatory  system,  operations  and,  7 
Clavicle,    conditions    of,    which    call    for 
operation,  242 

dislocation  of,  operation  for,  243 

fracture  of,  operation  for,  242 

growths  of,  removal  of  clavicle  for,  240 

ojierations  on,  240 

removal  of,  240 

removal  of  greater  part  of,  234 

sarcoma,  angeio-,  241 
Cleft  palate.     See  tinder  Palate 
Clemot's  operation  for  hare-lip,  483 
Collapse  after  operations,  28 

infusion  in,  35 
"  Collar  "  incision  for  goitre,  021 
Collateral  circulation  of  common  femora], 
838 
of  popliteal  arterj',  895 
of  superficial  femoral,  840 
Colles's  fracture,  mal-united,  operation  for, 

120 
Collodion  in  treatment  of  nsevi,  401 
Coma,    diabetic,    danger    of    patient    in, 
10 

middle  meningeal  haemorrhage  and,  204 
Compresses,  antiseptic,  preparation  of  skin 

by,  10 
Concussion,  symptoms  of,  263 
Condyle  of  jaw,  excision  of,  to  relieve  fixity, 

440 


Congenital  dislocation  of  hip,  827 

lymphangioma,  (>45 

torticollis,  treatment  of,  (i(»4 
Contractions,  Dupuytren's,  82 

(»f  lingers,  8.3 

of  l<gs,  sevens  o])erations  for,  973 
Cornea,    ulceration    of,    in    operation    on 

gasseriaii  ganglion  by  intracianial  route, 

381 
Counter-trephining  f'jr  removal  of  bidlets, 

280 
Coxa  vara,  831 

osteotomy  for,  953 
Cranial  bones,  exostoses  of,  245 
growths  of,  245 

injury,  trephining  for,  244,  272 
See  also  Skull 
Craniectomy  for  idiocy,  325 

for  microcephalus,  325 

operation  of,  320 
dangers,  327 
Crile's  anoci-association  theory,  28,  1006 

artery  clamp,  51 

on  causes  and  prevention  of  shock,  27,  29 

technique  in  shock,  1000,  1008 
Cuneiform  osteotomy  of  neck  of  femur,  832 

subtrochanteric  osteotomy,  832 
Curetting  in  rodent  ulcer,  395 
Cushing's  operation  for  decompression  of 

brain,  318 
Cystic  goitre,  612 

hygroma,  045 
Cysts,  branchial,  646 

dental,  removal  of  upper  jaw  for,  421 

dentigerous,  removal  of  upper  jaw  for, 
421 

dermoid,  of  neck,  040 

of  brain,  304 

of  thyroid,  treatment  of,  033 

sebaceous,  of  neck,  046 

thyroglossal,  045 
Czemy  methoel  of  tenelon  lengthening,  99 


Davies-Colley's     flap     method     for     hard 
palate,  513 
stages  of  operation,  51.3-516 
De  Vilbiss's  skull-cutting  forceps,  312 
Death,   dangers  and  causes  of,  following 

removal  of  growths  from  larynx,  000 
Decompression,    Cushing's    operation    for, 

318 
Delirium  tremens,  post-operative,  4 
Delorme's  tempory  resection  of  thoracic 

wall,  788 
Deltoid  flap  in  excision  of  shoulder,  208,  220 
Denonviller's  method  of  rhinoplasty,  451 
Dental  cysts,  421 
Dermoid  cysts  of  mouth,  548 

of  neck,  646 
Desossement,  methoel  of,  72 
Desquin's  method  of  tendon  grafting,  102 
Dextrose,  intravenous  injections  of,  37 
Diabetes,  coma  in,  danger  to  patient,  10 

infusion  and,  36 

complications  likely  to  occur  in,  11 

operation  risks  in,  10 

tissues  of  patient  liable  to  infection  by 
pyogenic  organisms,  10 
Diathermy  in  rodent  ulcer,  396 
Didot's  operation  for  webbed  fingers,  81 


1014 


INDEX 


Dieffenbach's    method    of    restoration    of 
mouth,  499 

oi)eration  on  u])]K'r  lip,  by  vertical  flajis, 
500 
Digits,  leunion  of  severed,  78 

supernumerary,  78 

treatment  of,  78 
Diplegia,  cerebral,  tendon  transplantation 

in,  108 
Diplopia  after  operations  on  frontal  sinuses, 

417 
Discission,  subcutaneous,  in  treatment  of 

najvi,  404 
Dislocation  of  fingers,  reduction  of,  09 

of  hiji,  congenital,  827 

operative  interference  in,  826 

of  humerus,  211 

of  thumb,  reduction  of,  69 
Dissectors  and  spatulse  combined,  used  by 

Sir  V.  Horsley,  320 
Distance  sutures  for  tendon  lengthening, 

100 
Diverticulum  of  the  oesophagus,  653,  655 
Dorrance's  method  of  arteriorrhaphy,  50 
of  end-to-end  anastomosis  of  vessels, 

53 
of  suture  of  vessels,  52 
Dorsalis  pedis,  ligature  of,  930 
Doyen's  guarded  chisel  for  operations  on 
brain,  314 

guarded  saw  for  operations  on  brain,  314 

perforator  and  burr  for  ojjerations  on 
brain,  316 

rib  raspatory,  769 
Drainage  in  operations  on  wrist,  117 

in  wounds  of  heart,  801 

methods  of,  24 

through  nose,  433 
Drainage-tubes,  materials  for,  25 
Dressings,  after  oi)eration  for  malignant 
disease  of  breast,  747 

infection  by,  14 

])reparation  of,  21 
Drug  habits,  4 
Dubreuil's  amputation,  123 
Dupuytren's  contraction,  82 

fracture,  923 
Dura  mater,  growths  of,  245 

pus  between  skull  and,  259 
Diuham's  cleft-imlate  needles,  508 
Dyspnoea  complicating  embolism,  33 

complicating  goitre,  610 

tracheotomy  in,  581 

Ear,  external,  operations  on,  330 
foreign  bodies  in,  330 
operations  on,  330 
Ear   trouble   complicating   enucleation   of 

tonsils,  478 
Echl'Ondl'Omata,  removal  of  upper  jaw  foi', 

422 
Effusions,  paracentesis  in,  761 
Elastic    compression    controlling     luemor- 
rhage  during  amputation  of  hip-jf)int,  805 
Elbow,  ligature  of  brachial  artery  at  })end 

of,  168 
Elbow-joint,  amputation  at,  142 
by  antero-internal  flap,  142 
by  circular  method,  144 
by  long  anterior  and  short  posterior 
flaps,  143 


Elbow-joint,  amputation  at,  by  one  lateral 
tia])  or  by  lateral  skin  flaps,  144 

by  short  postero-extcsrnal  flap,  142 
j)ractical  points,  142 
ankylosis  of,  147 
arthritis  of,  148 

arthrotomy  for  opening,  140,  166 
erasion  of,  160 

after  treatment  of  operation,  162 

operation  for,  160 
excision  of,  145 

age  and,  148 

caries  following,  160 

complications,  149 

Esmarch's  wire  splint  for,  154 

flail-like  joint  following,  160 

for    recent     injury    and     its    result, 
145 

for  tuberculous  disease,  145 

indications  for,  145 

injury  to  ulnar  nerve  during,  160 

Ollier's  method  by  a  bayonet-shaped 
incision,  156 

operation,  150 

other  methods,  156 

partial,  158 

IJractical  points,  145 

preservation  of  periosteum  and,  149 

repeated,  155 

results,  160 

sequelae,  160  « 

site  of  bone  section,  151 
forcible    movement    under    anaesthetic, 

146 
gunshot  wounds  of,  treatment,  157 
incision    of,    Kocher's    modification    of 

Ollier's  method,  157 
old  injuries  to,  excision  for,  146 
operations  in  neighbourhood  of,  142 
osteo-arthritis  of,  148 
Electrolysis  in  treatment  of  najvi,  402 
Elephantiasis  of  leg,  ligature  of  superficial 

femoral  for,  840 
Embol^m  after  operations,  32 
Emphysema,  complicating  after-treatment 
of  tracheotomy,  574 

Empyema,  760,  763 
anaesthetic  in,  765 
complications  of,  768 
conditions  contra-indicating  operation, 

775 
operation  risks  in,  8 
resection  of  ribs  in,  769 
treatment  of,  763 
by  incision,  764 

points  of  importance,  765 
simple    puncture    with    aspirator    or 
fine  trocar,  763 
Endo-aneiu-ysmorrhaphy,  53 

Enemata,  administration  of,  30,  31 
Epilepsy,  excision  of  cortex  centres  for,  277, 
323 
traumatic,   causes  of  failure  after  tre- 
phining, 279 
trephining  for,  272 
operation  of,  276 
results  of  operation,  272 
Epiphyses,  lower,  of  humerus,  rare  injuries 
of,  146 
of  radius,  separation  of,  120 
of  humerus,  separation  of,  165 


INDEX 


101; 


Epithelioma  of  left  vocal  cord,  590 

uf  luwir  lii>,  irmoval  of,  with  restora- 
tion of  lijt,  4JV2 
of  tongue,  529 

and  adjacent  parts,  544 
Epithehomata  of  scalp.  248 

Epulis,  reiiKival  of  iipper  jaw  for,  419 
Equinovaras,  W-i 
Ei-asionof  (•ll.(i\v-j<.int,  ICO 
uf  knee-joint.  8(54 

causes  of  faihuv  after,  870 
of  lupus.  390 
Esmarchs   operation  to   relieve   fixity   of 
lower  jaw,  441 
wire  splint  for  excision  of  left  elhow,154 
Ethmoid,  disease  of,  410 
Eucaine,  use  of,  550 
Evisceration  of  the  eyeball.  408 
Exanthemata,  cause  of  failure  of  operation 

for  cleft  palate,  527 
Excision  of  elbow- joint,  145 

comparative  results  of  methods,  158 
unfavourable  results,  160 
of  hip,  815 
of  humerus.  181 
of  knee-joint,  864,  867,  872 
of  lupus,  389 
of  nsevi,  401 
of  rodent  ulcer,  394 
of  scapula,  228 
of  shoulder-joint,  209 
of  superior  radio-ulnar  joint,  159 
of  tuberculous  glands,  641 
Exostoses    near    the    adductor    tubercle, 
removal  of,  858 
cranial  bones,  245 
of  external  auditory  meatus,  330 
Exophthalmic    goitre^.       See    Goitre,    ex- 
ophthalmic 
Exothyropexy,  617 
Extra-laryngeal  operations  for  removal  ot 

growths  of  larynx,  582 
Extremity,  lower,  compound  fractures  of, 
914 
operations  on.  805 

operative   treatment   of   simple   frac- 
tures, 917 
paralyses  of,  tendon  transplantation  in, 

108 
upper,  removal  of,  234 

See  also  Arm,  &c..  Leg,  &e. 
Eye,   effect  of  excision  of  Gasserian  gan- 
glion on,  378 
removal  of,  in  rodent  ulcer  of  face,  394 
Eyeball,  evisceration  of,  408 
excision  of,  406 

operation,  406 
Mules'  operation  for  excision  of,  408 
Eyelids,  defects  of,  503 


Face,  lupus  of,  treatment,  387 
operations  on,  363 
plastic  operations  on,  488,  501 
flaps  with  pedicles,  490 
Facial  artery,  ligature  of,  670 
Facial  nerve,  anastomosis  of,  382,  385 

inframandibular   branch   of,    division 
of,  in  tuberculous  glands  of  neck,  643 
injury    to,    in    operation    for    acute 
mastoid  abscess,  343 


Facial  nerve,  operation  on,  381 

stretching  of,  381 
Facial  paralysis  of  peripheral  origin,  treat- 
ment, 382 
parotid  growths  and,  399 
Faraboeuf's  Uugine,  154 
Fauces,  giowtlis  of,  oi^erations  for,  550 
Feeding  after  operations,  30 
Femoral  artery,  common,  ligature  of,  837 
ligature  of,  causes  of  failure  after,  845 

in  Hunter's  canal,  843 
superficial,   ligature    of,    in    Scarpa's 
triangle,  839 
common,  collateral  circulation  of,  838 
superficial,  collateral  circulation  of,  840 
vessels,  application  of  forceps-tourniquet 
to,  809 
Femur,  division  of  lower  end  from  inner 
side,  955 
division  of  shaft  from  outer  side,  955 
fractures  of,  858 
growths  of,  913 

lower  end  of,  injuries  about,  860 
neck  of,  cuneiform  osteotomy  of,  832 
curvatui-es  of,  831 

operation  for,  831 
ununited  fractures  about,  858 
osteotomy  of,  953 
periosteal  sarcoma  of,  913 
resection  of  head  by  posterior  incision, 

822 
sequestra  of,  817 

shaft  of,  ununited  fractures  of,  859 
site  of  section  of,  823 
Fibro-adenomata  of  breast,  treatment,  758 
Fibro-cartilage  of  jaw,  displaced,  suture  of, 
440 
of  knee,  detachment  of,  888 
indications  for  operation,  891 
Fibro-cellular  growths  of  scalp,  244 
Fibroma,    naso-pharyngeal,    dangers    and 
lUawbacks  of  osteoplast  ic  operations 
for,  471 
operations  for,  462 

by  removal  of  upper  jaw,  4G9 
through  mouth,  464 
removal  of,  by  avxilsion,  463 
by  excision  of  bone,  463 
by  ligatirre,  463 
choice  of  operation,  471 
removal  of  upper  jaw  for,  420 
Fibula,  division  of,  957 
Fifth  nerve,  fu'st  division,  neurectomy  of, 

364 
Finger,    distal    phalanx    of,    methods    of 
amj^utation  at,  58 
interphalangeal  joint  of,  excision,  68 
mallet,  87 
metacarpo-phalangeal    joint,    reduction 

of  dislocation  at,  69 
second,  amputation  of,  at  second  meta- 
carpo-phalangeal joint,  62 
snap,  87 

third,    amputation    of,    at    metacarpo- 
phalangeal joint,  62 
trigger,  87 
Fingers,  amputations  of,  57 
anatomical  points,  57 
by  single  flap,  65 
contiguous,  66 
dorso-palmar  flaps,  61 


1016 


INDEX 


Fingers,  amputations  of,  lateral  flaps,  61, 
63 
methods,  61 
operations  for,  58 

with  removal  of  metacarpal  bone,  65 
congenital  contractions  of,  87 
contraction  of,  82,  87 
congenital,  87 
severe,  87 
deformities  of,  87 
disarticulation  of,  by  circular  incision, 

64 
dislocations  of,  reduction  of,  69 
distal  phalanx  of,  amputation  at,  58 

difficulties  and  mistakes  in  amputa- 
tion of,  59 
injuries  of,  71 
joints  of,  excision,  68 
injury  to,  73 
shajie,  57 
phalanges  of,  excision,  68 
reunion  of  severed  digits,  78 
second  phalanx,  amputation  of,  59 
disarticulation  at,  59 
severe  injuries  of,  71 
supernumerary,  78 
theca  tunnel  of,  57 
webbed,  79 

Agnew's  operation  for,  80 
Norton's  operation  for,  80 
Finsen-light  treatment  of  lupus,  388 
Fistulse,  congenital  brachial,  646 
Fits  not  belonging  to  traumatic  epilepsy, 

trephining  for,  280 
Flail  joints,  prevention  of,  153 
Flaps,  anterior  and  posterior,  142 
combined  methods,  180 
in  operations  on  fingers,  58 
in  plastic  operations,  489 
in  restoration  of  nose,  445,  451 
lateral,  144 

amputation  of  leg  by,  905 
methods  of,  by  transfixion,  48 
in  amputations,  48,  812 
in  cleft  palate,  516,  520 
osteoplastic,  315 

pedunculated,  in  injuries  of  the  hand, 
74 
value  of,  74 
semilunar,  870 
skin,  178 

with  ijedicles  in  plastic  operations  on 
face,  490 
Flexor  longus  poUicis,  tuberculous  infec- 
tion of,  92 
Food,  solid,  cause  of  failure  of  operation 

for  cleft  palate,  527 
Foot,  amputation  of,  .Syme's,  930,  933 
deformities  of,  operative  treatment  of, 

965 
flat-,  965 

operations  for,  976 
gunshot  injuries  of,  940 
operations  on,  930 

incisions  in,  932,  934 
tenotomy  of  tendons  about,  961 
Forceps,  De  Vilbiss  skull-cutting,  312 
Hoffmann's  skull-cutting,  312 
Lane's  skull-cutting,  312 
Forceps-tourniquet,  Lynn-Thomas,  932 
Thomas's,  807 


Forearm,  amputation  of,  137 
anatomical  points,  137 
by  modified  circular  method,  140 
by  transfixion  flajjs,  141 
circular  division  of  muscles  in,  136 
different  methods,  137 
lateral  flaps  and,  139 
skin  flaps  in,  137 
gunshot  wounds  of,  176 
operations  on,  126 
Foreign   bodies,   extraction  of,   from   air- 
jiassages,  607 
in  brain,  operative  interference  in,  281 
in  cranium,  253,  283 
in  ear,  removal  of,  330 
in  nose,  removal  of,  454 
in  oesophagus,  removal  of,  602,  608 
in  upper  air-passages,  removal  of,  602 
Fractures,  comminuted,  of  shoulder-joint, 
223 
compound  comminuted,  amputation  at 

shoulder-joint  for,  196 
compound,  complications  of,  916 
of  lower  extremity,  914 
question  of  amputation  in.  916 
dovetailing  or  mortising  the  fragments 

in,  921 
lJu])uytren's,  923 
greenstick,  958,  960 
Oussenbauer's  staple  for,  921 
-'  gutter  "  of  cranium,  256 
of  condyles  of  humerus,  164 
of  femur,  858 
of  humerus,  225 
of  olecranon,  162 
of  jjatella,  wiring  of,  880 
of  skull,  trephining  in,  250,  258 
Pott's,  921 

simple,  indications  for  operative  inter- 
ference in,  919 
of  lower  extremity  :  operative  treat- 
ment, 917 
spinal,  988,  995 
ununited,  925 

operation  for,  925 
wiring  long  standing  cases  of,  164 
Fragments,   bony,  protrusion  of,  in  com- 

jjound  fractures,  915 
Freezing   by   solid   CO2   in   treatment    of 
nsevi,  401 
of  rodent  ulcer,  395 
Frontal  sinus  cannula,  Symonds',  415 
Frontal    sinuses,    infective    trouble    after 
operations,  417 
oi>erations  on,  410 
diplopia  after,  417 
disfigurement  after,  417 
indications,  411,  414 
keloid  scar  following,  418 
persistence  of  disease  after,  417 

of  external  sinus  after,  418 
sequelse,  417 
surgical  anatomy  of,  410 
Fulguration  in  rodent  ulcer,  396 
Fumeaux- Jordan  method  of  amputation 

of  shoulder-joint,  209 
Furuncles  of  external  auditory  meatus,  330 

Cralvanism,  use  of  through  introduced 
coiled  wire  in  treatment  of  aneurysm, 
726 


INDEX 


101' 


Galvano-punctiire  in  trfatmont  of   aneur- 
ysms, 72."> 
CraingliOD.  coriiiMiuiKl  |iiiliiiar,  'Mi 

Gangrene,  i"  diabt'tu's,  lo 

of  luwcf  (.'xtreinity,  amputation  for,  851 
prevention  of  spread,  50 
Grant  S  operation  on  femur,  904 
Gras,  poisoning  by,  infusion  in,  37 
Gasserian  ganglion,  Hartley-Krause  opera- 
tion on, 372 
Hutchinson's  operation,  370,  373,  377 
Krausu's  retractor  for  exposing,  37;j 
nerves  and,  370 
operation  on,  371 

by  intracranial  route,  372 

closure    of    wound    and   after- 
treatment,  377 
difficulties  and  dangers,  379 
division  of  soft  parts,  373 
finding  the  ganglion,  374 
haemorrhago  in,  380 
infection  of  wound,  380 
mortality,  37!) 
opening  the  skull,  373 
results,  378 
shock  and,  380 

tension   and    bulging  of   dura- 
mater,  380 
ulceration  of  cornea  and,  381 
indications  for,  371 
Gauzes,  sterilisation  of,  21 
Genu  valgum,  osteotomy  for,  955 
Genu  varum,  958 
Gigli's  saw,  Marion's  guide  for,  316,  317 

thread  saw  for  oiierations  on  brain,  314 
Glands,  lymphatic,  removal  of,  in  opera- 
tions on  the  tongue,  534,  539 
of  neck,  curetting  or  scooping  out,  644 
tuberculous,  operative  treatment,  640 
Gliomata  of  brain,  298,  302 
Gloves,  rubber,  sterilisation  of,  18 
Gluck's  distance  sutures,  101 
Gluteal  artery,  ligature  of,  835 
surgical  anatomy  of,  835 
Glycosuria,  11 
Goitre,  adenomatous,  612 
cystic,  612 
dyspncea  in,  610 
exophthalmic,  612 
mortality  of,  615 

resection  of  cervical  svmpathetic  for, 
667 
exposure  of,  621 
growing   from    isthmus,    ojjeration    fr)r, 

632 
incisions  for,  621 
intrathoracic,  612 

treatment  of.  632 
lingual,  ojjeration  for,  636 
malignant,  618 
operation  on.  610,  619 
parenchymatous,  611 
persistence  of,  after  operation,  633 
Gouges  for  removal  of  bone,  .340 
Gout,  operations  and,  5 
Graves'  disease.     See  Goitre,  exophthalmic 
Grafts,  nerve,  981 
Greenstick  fracture,  958,  960 
Gritti's  transcondyloid  amputation  of  knee- 
joint,  856 
Gummata  of  brain,  303 


Gunshot  injuries,  aneurysms  due  to,  188 

of  brain,  281 

of  I' best,  776 

of  foot,  940 

of  forearm,  176 

of  heart,  802 

of  hip-joint,  excision  for,  819 

of  nerves,  982 

of  shoulder-joint,  223 

of  spinal  cord,  990 

removal  of  bullets,  285 
Gussenbauer's  staple  for  fractures,  921 


Habits  of  ))atients,  operations  and,  3 
Haematoma,  aneurysmal,  189 
Hsematorrachis,  987 
Haemophilia,  operations  and,  5 
Haemorrhage,  age  factor  in,  1 

and  removal  of  parotid  growths,  400 
arrest    of,  in  amputation    at    shoulder- 
joint,  199 
in  operations,  24 
as     cause     of     death    in    interscapulo- 

thoracic  amputation,  237 
cause  of  failure  of  operation  for  cleft 

palate,  527 
character  of,  8 
complicating  after-treatment  of  traehe- 

otomy^  574 
complicating     enucleation     of     tonsils, 
477 
operations  on  tongue,  548 
complicating  excision  of  Gasserian  gan- 
glion, 380 
control  of,   during  amputation  at  hip- 
joint,  805 
during  operations,  49 
following    operations    for    naso-pharyn- 
geal  fibroma,  471 
on  thyToid  gland,  633 
from  stump  after  amputation,  ligature 

of  femoral  artery  for,  844 
in  operations  of  brain,  320 

on  gasserian  Ganglion  by   intra- 
cranial route,  380 
ligature  to  prevent,  670,  685 
middle  meningeal,  indications  of,  262 
prognosis  of,  267 
treatment,  265 
trephining  for,  262 
palmar,  88 
early  cases,  89 
later  cases,  89 
secondary,  cause  of  failure  after  removal 

of  upper  jaw,  430 
sub-dural,  268 
tonsillectomy  causing,  681 
ulceration  of  throat  causing,  680 
Hsemostasis,  operation  for  malignant  dis- 
ease of  breast  and,  744 
Hagedom's  operation  for  dou))le  hare-lip, 
487 
oi^eration  for  hare-lip,  485 
Hair,  removal  of  before  operations,  17 
Hairy  moles,  405 
Hallux  valgus,  977 
Halstead's  method  for  removal  of  breast, 

750 
Hammer-toe,  952 
Hamstrings,  tenotomy  of  964 


1018 


INDEX 


Hand,  amputation  of,  71 

conservative  surgery  of,  70 
injuries  of,  complicated,  71 
extensive,  71 
operations  for,  74,  75,  76 
skin  grafting  for,  72 
value  of  pedunculated  flaps  in,  74 
needles  in,  87 
operations  on,  57 
Hands, antiseptic  jjrecautions for,  14,  Ifi,  18 
Handley  (Sampson)  lymphangioplasty  of, 

Hare-lip,  478 

best  time  for  operation,  479 
causes  of  failure  and  death  after  opera- 
tion, 487 
Clemot's  operation  for,  483 
condition  of,  480 
double,  485 

Hagedorn's  operation  for,  487 
Hagedorn's  operation  for,  485 
Konig's  operation  for,  485 
Malgaine's  operation  for,  483 
Mirault's  operation  for,  483 
Nelaton's  operation  for,  484 
operation  for,  repetition.  487 
operations  on,  where  cleft  is  narrow  or 
equal,  480 
Hartley-Krause     operation    on    Gas.serian 

ganglion,  372 
Head,  arteries  of,  ligature.  070 
bullet  wounds  of,  281,  284 
injuries  of,  trephining  for,  262 
operations  on,  244,  272,  292 
See  also  Skull 
Heart,  bullet  wounds  of,  802 
cardiolysis  operation,  803 
dilatation  of,  infusion  and,  41 
exposure  of,  for  suture  of  wounds,  798 
operations  and,  7 

suture  of,  closure  of  wound  and  drain- 
age, 801 
valvular  disease  of,  7 
wounds  of,  closure  and  drainage  of,  801 
suture,  794,  798 
Heel-flaps,  comparison  of,  934 
Hemilaminectomy  for  division  of  nerve- 
roots,  998 
Hemiplegia  following  concussion,  263 
Hernia  cerebri.  324 
Hey's  amputation,  948 
Hibb's  method  of  tendon  lengthening,  99 
Higbmore,  antrum  of,  suppuration  of,  431 
Hip,  congenital  dislocation  of,  827 

indications  for  operation,  828 
Lorenz's  manipulation  for,  827 
operation  for,  829 

risks     and     causes     of    failure     in 
operation  for,  831 
dislocation    of,    operative    interference, 

826 
excision  of,  815 

causes  of  failure  after,  823 
conditions  of  success  in,  818 
oi^eration  for,  820 
operation  to  straighten,  974 
traumatic  dislocation  of,  826 
Hip-joint,  abscess  of,  815,  817 
amputation  at,  805 
flap  methods,  812 
control  of  haemorrhage  during,  805 


Hip-joint,   amputation  at,  Furneaux-Jor- 

dan'.s  method,  805,  810 
Howse's     modification     of     Jordan's 

method  of,  812 
methods  of,  805 
mortality  of,  807 
disease  of,  analysis  of  cases,  816 

condition    of    after    excision    or    rest 

cure,  818 
operation  for  by  anterior  incision,  819 
by  posterior  incision,  819,  822 
rectifying  deformities  of,  824 

operative  treatment,  815 
Furneaux-Jordan's  amputation  at,  863 
gunshot  injuries  of,  excision  for,  819 
incision  of,  815 
operations  on,  805 
osteotomy  for  ankylosis,  953 
Wyeth's   bloodless  method  of  amputa- 
tion at,  806 
Hoffmann's  skull-cutting  forceps,  312 
Horsley  (Sir  V.),  combined  dissectors  and 
spatulse  used^by,  320 
operations  on  the  brain,  306,  310 
Howse's  method  of  excision  of  knee,  870 
Ivvo-.stage    modification    of     Furneaux- 
Jordan's  amputation  at  hip-joint,  812 
Humerus,  condyles  of,  fracture  of,  164 
operation  for  fracture  of,  165 
dislocation  of,  211 

epiphysis  of,  lower,  rare  cases  of  injury 
to,  146 
separation  of,  165 
upper,  separation  of,  225 
excision    of,    in    continuity,    causes    of 

failure  after,  182 
fractures  of,  of  condyles,  164 

operative  treatment,  182 
operative  treatment  of  acute  infective 

periostitis  of,  182 
pseudo-arthritis  of,  operation  for,  183 
sarcoma  of,  214 

shaft  of,  excision  in  continuity  of,  181 
site  of  section,  151 

upper  extremity  of,  simple  fractures,  225 
Hutchinson's  operation  on  Gasserian  gan- 
glion, 370,  373,  377 
Hydatid    disease    of    lung,  operation  for. 

784 
Hydrocephalus,     operative     treatment  of, 

328 
Hygroma,  cystic,  645 
Hyperthyroidism,  613 
Hysteria,  operation  risks  in,  11 

Idiocy  and  imbecility,  craniectomy  for,  325 
Incisions  in  excision  of  ankle,  939,  942 

in  excision  of  elbow,  156 
of  shoulder,  215,  218 

in  goitre,  621 

in  mammary  operations,  739 

in  Ollier's  operation  on  WTist-joint,  115 

in  operations  on  foot,  932,  934 

in  phuryngotomy,  552,  554,  556 

in  sub-astragaloid  amputation,  937 

of  bone,  956 

of  joints,  815 

of  perdicardium,  794 

of  Pirogoff's  amputation,  936 

of  scapula,  230 

planning  of,  23 


INDEX 


1019 


Infection,  invcautions  against,  1,'i 

SOUITCS  of,    1-4 

Inhision,  'M 

acuto  traimiatio  aiiajiuia.s  and,  ;{5 

dilatation  of  right  side  of  licait  and,  4 1 

in  cases  of  collapse,  35 

in  diabetic  coma,  3U 

in  gas-poisoning,  ,37 

in  poisoning,  3(> 

in  se])tica'niia,  36 

in  shock,  30 

Lane's  subcutaneous  apparatus  for,  40 

method  of,  38,  39 

(Rdema  of  lungs  and,  41 

of   ether  for  intravenous  induction    of 
anaesthesia,  37 

preparation  of  solution  for,  37 

sepsis,  and,  41 
Inhalation-pneumonia,    cause    of    failure 

after  removal  of  upper  jaw,  430 
Injection  treatment  of  ntevi,  404 
Innominate  artery,  ligature  of,  710,  710 
Insane,  paralysis  of,  general,  trephining  in, 

327 
Insanity,  operative  treatment  of,  327 
Instriunents,  infection  by,  14 

special,  for  operations  on  lung,  787 

sterilisation  of,  19 
Inter-crico-thyrotomy,  502 
Interphalangeal  joints, amputation  through, 

950 

Interscapulo-thoracic  amputation,  234 

air  in  veins  and,  239 

causes  of  death  from  operation,  237 

dangers  of  operation,  237 

haemorrhage  as  cause  of  death,  237 

(Septicaemia  and,  239 

shock  and,  238 

steps  of  operation  for,  235 
Intracranial  complications  of  otitis  media, 

349.  354 
operations  on  Gasserian  ganglion,  372 
tumours,  297 
Intrathoracic  goitre,  012 
Intravenous  induction  of  anaesthesia,  37 
Intubation  of  larynx,  575 

advantages  and  disadvantages,  570 

O'Dwyer's  method,  579 

technique  of,  575,  579 

withdrawal  of  tube,  579 
Iodine,  tincture  of,  applications  of,  10 
method,  preparation  of  skin  by,  16 
Iodoform  bone-filling  of  Moestig-Moorhof, 

184 
Iodoform  emulsion  in  abscess  of  hip,  815 
Ischsemic  paralysis,  operative  treatment  of, 

135 
Isotonic  solutions,  37 
Israel's   method  of  restoration  of  cheek, 

501 
Isthmus  of  thyroid,  crushing  the,  027 

separation  and  division  of,  024 

Jaw,   condoyle  of,    excision  of  to   relieve 
fixity,  440 
fibro-cartilage  of,  displaced,  suture  of, 

440 
lower,  fixity  of,  Esmarch's  operation  for, 
441 
operations  for  relief  of,  440 
incision  for  excision  of,  435 


Jaw,  lower,  removal  of,  partial  or  complete, 
434 

partial  or  complete,  difficulties  and 
mistakes,  430,  438,  545 
upper,  excision  of,  partial  or  complete, 
419 
extirpation  of  partial,  429 
growth  of,  malignant  or  not,  424 
Kocher's  antral  operation,  308 
malignant  disease  of,  recurrence    of, 

431 
osteo])lastic  operations  on,  469 
questions  before  removal  of,  423 
relation  of  growth  to,  423 
removal   of,    causes   of  failure   after, 
430 
complete,  424 
ditiiculties     and     dangers     during 

operation,  430 
for  carcinomata,  420,  545 
for  dental  cysts,  421 
for  cchondromata,  422 
for  odontomes,  421 
for  osteomata,  422 
for  sarcoma,  420 
in    operations    for  naso-pharyngea 

fibroma,  409 
partial  or  complete,  419 
for  epulis,  419 
for  fibroma,  420 
indications,  419 
Jaws,     both,     operations     for     complete 
removal  of,  439 
operations  on,  419,  545 
Joints,    movements    of,    after    operation, 
152,  154,  101,  219 
of  hands  and  fingers,  position  of,  57 
See  also  Ankle-joint,  &c. 
Jones's  line  of  section  through  trochanter, 

820 
Jordan's  amputation  at  hip-joint,  805,  810 
Jugular   vein,   internal,   treatment   of,    in 
thrombosis  of  lateral  sinus,  359 

Kaufmann's  operation,  386 
Keegan's  method  of  rhinoplasty,  446 
Keloid  scar  following  operations  on  frontal 

sinuses,  418 
Kidney,  movable,  3 

Knee,  fibro-cartilage  of,  detachment,  888 
indications  for  operation,  891 
internal  derangement  of,  888 
loose   internal   semilunar    cartilage    of, 
operation  for,  892 
Knee-joint,       amputations      immediately 
above,  853 
through,  862 
flaps  for,  862 
arthrodesis  of,  879 
Garden's  amputation  of,  853 
disease  of,  excision  for,  867 
erasion  of,  804 

causes  of  failure  after,  876 
excision  of,  867,  872 
after-treatment,  875 
Barker's  method,  870 
by  removal  of  patella,  809 
Howse's  method,  870 
through  patella,  870 
Gritti's  transcondyloid  amputation  of, 
850 


1020 


INDEX 


Knee-joint,  injury  of,  excision  for,  868 
loose  bodies  of,  removal  of,  887 
operations  involving,  862 
Stokes's  supracondj'loid  amputation  of, 
856 
Knees,  operation  to  straighten,  974 
Kocher's   angular  incision   for   malignant 
goitre,  622 
antral    operation    for     neurectomy     of 

second  division  of  fifth  nerve,  368 
"high"  collar  incision  for  excision  of 

larynx,  594 
modification     of     Ollier's     incision     of 

elbow-joint,  157 
modification    of    Syme's    operation    for 

removal  of  tongue,  540 
IDOsterior  curved  incision  for  excision  of 

shoulder,  218,  220 
thyroid  enucleator,  628 
Konig's  operation  for  hare-lip,  485 
Krause-Hartley    operation    on    Gasserian 

ganglion,  372 
Krause's  antrum  cannula,  434 
nasal  polypus  snare,  460 
retractor    for    exposing    the    Gasserian 
ganglion,  375 
Kuttner's  operation,  386 


Laminae,  fractures  of,  989 
Laminectomy,  causes  of  failure  and  death 
after.  1001 
contK-indications,  992 
(hemilaminectomy)  for  division  of  nerve- 
roots,  998 
in  cases  of  injury,  987 
indications  for,  991,  996 
in  extradural  tumour,  997 
in  fracture-dislocation  of  spine,  995 
in  gunshot  injuries,  990 
in  inflammatory  disease,  991 
in  intramedullary  tumour,  997 
in  penetrating  wounds,  990 
operative  details,  994 
treatment  of  the  wound,  1000 
Lane's  cleft-palate  gag,  508 
infusion  bag.  41 
method   of  Operation   for  cleft    palate, 

516-522 
needle  holder  and  needles,  517 
plates  in  fracture  of  tibia,  920 
skull-cutting  forceps,  312 
subcutaneous  infusion  appratus,  40 
von  Langenbeck's  method  of  cheiloplasty, 
493 
opemtion  for  cleft  palate,  507 

for  malignant  growths  of  nose,  468, 
470 
Laryngeal  nerve,   recurrent,  injury  to  in 
operation  on  thjToid  gland.  634 
papillomata,    treatment   of    by    trache- 
otomy alone,  561 
Lai^ngectomy,  complete,  592 
indications  for,  593 
operation  of,  593 
technique  of,  modifications,  597 
Laryngitis,  acute,  tracheotomy  for,  580 
membranous,  intubation  in,  575 

tracheotomy  for,  recoveries  after,  564 
right  time  for  operation,  564 
Larsmgoscopy,  direct  vision,  604 


Larjmgotomy,  562 

complications  of,  597 
indications  for,  562 
operation  of,  562 

preliminary,  question  of,  in  oiierations  on 
tonsils,  555 
Lar3mx,  cancer  of,  582 

examination  of,  for  foreign  bodies,  606 
excision  of,  partial  or  complete,  ,582 
growths  of,  removal,  after-treatment,  600 
dangers  and  cause  of  death  following, 

600 
extra-laryngeal  operations  for,  582 
thyrotomy  for,  585 
half  of,  removal,  590 
innocent  growths  of,  removal,  609 
intubation  of,  advantages,  576 

disadvantages,  difficulties,  and  dangers, 

577 
O'Dwjer's  method,  579 
substitute  for  tracheotomy  in  mem- 
branous laryngitis  or  stenosis  of  the 
larynx,  575 
technique,  579 
withdrawal  of  tube,  579 
malignant  disease  of,  tracheotomy  for, 

580, 582 
papillomata  of,  561 
scalds  of,  tracheotomy  for,  581 
spasmodic  affections  of,  tracheotomy  for. 

581 
stenosis  of,  575 
syphilitic  ulceration  of,  tracheotomy  for, 

580 
tuberculous  ulceration  of,  tracheotomy 
for,  580 
Lateral  position  in  operations,  22 
Lateral  sinus,   injurj'  to,  in  operation  for 
acute  mastoid  abscess,  342 
thrombosis    of,    complicating     otitis 
media,  353 
septic,  operation  for,  359 
Le  Dentu's  method  of  tendon-suture,  95 
Leg,  amputation  of,  904 
by  lateral  flaps,  905 
flaps  in,  904 

lateral  skin  flaps,  with  circular  divi- 
sion of  muscles,  905 
methods,  904 
operation,  905 
Bier's  osteoplastic  method  of  amiJutation, 

906 
contractures  of,  severe,  973 
operations  on,  898 
paralysis  of,  tendon  transplantation  in, 

108 
Teale's  amputation  of,  907 
Ligaments  of  foot,  division  of,  962 
Ligature,  in  treatment  of  naevi,  404 
(if  anterior  tibial,  902 
of  arteries,  49 
in  buttock  and  thigh,  835 
in  head  and  neck,  670 
of  common  femoral  artery,  837 
of   femoral   artery   in    Hunter's    canal, 

843 
of  innominate,  710 
of  middle  meningeal  artery,  266 
of  peroneal  arterj-,  904 
of  popliteal  artery,  894 
of  posterior  tibial  artery,  898 


INDEX 


1021 


Ligature,  "f  radial  artory,  12G 
of  .sciatic  artery,  H'Mi 
of  subclavian,  OiM),  707 
of  superficial  femoral  in  Scarpa's  trian<;le, 
s;j!) 
Ligatures,  infection  by,  15 

stciilisation  of,  19 
Light  treatment  of  lupus,  388 
Limbs,  condition  of,  in  concussion,  2()3 

iSVr  (il.io  Extremity 
Lingual  arteries,  ligature  of,  in  removal  of 
tongue,  r>35 
artery,  ligature  of,  072 
goitre,  operation  for,  ()3() 
nerve,    neurectomy  within    the    mouth 
of,  370 
Lip,  lower,  epithelioma  of,  removal  of  with 
restoration  of  lip,  492 
restoration  of.  494 

by  Sorre's  operation,  493 
Kegnier's  ojjeration  for,  495 
replacement  of,  49(5 
Lip,    upper,    Chauvel's   operation   on,    by 
vertical  flaps,  500 
Diffenbach's  operation  on,  by  vertical 

flaps,  500 
.Sedillot's   oi^eration   on,    by    vertical 
flaps,  500 
Lipomata  of  neck,  647 
Lips,  operations  on.  479,  488 

plastic  operations  on,  489,  493,  496 
Lisfranc's  amputation,  948,  950 
Lister's    o])eration   for   excision   of    wrist- 
joint,  112 
Lithotomy  position  in  operations,  23 
Loose  bodies  of  knee-joint,  removal  of,  887 
internal   semilunar  cartilage,   operation 
for,  892 
Lorenz's  manipulation  for  congenital  dis- 
location of  hip,  827 
indications  for  operation,  828 
^         operation,  829 
Lung,    actinomycosis    of,     operation    for, 
784 
cavity  in,  opening  and  draining  of,  786 

difficulties  and  dangers,  790 
decortication  of,  in  empyema,  773 
oedema  of,  infusion  and,  41 
hydatid  disease  of,  operation  for,  784 
operation  risks  in  disease  of,  8 
operations  on,  778 
dangers,  781 
for  injuries,  782 

for  pulmonary  suppurations,  782 
for  tuberculous  disease,  783 
opening  the  thorax  and  exposure  of 

lesion,  785 
prevention  against*  danger  of  exten- 
sive pneumothorax,  779,  785 
special  instruments  for,  787 
symptoms  resulting  from  large  opening 

in  thoracic  wall,  778 
use  of  cabinet  in,  780 
suture  of,  to  parietal  pleura,  780 
tumours  of,  operation  for,  784 
Lupus,  actual  cautery  in,  392 

application  of  caustics  and  other  chemi- 
cals in,  393 
erasion  of,  390 
of  face,  treatment,  387 
Finsen-light  treatment  of,  388 


Lupus,  scarification  in,  392 
linear,  392 
punctiform,  392 
treatment  of,  by  excision,  389 

general,  393 
X-ray  treatment  of,  389 
Lymphangioma,  congenital,  645 
Lymphangioplasty,  55 
Lymphatics,  operations  on,  55 

removal  of,  in  operations  on  the  toncue. 

539  ^ 

surgery  of,  46,  55 

Macewen's    combined    small   curette    and 
seeker,  341 
gouge,  339 
method    of   compression    of    abdominal 

aorta,  809 
supra-condyloid  operation,  955 
triangle,  333 
tubes,  573 
Makka's  clamps  for  control  of  luemorrhage 

from  scalp,  255,  31 1 
Malar  bone,  surgery  of,  368 
Malgaigne,  en  raquette  method  of,  (J2 
Malgaine's  operation  for  hare-lip,  483 
Malignant  disease  of  breast,  728 
of  larynx,  582 
of  nose,  462 

of  upper  jaw,  recurrence  of,  431 
(S'ee  also  Cancer,  Sarcoma. 
Malignant  goitre,  618 
Marion's  guide  for  Gigli's  saw,  316,  317 
Mastitis,  chronic  cvstic,  excision  of  breast 

for,  758 
Mastoid  abscess,  acute,  337 

operation  for,  337,  338,  343 

accidents  and  complications,  342 
after-treatment,  342 
retractor  in,  338 
Mastoid    antrum,    complications    of    sup- 
purative otitis  media  and,  333 
Mastoid  cells,   complications   of  suppura- 
tive otitis  media  and,  333 
Mastoid  operation,  radical,  337,  343,  344 
after-treatment,  342,  349 
plastic  operation,  346 
Mastoiditis,  acute,  337 
operation  for,  337 
Bezold's,  338 
Matas  operation  for  arteriorrhaphy,  53 
results  of,  55 
operation  for  aneurysm.  894 
Meatus,  external  auditory,  boils  of,  330 
exostoses  of,  330 
furuncles  of,  330 
Mediasfina,   suppuration  in,   complicating 

after-treatment  of  tracheotomy,  575 
Mediastinum,  anterior,  operation  on,  790 
operations  on,  778,  790 
posterior,  operations  on,  791 
"Melon-seed"    bodies    in    palmar    teno- 

sj'novitis,  90 
Meningeal    artery,     middle,    haemorrhage 

from,  262 
Meninges,  condition  of,  in  trephining  for 

epilepsy,  275 
Meningitis  complicating  otitis  media,  353 
following  operations  for  naso-pharyngeal 

fibroma,  472 
spinal,  chronic,  992 


1022 


INDEX 


Meningitis,  suppurative,  operation  for,  361 
Metacarpal    bone,    removal,    complete    or 

partial,  65,  68 
Metacarpo-phalangeal    joint,    amputation 
at,  62 
excision  of,  69 

of  finger,  reduction  of  dislocation  at,  69 
Metatarsal  bono,  removal  of,  952 
Metatarso-phalangeal   joints,   amputation 

through,  951 
Meyer's  suture  of  bronchus,  778 
Michel's  metal  clips,  19,  24 
Microcephalus,  craniectomy  for,  325 
Military  surgery,  excision  of  radius   and 

ulnar  in,  134 

See  also  Gunshot  wounds 
Mirault's  operation  for  hare- lip,  483 
Moestig-Moorrhof,  iodoform  bone- filling  of, 

184 
Moles,  hairy,  405 

pigmented,  405 
Molluscum  fibrosum  of  scalp,  244 
Morphin  and  scopolamin  in  anoci-associa- 

tion,  1006 
Mortality  of  amputation  at  hip-joint,  807 

of  exophthalmic  goitre,  615 

of  membranous  laryngitis,  564 

of  operation  on  Gasserian  ganglion,  379 

of  removal  of  breast,  728 
Morton's  fluid  injections   in  spina  bifida, 

983 
Moure's  operation  for  malignant  growths 
of  nose,  467 
for  nasal  polypi,  462 
Mouth,    angle    of,    Serre's    operation    for 
restoring,  500 

dermoid  cyst  of,  548 

operations  through,  551 

ronula  cyst  of,  548 

restoration  of,  498 

by  method  of  Dieffenbach,  499 
Mules'  of)eration  for  excision  of  eyeball, 

408 
Muscles,   circular  division  of,  in  amputa- 
tions, 178 

incisions  of,  24 

paralysed,  inspection  of,  107 
Muscle-splitting,  24 
Muscillo-spiral  nerve,  operations  on,   185, 

186 
Myxoedema  following  operations  on  thyroid 

gland,  635 


Nsevi,  caustics  in  treatment  of,  401 
collodion  in  treatment  of,  401 
operative  methods  of  treatment,  400 
radium  in  treatment,  401 
treatment  of,  by  cautery,  404 
by  electrolysis,  402 
by  freezing,  401 
by  injection,  404 
by  ligature,  404 
by  subcutaneous  discission,  404 
Nail-brushes,  use  of,  17 
Nasal  fossae,  operations  on,  454 
after-treatment,  458 
instruments  for,  456 
Nasal  polypi,  removal  of,  459 
Nasal  septum,   deflected,    operations    for, 
455 


Naso-pharyngeal   fibroma    and    sarcoma, 
operations  for,  462,  464 
by  removal  of  upper  jaw,  469 
Naso-pharyngeal  sarcoma,  462 
Neck,  anatomy  of,  of  an  adult,  569 
in  early  childhood,  563 
arteries  of,  ligature,  670 
cancer  of,  530,  540 

growths  of,  deep-seated,  operations  for, 
638 
excision  for  removal  of,  641 
nature  and  surroundings  of,  638 
operation  of,  main  points,  639 
o})erations  on,  244,  559 
tuberculous  glands  of,  640 
tumours  of,  9 
Necrosis,  acute,  operation  for,  908 
Needles  in  hand,  87 
Nelaton's  operation  for  hare-lip,  484 
Nephritis,  operation  risks  in,  9 
Nerve  anastomosis,  967,  980 
Nerve  crossing,  981 

Nerve  ends,  bringing  into  apjiosition,  979 
finding,  978 
resection  of,  979 
Nerve,  facial,  injury  to,  in  operation  for 
acute  mastoid  abscess,  343 
operations  on,  381 
stretching  of,  381 
Nerve,    fifth,   ganglion  inside   skull,    neu- 
rectomy    of     second     and     third 
divisions,  370 
operations  on,  363 

preliminary  remarks,  363 
second  division,  Carnochan's  modified 
operation   of   neurectomy   for, 
365 
neurectomy  of,  365,  368 
routes  for  neurectomy  of,  365 
third  division,  operation  on,  369 
inferior  dental,  neurectomy  of,  369 
lingual,  neurectomy  within  the  mouth  of, 

370 
musculo-spiral,  operations  on,  185,  186 

relations  of,  186 
optic,  growth  of.  408 
surgery  of,  407.  409 
spinal  accessory,  643,  661 
supra-trochlear,  365 
suture,  978 

sympathetic,  operations  on,  661 
vagus,  injury  to,  639 
Nerve-grafts,  981 

Nerve-stretching,  or  partial  neurectomy,6(Jl 
Nerves,  cervical  upper,  operations  on,  661 
resection  of  branches  of,  665 
freeing   of,  in   Volkmann's  conti'action, 

136  . 

gunshot  injuries  of,  982 
operations  on,  978 

aids  in  difficult  cases,  980 
causes  of  failure,  980 
period  required  for  repair,  981 
removal  risks  in  spina  bifida,  986 
spinal,  hemilaminectomy,  for  division  of 
roots,  998 
injuries  of,  988 
surgery  of,  967 
Nervous  system,  operations  and,  11 
Neuralgia,  traumatic,  982 

trigeminal,  treatment  of,  370,  372 


INDEX 


1 023 


Neurectomy  uf  tiist  division  of  tifth  ikivc, 
.364 
of  inferior  dental  nerve,  .'{()!» 
of  lingual  nerve  within  tln^  mouth,  ."{TO 
of  seeond  division  of  tiftli  nerve,  365 
])artii>l  operations  for,  (161 
partial,  or  nerve-stretching,  661 
Norton's  operation  for  wehhed  fingers,  80 
Nose,  detlected  septum  operations,  45") 
drainage    through,    in    suppuration    of 

antrum  of  Highmore,  4:{;{ 
foreign  bodies  in,  removal  of,  454 
malignant  growtlis  of,  462,  465 

von    Langenbeek's    operation    for, 

468 
Moure's  operation  foi'.  467 
Ollier's  operation,  466 
Rouge's  operation  for,  466 
operation  on  fossa?,  454 
polypi,  removal  of,  459,  461 
repair  of,  plastic  operations  for,  44.'3 
restoration  of,   complete,   by  double  or 
superimposed  flaps,  445 
by  frontal  or  Indian  method,  448 
by  Italian  or  Tagliacotian  method, 

449 
operations  for,  446 
partial,  operations  for.  451 
t  urbinectomj-,  455 
Novocain  in  anocl-assoclation,  1007 


Obesity,  operations  and,  4 
Occipital  arter}',  ligature  of,  671 
Odontomes,   removal   of   upper    jaw   for, 

421 
O'Dwyer's  intubation  instruments,  576 
method  of  intubation  of  larynx,  579 
(Edema,  pulmonary,  41 
(Esophagectomy,  652 
(EsophagOSCOpy,  direct  vision,  indications 

for,  6U5 
(Esophagostomy,  652 
(Esophagotomy,  649 
after-treatment,  651 
causes  of  death  after,  652 
difficulties  in,  652 
operation  of,  650 
(Esophagus,  foreign  bodies  in,  removal  of, 
602,608 
operations  on,  649 

pouches  of,   operation  for  removal   of, 
656 
removal,  653 
Olecranon,  fracture  of,  compound,  163 
old-standing,  163 
operation  for,  162,  163 
operation  for  lengthening  triceps  in, 

164 
simple,  162 
Ollier's    bayonet-shaped    method    for    ex- 
cision of  elbow,  156 
method  of  tendon  shortening,  104 
operation  for   excision    of    WTist-joint, 

114 
operation    for    malignant    growths    of 

nose,  466 
periosteal  elevator,  154 
Omo-hyoid,  ligature  below,  685 
Openshaw's  method  of  osteoclasis,  959 
Operating  room,  preparation  of,  18 


Operations,  after-treatment  of.  27 

effect  of  the  lesion  ui)on  ultimate  result 
of,  7 

immediate  danger  of,  7 

lateral  position  in,  22 

litliotomy  position  in,  23 

mode  of  procedure  of,  21 

|)(>siti(m  of  patients  during,  22 

preparation  of  patient  for,  12 

prevention  of  shock  after,  27, 1006, 1008 

prone  position  in,  22 

risks  in,  6 

technifjue  of,  22 

Ticndelenberg  position  in,  22 
Optic  nerve,  surgery  of,  407,  409 
Oral  sepsis,  11 
Orbit,  exenteration  of.  408 

inner  angle  of,  fracture  of,   trephining 
in,  253 
Orbital  aneurysm,  677 
Orbital  wall,  external,  temijorary  resection 

of,  409 
03  calcis,  excision  of,  944 

nonunion  in  Pirogoff's  amputation,  935 

removal  of  fore-part,  969 
Osteitis,  cranial,  261 
Osteo-arthritis  of  elbow-joint.  148 
Osteoclasis,    manual    in    tibial    curvature, 

959 
Osteomata,    removal    of    upper    jaw    for, 

422 
Osteo-myelitis,  excision  of  elbow-joint  and, 

160 
Osteoplastic    amputaion    of    leg.     Bier's 

method,  906 
Osteoplastic  flap  in  operation  for  growths 

of  brain,  313,  315 
Osteoplastic   operations    on    upper    jaw, 

4()9 
Osteotomy,  Adams'  operation,  953 

causes  of  trouble  after,  959 

cuneiform,  of  neck  of  femiu",  832 
subtrochanteric,  832 

for  ankylosis  of  hip-joint,  953 

for  coxa  vara,  953 

for  genu  valgum,  955 

(plant's  operation,  954 

indications  for,  953 

of  tibia,  958 

splints  after,  957 

subtrochanteric,  of  neck  of  femur,  832 

tendon  lengthening  by,  100 
Osteotribes  or  burrs,  339 
Otitis  media,  complications  of,  by  meningi- 
tis,  353 
by  thrombosis  of  lateral  sinus,  353 
intracranial  complications  of,   opera- 
tion for,  354 
treatment,  349 
results  of,  336 

stippuration,  operations  for  complica- 
tions, 332 
Overalls,  preparation  of,  19,  21 


Pachydermatocele  of  scalp,  244 
Palate,  cleft,  after-treatment  of  operation 
for,  525 
Brophy's  operation  for,  523 
flap     operation     and     Langenbeek's 
operation  compared,  522 


1024 


INDEX 


Palate,  cleft,  flap  method  of  Sir  W.  Arbuth- 
not  Lane,  516,  522 
involving  soft  palate,   operation  for, 

512 
Langenbeck's  operation  for,  507 
operation  on  hard  palate  alone  in,  512 
operations  for,  504 

age  of  patient  and,  504 

amount    to    be    closed    at    one 

sitting,  507 
causes  of  failure,  527 
closure  of  cleft,  510 
paring  the  edges  of  cleft,  510 
preliminary  preparation,  507 
raising  the  muco-periostcum,  50'J 
relief  of  tension  after,  512 
severity    of    case    and    kind    of 

patient  in,  506 
varieties  of,  504 
order  of  operation  onlip  and  palate, 506 
Palate,  growths  of,  removal,  504,  528 
Palate,  hard,  Davies-Colley's  flap  method 
for,  513 
stages  of  operation,  513-516 
operation  on  a  cleft  palate,  512 
operations  on,  504 
soft,  operation  on,  512 
Palm,  surgical  procedures  of,  63 
Palmar  aneurjsm,  89 
Palmar  fascia,  contraction  of,  82 

excision  of  contracted  bands,  85 
by  rectangular  flaps,  85 
by  V-shaped  incision,  85 
operation  for,  82 

by  subcutaneous  method,  82 
by  transverse  cuts,  84 
Palmar  ganglion,  compound,  90 
Palmar  hfemorrhage,  88 
Papillomata,  laryngeal,   treatment  of,   by 

tracheotomy,  561 
Paquelin's  cautery,  404 
Paracentesis  and  incision  of  chest,  760 
exploratory'  puncture  in,  760 
for  serous  effusions,  762 
indications  for,  760 

in  non-purulent  effusions,  761 
is  the  fluid  purulent  or  not  ?,  760 
presence  of  pjTCsia  and  hectic,  760 
risks  of,  761 

treatment  of   non-purulent  serous  effu- 
sions, 760 
Paraflftn,  sterilised,  su1x;utaneous  injection 

of.  for  saddle-nose,  452 
Paralyses,  motor  area  in  relation  to,  291 

surgical  treatment  of,  967.  973 
Paralysis,    cerebral,    of     children,    tendon 
transplantation  in,  107 
facial,   of   peripheral  origin,  treatment, 
382 
parotid  growths  and,  399 
following  concussion,  263 
general,  of  insane,  trephining  in,  327 
infantile,    spastic,    tendon    transplanta- 
tion in,  104,  107 
ischaemic,  operative  treatment  of,  135 
Paraplegia,  laminectomy  for,  991 
mode  of  progression  in,  974 
spastic  congenital,  operations  for,  973 
Parenchymatous  goitre,  611 
Parotid,  carcinoma  of,  398 
sarcoma  of,  397 


Parotid  growths,  characters  of,  398 
facial  paralysis  and,  399 
removal  of,  397 

haemorrhage  and,  400 
practical  points,  308 
Patella,  excision  of  knee-joint  through,  870 
fracture    of,     causes     of    failure    after 

wiring  for,  886 
old  fracture  of,  wiring  for,  884 
plating  of,  for  fracture,  883 
removal   of,   in   excision   of   the   knee- 
joint,  869 
wiring  of,  difficulties  in,  880,  885 
Patient,  examination  of,  1 
l^rcparation  of,  1,  12 
for  skin-grafting,  42 
Pericardium,  adherent,  803 
incision  of,  794 
tapping  of,  794 

cause  of  failure,  797 
indications  for,  794 
Periosteum  of  scalp,  condition  of  in  trephin- 
ing for  epilepsy,  274 
preservation  of,  149,  943,  945 
in  excision  of  wrist-joint,  117 
Periostitis,    acute    infective    of    humerus, 

operative  treatment,  182 
Peroneal  artery,  ligature  of,  904 
Peronei,  division  of,  963 
Phalanges,  amputation  of,  66,  68 

amputation  through,  950 
Pharyngotomy,  incisions  in,  552,  554,  556 
lateral,  for  growths  of  tonsils,  552 
median,  556 

trans-hyoid,  by  vertical  incision,  558 
for    malignant    disease    of    pharynx, 

599 
for  removal  of  tongue,  543 
PharjTlx,  closure  of  after  lateral   pharyn- 
gotomj',  553 
growths  of,  operations  for,  550 
malignant  disease  of,  palliative  trache- 
otomy for,  600 
trans-hyoid-i^harj^ngotomy  for,  599 
malignant   disease   involving   operation 

for,  599 
operations  on,  risks  of,  9 
Pigmented  moles,  405 
Pirogoff  S  amputation,  932 
incisions  of,  936 
modifications  of,  937 
value  compared  with  Symc's  amputa- 
tion, 935 
Pituitary  tumours,  removal  of,  472 
Plantar  fascia,  division  of,  962 
Plastic    operations,    in    mastoid    disease, 
346 
on  face,  488 

on  lips,  478,  489,  493,  496 
on  nose.  443 
Plating  patella  for  fracture,  883 
Pleura,  transpleural  operations  on  abdo- 
men, 784 
Pleurisy  with  effusion,  paracentesis  in,  760 
Pneumonia  following  anaesthetics,  31 

operation  risks  in,  9 
Pneumothorax,  prevention  of,  in  operations 

on  lung,  779,  785 
Poisons,  infusion  in  certain,  36 
Polydactylism,  78  ■ 
treatment  of,  78 


INDEX 


1025 


Polypus,  aural,  removal  of,  iJ.Jl 

nasjil.  Moure's  operation  for,  462 
removal  of,  459 

dangers  of  ojxration,  461 
Rouge's  operation  for,  462 
simple,  451) 
reeurring,  treatment  of,  401 
snare,  Krause's  nasal,  460 
Popliteal    artery,  collateral  eirculation  of, 
805 
ligature  of,  894 
relations  of,  894 
Popliteal  space,  operations  on,  894 
Port- wine  stain,  404 
Pott  S  curvature,  991 
Pott's  fracture,  921 

correction  of  deformity  and  restora- 
tion of  function  in  late  cases,  924 
operation  for,  early,  922 
treatment  of,  conservative,  921 
Pouches  of  the  oesophagus,  removal  of,  653 
Pregnancy,  operations  during,  2 
Probe,  telephone,  286 
Prone  position  in  operations,  22 
Prostatectomy,  results  of,  2 
Pulmonary  complications  after  operations, 

31 
Pulmonary    suppurations,    operation    on 

lung  for,  782 
Pulse,  middle  meningeal  haemorrhage  and, 

264 
Punctiu:e,  exploratorj-,  in  paracentesis,  760 
Pupils,  condition  of,  in  middle  meningeal 

ha?morrhage,  265 
Pus  between  skull  and  dura  mater,  tre- 
phining for,  259 
Pyaemia,  cerebral,  260 
Pyogenic    organisms,    tissues    of   diabetic 

patient  liable  to  infection  by,  10 
Pyrexia    and    hectic,    presence    of,    para- 
centesis and,  760 

Quinin  and  xu-ea  hydrochlorid  in   anoci- 
association,  1007 

Radial  artery,   ligature    of,   at    back   of 
wTist,  123 
in  forearm,  126 
Radio-ulnar  joint,  excision  of,  159 
Radium  treatment  of  malignant  disease  of 
breast,  757 
of  nsevi,  401 
of  rodent  ulcer,  396 
Radius,  epiphysis  of,  separation  of,  120 
excision  of,  in  military  surgery,  134 

partial,  132 
operation  for  removal  of,  132 
Regnier's  operation  for  restoration  of  lower 

lip,  495 
Renula  cyst  of  mouth,  548 
Respiration,  mjddle  meningeal  haemorrhage 

and, 265 
Respiratory  passages,  upper,  condition  of 

in  operations,  9 
Respiratory  sj-stem,  operations  and,  8 
Reverdin's  method  of  skin-grafting,  45 
Rheumatism,  operations  and,  5 
Rhinoplasty,   complete,   causes   of   failure 
after,  451 
Denonviller's  method  of,  451 
Keegan's  method  of,  446 

SURGERY  I 


Rhinoplasty,  Syme's  method  of,  447 

Weber's  method  of,  452 
Rib  retractor  for  operations  on  lung,  786 

shears,  769 
Ribs,  cervical,  removal  of,  (i47 
resection  of,  760 

in  empyema,  769,  770 
'"  Rice    grain "    bodies    in    palmar    teno- 
synovitis, 90 
Rochet's  method  of  tendon-grafting,  102 
Rodent  ulcer,  after-treatment  of  operations 
for,  395 
curetting  in,  395 
diathermy  in,  396 
freezing  in  treatment  of,  395 
fulguration  in,  396 

of  face,  removal  of  eye  where  conjunc- 
tiva is  involved,  394 
operative  treatment,  393 
excision,  394 
steps,  394 
radium  treatment  of,  396 
X-ray  treatment  of,  395 
Rolando,  fissure  of,  289 
Rouge's  operation  for  malignant  growths 
of  nose,  466 
for  nasal  polypi,  462 
Roux's  amputation,  934 

modification  of  Syme's  amputation,  934 
Rugine,  Farabceuf's,  154 

Sacro-iliac  joint,  824 
Saddle-nose,  operation  for,  443 

subcutaneous     injection     of     sterilised 
paraffin  for,  452 
Saline  solution  injections  in  shock,  29,  36 

See  al^o  Infusion 
Saphenous  vein,  wounding  of,  in  ligature 

of  femoral,  842 
Sarcoma,  naso-pharyngeal,  operations  for, 
462 
of  brain,  298,  302 
of  clavicle,  241 
of  humerus,  214 
of  parotid,  397 
of  scalp,  245 
of  scapula,  228 
of  tongue,  operation  for,  548 
of  tonsils,  550 

removal  of  upper  jaw  for,  420 
Scalds,  35 

of  upper  aperture   of  larynx,   tracheo- 
tomy for,  581 
Scalp,  condition  of,  in  trephining  for  epi- 
lepsy, 274 
epitheliomata  of,  248 
fibro-cellular  growths  of,  244 
molluscum  fibrosum  of,  244 
operations  on,  244 
pachydermatocele  of,  244 
sarcomata  of,  245 

state  of,  in  middle  meningeal  haemor- 
rhage, 265 
Scapula,  caries  of,  removal  for,  233 
excision  of,  228 
incision  for  excision  of,  230 
partial  removal  of,  228 
removal  of,  234 

age  of  patient  and,  232 
condition  of  limit  after,  232 
dangers  of  operation,  233 

65 


1026 


INDEX 


Scapula,  sarcoma  of,  228,  231 

removal  of  entire  scapula  for,  229 
Scarpa's    triangle,    ligature    of    supt-rficial 

f(-moral  in,  839 
Scarlet  fever,  ulceration  of  throat  after,  680 
Scars,  painful  or  ulcei-ating,  46 
Schwartze  S  antrectomy,  338 

method  of  tendon  suture,  95 
Sciatic  arterv'.  ligature  of,  836 
Scopolamin  and  morphin  in  anoci-associa- 

tion.  1006 
Screws,  long,  in  fractures,  921 
Sebaceous  cysts  of  neck,  646 
Sedillot  S  operation  on  upper  lip,  by  ver- 
tical flaps,  500 
Semilunar    cartilage,    internal,    operation 

for  loose.  892 
Semi-membranosus    and   semi-tendinosus, 

division  of,  9(54 
Sepsis,  infusion  and,  41 
Septiceemia  and  interscapulo-thoracic  am- 
putation, 239 
infusion  in,  36 
Septic  thrombosis,  359 

wounds,  treatment  of,  25 
Sequestrotomy,  907 

early  subperiosteal  resection,  911 
indications  for,  907 
operation,  908 
Serre  S  operation  for  restoration  of  lower 
lip.  493 
for  restoring  one  angle  of  mouth,  500 
Sex,  operations  and,  2 
Shock  after  interscapulo-thoracic  amputa- 
tion, 238 
after  ojjerations,  27 
and  operations  on  Gasserian  ganglion  by 

intracranial  route,  380 
Anoci-association  and,  1006 
complicating  enucleation  of  tonsils,  477 
Crile's  technique  in,  1006,  1008 
infusion  in,  36 
kinetic  theory  of,  1008 
post-operative,  in  children,  1 
prevention  of,  27,  29,  1006 
prolonged,  cause  of  failure  after  removal 

of  upper  jaw,  430 
saline  solution  injections  in,  36 
symptoms  of,  28 
treatment  of,  29 
Shoulder,  arthrotomj-  of,  226 

dislocation  of,  chief  obstacle  to  reduc- 
tion, 213 
recurrent,  224 
habitual  dislocation  of,  212 
operations  on,  187 
Shoulder-joint,  amijutation  at,  177,  19G 
arrest  of  hemorrhage  in,  199 
by  anterior  and  posterior  flaps,  20s 
by  deltoid  flaps,  208,  220 
by  circular  method,  177 
by  en  raquette  method,  202 
by  Furneaux- Jordan  method,  209 
by  lateral  flaps,  201 
by  skin  flaps,  178 
by  superior  and  inferior  flaps,  207 
by  transfixion  flaps,  180 
for  aneurysm,  197 
for  new  growth>s,  197 
indications  for,  196 
lateral  flaps  in,  202 


Shoulder-joint,  amputation  at, 
methods  of,  198,  201 

Spence's  method  for,  204,  206 
disarticulation  at,  200 
dislocation  of,  habitual,  212 
excision  of.  209 

bv  anterior  incision,  215 

deltoid  flap  for,  220 

indications,  210 

Kocher's  posterior  curved  incision  for, 

218,  220 
methods,  215 
section  of  bone  in,  220 
subperiosteal  resection  in,  222 
fractures  of,  comminuted,  223 
c.'unshot  injuries  of,  treatment,  223 
Silk  sutures  ,  sterilisation  of,  20 
Sinus,  infected,   exposure   and  treatment 
of,  359 
lateral  thrombosis  of,  359 
Sinuses,  frontal,  operations  on,  410 
sphenoidal,  operations  on,  472 
Skey  S  amputation,  948 
Skin,  infection  of,  in  operations,  14 
j:)reparation  of,  16 

by  antiseptic  compresses,  16 
by  iodine  method,  16 
for  skin-grafting,  43 
sterilisation  of,  methods  of,  14,  16 
transplantation  of,  57 
Skin-grafting,  34,  42 
in  injuries  of  hand,  72 
in  operations  on  palm  of  hand,  85 
preparation  of  patenti  for,  42 
Rcvcrdin's  method  of,  45 
Thiersch's  method,  42 
AVolfe's  method  of,  45 
Skull,  condition  of,  in  trephining  for  epi- 
lepsy, 275 
foreign  bodies  fissuring,  253,  288 
fractures  of,  compound  depressed,  tre- 
phining. 250 
influence  of  site  and  trephining,  253 
punctured,  trephining  in,  252 
simple  depressed,  251 
trephining  for,  250,  254 
gunshot  wounds  of,  281,  287 
middle  or  posterior  fossa  of,  opening, 

343 
osteitis  of,  261 
osteoplastic  flaps,  313 
sarcomata  of,  245 
Soap,  preparations  of,  17 
Sodium  chloride  poisoning,  37 
Spastic  p)araplegia,  congenital  operations 

for.  973 
Spence's     method     for     amputation     at 

>houlder-joint,  204,  206 
Sphenoidal  sinuses,  operations  on,  472 
Spina  bifida,  causes  of  failure  after  radical 
ciu-e,  987 
drainage  into  tissues,  986 
excision  of  sac,  984 
indications  for  operation,  983 
injections  with  Morton's  fluid,  983 
risks  of  removal  of  nerves,  986 
tapping  in,  983,  985 
Spinal  accessory  nerve,  anatomy  of,  661 
operations  on,  661 

tuberculous  glands  of  neck  and,  643 
Spinal  analgesia,  1002,  1004 


IXDKX 


1027 


Spinftl  cord,  gunshot  wounds  of,  OiK) 
injuries  of,  laminectomy  in,  987 
jK-net rating  wounds  of,  990 
tumours  of,  993 
Spinal  tlu'ca,  blooding  into,  987 

tapping  of.  1001 
Spine,  caries  of,  992 

laminectomy  in,  996 

fracture-dislocation  of,  995 

gunshot  wounds  of.  990 

injuries  of,  laminectomy  in,  987 

partial  resection  of  vertebra;,  987 

Potts'  curvature,  991 

tulx>rculous  disease  of,  992 

tumours  of,  993 
Spinous  jirocesses,  fractures  of,  989 
Splints  after  osteotomy,  957 

ellxjw,  154 
Stacke's  antrectomy,  338 

guide,  341 

method  of  operation  in  acute  mastoid 
abscess,  346 
Status  lyinphaticus,  operations  and,  5 
Stellwagen's   trephine    for    operations    on 

brain,  316,  318 
Steno's  duct,  restoration  of,  386 
Sterilisation,  methods  of,  15 

of  catgut.  20 

of  dressings  and  swabs,  21 

of  hands.  14,  16,  18 

of  instruments,  19 

of  ligatures,  19 

of  skin,  14,  16 

of  sutures  and  ligatures,  19 

of  towels  and  overalls,  21 
Stemo-clavicular  joint,  diseases  of.  243 
Sterno-mastoid,  lengthening  the.  965 

operation  Ix-low,  in  partial  neurectomv, 
662 

ojjeration  in  front  of,  in  partial  neu- 
rectomy', 662 

tenotomj-  of,  964 
Stokes's    supracondyloid    amputation    of 

knee-joint,  856 
Stovaine,  Barker's  solution  of,  1003 
Stiimps,  amputation,  47 
Sub-astragaloid  amputation,  937,  939 
Subclavian  artery,  first  part,  ligature  of, 
707 
second  and  third  part,  ligature  of,  699 
Subperiosteal  resection.  149 

early,  in  sequestrotomy,  911 
Subtrochanteric    osteotomy    of    neck    of 

femur.  832 
Suppuration,  complicating  otitis  media,  332 

treatment  of,  26 
Supracondyloid  operation  of  Macewen,  955 
Supra-trochlear  nerve,  365 
Surgeon   and   his   assistants,    preparation 

of,  18 
Suture  of  arteries,  51 

of  nerves,  primary  and  secondary-,  978 

of  tendons,  94 
Sutures,  distance,  100 

infection  by,  15 

premature  cutting  of,  cause  of  failure 
of  operation  for  cleft  palate,  527 

sterilisation  of,  19 
Swabs,  infection  by,  14 

preparation  of,  21 
Sweet  method  of  artcriorrhaphy,  52 


Sylvius,  fissure  and  point  of,  291 
Sjrme  S  amjjutation,  930,  933 
causes  of  failure  after,  934 
value  compared  with  Pirogoff's  am- 
putation, 935 
method  of  rhino])lastj%  447 
operation  on  tongue,  540 
Sjrmond's  frontal  sinus  cannula,  415 
Sympathetic  cervical,  resection  of,  for  exoph- 

tbaliiiic  goitre,  667 
Sympathetic  ii<rve,  ojicrations  on,  661 
Syndactylism,  79 
Syndesmotomy,  962 
Syphilis,  intracranial,  299 
iipcrations  and,  5 

TagUacotian  method  of  complete  restora- 
tion of  nose,  449 
Talipes  calcaneo  valgus,  severe,  operations 
for,  972 
congenital,  965 

equino-valgus,  treatment  of,  972 
equino- varus,  severe,  operation  for,  967, 

969 
operative  treatment  of,  965 
severe,  points  in  treatment  of,  965 
valgus,  mode  of  progression,  974 
operations  for,  976 
Tapping  of  sac  in  spina  bifida,  985 
the  pericardium,  794 
the  spinal  theca,  1001 
Tarsal  bones,  disease  of,  939 
Tarsectomy,  complete,  945 
Tarso  -  metatarsal      joints,      amputation 

through,  948 
Tarsus,  excision  of  bones  and  joints,  943 
Teale  S  amputation  of  leg,  907 

rectangular  flaps  of,  850 
Technique  of  operations,  22 
Teeth,  cysts  due  to  carious,  421 
Temperament,  operations  and,  3 
Temporal  artery,  ligature  of,  670 
Temporal  fossa,  bony  floor  of,  374 
Temporo-sphenoidal  lobe,  abscess  in,  opera- 

tion  for.  356 
Tendo  Achillis,  death  of,  935 
division  of,  963 

influence  of  after  Chopart's  amputa- 
tion. 947 
Tendon  grafting,  57,  101 
Tendons  about  foot,  tenotomy  of,  961 
anastomosis  of,  97 

by  bifurcation  or  splitting,  97 
divided,  operations  for  union  of,  93 
union  when  impossible  to  adjust  ends, 

98 
union  where  onlv  one  end  can  be  found, 
93 
lengthening  of,  164,  961,  965,  968 
by  osteotomy,  100 
by  zig-zag  incisions,  100 
Czernv  method,  99 
Hibb's  method,  99 
in  Volkmann's  contraction,  135 
Trnka  method,  99 
shortening  of,  103 
Ollier's  method.  104 
Willet's  method,  103 
suture  of,  94 

Le  Dentu's  method,  95 
resection  of  bone  in,  103 


1028 


INDEX 


Tendons,    suture   of,  Schwartz's  method, 
95 
Wolfler's  method,  95 
transplantation  of,  96G 
after-treatment.  107 
in  cerebral  paralysis  of  childi-cn,  107 
in  infantile  paralysis,  104 
in  infantile  spastic  paral3^sis,  107 
in  lower  extremity,  109 
in  upper  extremities,  109 
methods,  105,  106 
preliminary'  points,  105 
technique  of  operation,  106 
union  of,  methods  of  inserting  sutures, 
94 
wher.^  ends  can  be  easily  adjusted.  94 
Tenoplasty,  93 
Tenorrhaphy,  93 

Teno-synovitis,  tuberculous  palmar,  90 
Tenotomes,  962 

Tenotomy,  causes  of  failure  after,  965 
in  dislocations  of  fingers,  69 
of  hamstrings,  964 
of  sterno-mastoid,  964 
of  tendons  about  foot,  961 
reduction  of  dislocation  of  thumb  and,  69 
Tetany   following   operations   on   thjToid 

gland.  636 
Theca.  spinal.  987,  1001 

tunnel  of  fingers,  57 
Thiersch's  method  of  skin-grafting.  42 

skin-grafting  knife,  43 
Thigh,  amputation  of,  by  circular  method, 
848 
bv  transfixion  flajis,  848 
flaps  for,  846 
amputation  through,  846 
arteries  in,  ligature  of,  835 
Thomas,  Lvnn-,   forceps-tourniquet,   807, 
932 
method  of  removal  of  innocent  mammary 
tumours,  759 
Thoracostomy,  precordial,  804 
Ttu'ombosis  after  operations,  32 

of     lateral     sinus     complicating     otitis 

media,  353 
septic,  of  lateral  sinus,  operation  for,  359 
Thoracic  duct,  wounds  of,  in  operations 

on  neck,  640 
Thorax,  operations  on,  727,  778 
Thumb,  amputation  of.  66 

carpo-metacarpal  joint,  amputation  at, 
66 
by  transfixion.  67 
dislocation  of,  reduction  of,  69 
dorsal  incision  and,  70 
palmar  incision  and,  70 
tenotomy  for  reduction  of,  69 
metacarpo-phalangeal    joint,    reduction 

of  dislocation  at,  69 
partial  excision  of,  68 
phalanges  of,  amputation,  66 
removal  of  phalanges  of,  68 
supernumerary.  78 
Thymus,  enlargement  of,  5 
Thyroglossal  cysts,  645 
Thyroid  adenomata,  enucleation  of,  628 
arteries,  ligatiure  of,  610,  618,  630 
arterj-,  inferior,  ligature  of,  631 
superior,  ligature  of.  625,  630 
cysts,  treatment  of,  633 


ThsTOid  gland,  extirpation  of  jjart,  610 
isthmus,  crushing  of,  627 
operations  on,  610,  619 
accessory,  636 
dangers  of  operation,  633 
securing  vessels  in,  623 
resection-enucleation  of,  629 
Thyrotomy,  559 

after-treatment,  590 
for  growths  of  larjmx,  585 
indications  for,  559,  586 
inter-crico,  562 
operation  of,  560,  588 
Tibia,  cuneiform  division  of,  958 

curvatures  of,  manual  osteoclasis  in,  959 
division  of,  as  well  as  femur,  957 
fracture  of.  Lane's  plates  for,  920 
growths  of,  913 

oblique  fracture  of,  reduced  by  angula- 
tion and  leverage,  920 
oblique  or  spiral  fracture  of,  919 
osteotomy  of,  simple,  958 
Tibial  artery,  anterior,  ligature  of,  902,  931 
at  junction  of  lower  and  middle 

thirds  of  leg,  904 
at  junction  of  upper  and  middle 
thirds  of  leg,  903 
relations  of,  902 
posterior,  ligature  of,  898 

ligatiu-e  of,  at  inner  ankle,  902 
in  lower  third  of  leg,  901 
in  middle  of  leg,  900 
relations  of.  900 
Tibiahs  anticus,  division  of,  961 
Tibialis  posticus,  division  of,  961 
Tobacco  smoking,  operations  and,  4 
Toe.  ureat,  amputation  of,  951 
Toe-nail,  ingrowing,  952 
Toes,  amputation  of,  950 
deformities  of,  952 
ojjcrations  on,  976 
Tongue,  base  of,  operations  for  growths 
at,  550 
epithelioma  of,  operation  for,  529,  544 
half  of,  removal,  538 
operations  on,  after-treatment,  547 
causes  of  failure,  547 
complications,  547 
haemorrhage  complicating,  548 
pre-canccrous  stage  of,  529 
removal  of,  529 

by  transhj-oid  pharyngotomy,  543 
Kocher's   former   method    b}'-   lateral 

inframaxillary  incision,  542 
Kocher's     modification     of     S3'me's 

operation,  540 
lymphatic  glands  and,  539 
AVhitehead's  operation  for,  532 
sarcoma  of,  operation  for,  548 
Tonsils,  enlarged,  removal  of,  474,  475 
anaesthetic  for,  474 
enucleation  of,  476 
after-treatment,  477 
broncho-pneumonia,  complicating,  477 
complications  and  sequela?  of,  477 
ear  trouble  complicating,  478 
haemorrhage  complicating,  477 
shock  complicating,  477 
growths   of,   after-treatment   of    opera- 
tions, 556 
aids  in  operations  for,  555 


INDEX 


1029 


Tonsils,  growths  of,  cases  favourable  for 
f)|)('ration,  551 
clioic'c  of  operation,  550.  554 
lateral  pharyngotomy  for,  552 
(>|)ciatioii  through  mouth  alone,  551 
Torticollis,  congenital,  treatment  of,  ()()4 
Tourniquet,  value  in  operations  on  foot, 

!»(i!t 
Towels,  infection  hy,  14 

pr('|)aration  of,  21 
Trachea,  t  reatmcnt  of,  in  laryngectomy,  595 
ulceration   of,  complicating  after-treat- 
ment of  tracheotomy,  575 
Tracheotomy,  5()3 

after-treatment,  570 

breathing  difticulties  after,  573 

chief  difficulties  of,  568 

in  dvspncea,  581 

intulbation  of  larynx  as  substitute  for, 

575 
other  indications  for,  580 
palliative,     for     malignant    disease     of 

pharynx,  600 
points  in  the  operation  of,  566 
question  of,  in  operations  on  tonsil,  555 
removal  of  tube  after,  571 
site  of  operation,  567 
treatment  of  laryngeal  papillomata  by, 

561 
under  lo3al  analgesia,  581 
with  special  reference   to   membranous 
laryngitis,  564 
Transfixion  methods,  48,  67 
Transfusion  compared  with  infusion,  34 
Transfusion  of  blood,  34,  42 
Trans-hyoid  pharyngotomy  for  malignant 
disease  of  pharynx,  599 
for  removal  of  tongue,  543 
Trendelenberg  position  in  operations,  22 

in  operations  on  the  larynx,  555 
Trephine.  Stellwagen's,  for  operations  on 

brain.  316,  318 
Trephining,  250 

and  exploration  of  cerebral  abscess  due 

to  injury,  269 
for  cranial  injury,  272 
for  epilepsy,  272 

for  middle  meningeal  hsemorrhage,  262 
for  pus  between  skull  and  dura  mater, 

259 
for  removal  of  bullets,  286 
in  fractures  of  skull,  250,  254 
in  general  paralj'sis  of  insane,  327 
Triceps,  lengthening  of,  164 
Trnka  method  of  tendon-lengthening,  99 
Trochanter,  section  through,  Jones'sline  of, 

820 
Tuberculosis  of  wrist-joint.  111 

operations  and,  5 
Tuberculous  disease  of  breast,  excision  of 
breast  for,  758 
of  elbow-joint,  excision  for,  145 
of  knee-joint,  excision  for,  867 
of  lung,  operation  for,  783 
glands  of  neck,  operative  treatment  of, 

640 
growths  of  brain,  301 
tenosynovitis,  90 
palmar,  90 
Tumours,  intracranial,  297 

of  cerebellum,  operation  for,  322 


Tumours  of  cranium,  245 
of  lung,  operation  for,  784 
pituitarj',  removal  of,  472 
Src  also  Sarcoma,  &c. 
Turbinate,  i  nferior,  removal  of  anterior  end, 
455 
postciior  end,  455 
Turbinectomy,  454 

Tympanic  membrane,  incision  of,  331 
Tympanum,  complications  of  suppurative 
otitis  media  and,  332 


Ulcer,  rodent,  operative  treatment,  393 
Ulna,  excision  of,  in  military  surgerv,  134 
partial,  132 

operation  for  partial  removal  of,  133 

site  of  section,  151 
Ulnar  artery,  ligature  of,  in  forearm,  130 

nerve,  injury  to,  from  excision  of  elbow, 
160 
Ununited  fractures,  925 
Urea   hydrochlorid  and  quinin  in  anoci- 

association,  1007 
Urinary  system,  operations  and,  9 
Urine,  examination  of,  9 

retention  of,  after  operation,  31 


Vagus  nerve,  injury  to,  in  operations  on 

neck,  639 
Varicose  veins,  excision  of,  928 

indications  for,  926 
Varix,  aneurysmal,  188,  190 
Veins,     air    in,    in    interscapulo-thoracic 

amputation,  239 
Veins,  saphenous,  wounding  of,  in  ligature 

of  femoral,  842 
Veins,  varicose,  excision  of,  926, 928 
Venesection,  166 

complications  after,  167 
difficulties  during,  167 
indications  for,  166 
in  gas-poisoning,  37 
operation  for,  167 
Ventricles  of  brain,  drainage  of,  328 
Vertebrae,  partial  resection  of,  987 
Vertebral  artery,  ligature  of,  697 
Viscera,  examination  of,  before  operation,  6 
Vocal  cords,  epithelioma  of,  590 
Volkmann's  contraction,  freeing  of  nerves 
in,  136 
operative  treatment  of,  135 
resection  of  bones  in,  136 
tendon-lengthening  in,  135 
Vomiting  after  operations,  30 

cause  of  failure  of  operation  for  cleft 
palate,  527 

Wagner's  osteoplastic  method,  310 

Water,  infection  by,  15 

Watson's    modification   of   PirogofE's   am- 
putation, 936 

Watson's  operation,  945 

Webbed  fingers,  79 

Didot's  operation  for,  81 

Weber's  methocl  of  rhinoplasty,  452 

Whitehead's    operation    for    removal    of 
tongue,  532 

Whooping    cough,    cause    of    failure    of 
operation  for  cleft  palate,  527 


1030 


INDEX 


Willet  method  of  tendon-shortening.  103 
Wire,    coiled,    use    of,    in    treatment    of 
aneurysm,  726 
use  of,  in  fractures,  921 
Wiring  fractures  of  patella,  880 
in  long-standing  fractures,  164 
the  patella,  difficulties  in,  885 
Wolfe's  method  of  skin-grafting,  45 
Wolaer's  method  of  tendon  suture,  95 
Women,  operations  on,  2 
Worry,  operations  and,  3 
Wounds  about  lower  end  of  femur,  860 
after-treatment  of,  25 
clean-cut,  advantages  of,  1008 
gunshot,  amputation    at  shoulder-joint 
for,  196 
aneurysms  due  to,  188 
of  axillary  artery,  188 
of  brain,  281 
of  chest,  776 

of  elbow-joint,  treatment,  157 
of  forearm,  176 
of  heart,  802 
of  wrist,  119 
infection  of,  cause  of  failure  after  re- 
moval of  upper  jaw,  430 
prevention  of,  13 
of  chest  involving  the  diaplu'agm  and 

abdomen,  776 
septic,  treatment  of,  25 


Wounds,  sloughing  of,  complicating  after- 
treatment  of  tracheotomy,  574 
treatment  of,  in  compound  fractures,  914 
Wrist-joint,     amputation    at,     by     ec|ual 
antcro-posterior  flaps,  123 
by  method  of  Dubrcuil,  123 
amputation  through,  120 

by  long  palmar  t\a.p,  121 
different  methods,  121 
indications,  121 
circular  amjiutation  at,  123 
excision  of.  111 

after-treatment,  118 
failure  after,  120 
for  gunshot  injury,  119 
Lister's  operation,  112 
Ollier's  operation,  114 
ligature  of  radial  artery  at,  123 
operations  on.  111,  119 
stages  of  operation,  115,  116,  117 
Wyeth's  bloodless  method  of  amputation 
at  hip-joint,  806 
method  of  ligature  of  axillary  artery,  201 


X-ray  diagnosis  of  gunshot  wounds,  282, 
284 
treatment  of  lupus,  389 
of  malignant  disease  of  breast,  757 
of  rodent  ulcer,  395 


BALLANTYNK,   HANSOX   &=    CO.    LTD. 
LONDON   AND    EDINBURGH 


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